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The ‘Minute Clinic’ Approach To Medicine

Retailers from Walgreens to Wal-Mart to CVS are looking to turn into health care outlets. It’s convenient. Is it good medicine? Plus: using tech to disrupt the healthcare market.

A woman walks past a CVS store window in Foxborough, Mass., Tuesday, Feb. 7, 2012. The nation’s major drugstore chains are opening more in-store clinics in response to the massive U.S. health care overhaul, which is expected to add about 25 million newly insured people who will need medical care and prescriptions, as well as offering more services as a way to boost revenue in the face of competition from stores like Safeway and Wal-Mart. (AP)

A woman walks past a CVS store window in Foxborough, Mass., Tuesday, Feb. 7, 2012. The nation’s major drugstore chains are opening more in-store clinics in response to the massive U.S. health care overhaul as a way to boost revenue in the face of competition from stores like Safeway and Wal-Mart. (AP)

While the political world wrangles over Obamacare, everyday health care in this country is on the move – and a lot of it is headed out of the doctor’s office.  Big retailers are moving in big-time.  Wal-Mart, Walgreens, CVS, Target.  You need a vaccination for chickenpox, hepatitis, shingles, the flu?  They’re there.  Around the corner from toothpaste and cat food, you can get your school physical.  Your cholesterol screen.  Your strep test.  And now, care coming for diabetes, heart  disease, asthma, more.  This hour On Point:  what’s it mean when health care moves to the corner store?

– Tom Ashbrook

Guests

Sumathi Reddy, consumer health columnist for The Wall Street Journal. (@rddysum)

Dr. Jason Hwang, internal medicine physician. Co-founder and chief medical officer at PolkaDoc, a California-based health care startup. Author of “Innovator’s Prescription: A Disruptive Solution for Health Care.” (@drjhwang)

Dr. Reid Blackwelder, president of the American Academy of Family Physicians.

Tine Hansen-Turton, executive director of the Convenient Care Association. (@tine_nncc)

From Tom’s Reading List

The Wall Street Journal: Drugstores Play Doctor: Physicals, Flu Diagnosis, and More — “Currently there are about 1,600 walk-in medical clinics across the country in drug and big-box stores and supermarkets like CVS, Walgreens, WAG -1.63% Target and Kroger. The number is projected to double in the next three years due in part to the increased demands of newly insured patients under the Affordable Care Act, according to a 2013 report from Accenture, a global management-consulting firm.”

The Daily Beast: Retail Clinics Are More Common Than Ever, But That Doesn’t Mean You Should Use Them — “On the surface, it may seem as though there is nothing wrong with visiting a retail clinic for concerns about a cough or ear infection. The physical exam isn’t that complicated, and for most of the complaints the management is relatively cut and dried. Why shouldn’t parents bring their kids to the walk-in clinic around the corner?”

The Economist: Health care in America — “In theory, patients with ordinary Medicare and Medicaid coverage can turn up at any clinic and ask to be treated, with the bill sent to the government. In practice, many doctors turn them away because the government’s reimbursement rates are too low. And Medicare does not cover the full cost of all treatments, so most patients buy private insurance to cover the gaps.”

A Look At Start-Up Health Insurance, Oscar

Kevin Nazemi, co-founder of Oscar. (@kevinnazemi)

New York Times: Start-Up Health Insurer Finds Foothold in New York — “Oscar is Silicon Alley’s challenge to the staid business of health insurance. It is trying to use its tech-world skills to provide an easier experience to consumers. Its snazzy website is extremely easy to navigate (typing in ‘I have a stomachache’ will pull up many options of types of doctors or facilities to visit). But what sets it apart, at least for now, is telemedicine, or unlimited phone calls with physicians, and greater price transparency.”

 

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  • Shag_Wevera

    You ask in the intro if this is good medicine. Maybe you should ask how high a priority IS good medicine?

  • HonestDebate1

    There are also clinics switching to a no insurance model where patients pay a monthly fee. We will see a lot of scrambling to avoid Obamacare.

    • anamaria23

      As long as the person has access to hospital care and insurance for it, that should work. Otherwise it may the same use of the ER for serious issues without coverage for it.

      • HonestDebate1

        Unfortunately the ER situation is unaffected by Obamacare. I am 54 and don’t have a doctor. I’m looking for one because at my age it’s time. The idea appeals to me.

        • Don_B1

          That is not true!

          What is true is that it has not been immediately effective in changing the ER use, but it recognized that it would take a while (at least a few years) to get people who have known only the ER to understand the added benefits of having their own doctor.

          Some hospitals are already setting up “classes” where ER patients who fit the mold of those who are using the ER as their only health care provider are encouraged to find a general practitioner for those healthcare services that they should not be going to the ER for.

          But that transition does take time. Remember, getting the medical profession to change their approaches to some illnesses can take 10 years before the doctors/hospitals change.

          • HonestDebate1

            It is true. Anecdotally I know a couple of ER doctors. One commutes from here in NC to Florida because of the demand. She is very dubious about Obamacare as are others I know.

            Beyond that, there have been studies to confirm my claim:

            http://www.npr.org/blogs/health/2014/01/02/259128081/medicaid-expansion-boosted-emergency-room-visits-in-oregon

            http://www.foxnews.com/politics/2014/01/04/study-suggests-medicaid-expansion-will-lead-to-more-emergency-room-visits-under/

          • Don_B1

            Those are studies that just looked at the immediate response, before the PPACA coverage had really begun, and those who had never had a doctor before were still going to the ER.

            But that will change over the next years, as I pointed out, but you just ignored because that is what you do with anything that contradicts your need to tear down the PPACA.

          • HonestDebate1

            The Science study disagrees. You are entitled to make whatever prediction you want but I don’t think you have a basis. IMHO you will do anything, regardless of the realities, to put lipstick on the pig that is Obamacare.

          • Don_B1

            The “Science” study is likely much too premature, which is what I was trying to convey.

          • HonestDebate1

            You are entitled to your opinion but it is not a basis to write: “That is not true!”

          • Don_B1

            It seems to work for you, or at least you continue to try to substitute your opinions for facts in most of your posts.

            Notice that I pointed out that the data you took as forever conclusive was only preliminary and the data would change over time.

          • hennorama

            Don_B1 — there is also the factor that many in the general public are still unaware of the PPACA, and some think is has been repealed.

            Education takes time, especially when combined with a steady stream of dis- and misinformation.

    • Shag_Wevera

      Maybe that model will work. Likely it won’t. I’m open to anything that drags medicine in this country out of the dark ages. Heck, maybe conservatives are right. All you need to do is enact tort reform and allow insurance sales across state lines. Presto! American healthcare fixed!

      • HonestDebate1

        It seems like a good idea to me and it’s gaining traction. Tort reform and State competition are essential but by no means the solution. Who says that?

        • Shag_Wevera

          Since those are the only consensus ideas I’ve heard from the right, I assumed that was their solution.

          • HonestDebate1

            You should get out more.

    • Paul Gerrard

      This model was in place years before The Affordable Health Care Act. It was as a result of medical reimbursements and medicare.

      • HonestDebate1

        I’m sure it was, that wasn’t my point. There has been and will continue to be a massive surge in the concierge model because of Obamacare. it’s just a fact and not a criticism of Obamacare. As a matter of fact it may be a positive result of it.

    • TFRX

      Try better.

      I mean, that’s not your best shot, is it?

      • HonestDebate1

        I don’t follow.

  • MrNutso

    The move by retailers into low level health care combined with urgent care facilities is to date, the greatest improvement in health care in the U.S.

    • anamaria23

      Drug store clinics will take the load off the ER for minor issues. However, emergency type issues even a fall in the parking lot by a senior will still require the hospital attention.

  • Maureen Roy

    They need to re-think the touch screen kiosk approach to entering one’s personal information in terms of data privacy (HIPAA) as well as ease of use for seniors and those with vision issues….very disconcerting.

  • northeaster17

    I read yesterday that GP’s pay about $52 per patient to fill out and file insurance paperwork. These little Dr offices may be nice for some but they will do little to stream line the HC paper trail. They may make it worse. This should be an easy fix but since money is being made on the inefficiancy progress will be slow.

  • SjMills

    My family GP spends 20-30 minutes with each of us in a standard exam. He explains what the results of each test means. He does this despite the pressure from insurance companies to get a patient out in 10 minutes. I appreciate such depth of health care. This will never happen at a big box.

    • Shag_Wevera

      The model at the HC provider I work for is EIGHT minutes per patient.

  • Floyd Blandston

    I love the incredulity in Tom’s voice; always happens when gold plated suburban health insured ‘murca visits the other side of the fence. The small town rural health centers where I live *rarely* have a real doctor in them!

  • OnPointComments

    I was at my regular doctor last fall and asked about a flu shot. He said it would cost $120. I went to Walgreens and got the flu shot for $10.

    • Shag_Wevera

      That sure highlights the problem of American healthcare.

      • OnPointComments

        I wasn’t surprised that Walgreens could charge much less for the shot. It obviously is much more expensive to maintain a medical office with doctors, nurses, staff, and the ability to treat many more maladies, than it is to add giving shots at a drug store.

        • hennorama

          OPC — and as [Rollo Martins], a pharmacist, indicated above, “these clinics are not there to get people to get their rx profits within the store, but they are there to get a volume increase, to get toothpaste sold etc.”

          • OnPointComments

            Their plan worked, at least with me. They wanted me to stay in the store for 10 minutes after the shot to make sure there was no adverse reaction, and I bought about $50 of stuff.

          • hennorama

            OPC — a win-win it seems.

    • hennorama

      OPC — two questions:

      1. Did you have health insurance at the time?

      2. Were the $120 and $10 figures the amount you would pay out of pocket, or the total cost, including any charges covered by your insurer?

      Flu shots are on the list of “Preventive health services for adults” that are part of PPACA-compliant policies/plans:

      Free preventive services

      All Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible. This applies only when these services are delivered by a network provider.

      11. Immunization vaccines for adults–doses, recommended ages, and recommended populations vary:

      Hepatitis A
      Hepatitis B
      Herpes Zoster
      Human Papillomavirus
      Influenza (Flu Shot)
      Measles, Mumps, Rubella
      Meningococcal
      Pneumococcal
      Tetanus, Diphtheria, Pertussis
      Varicella

      See:
      https://www.healthcare.gov/what-are-my-preventive-care-benefits/

      • OnPointComments

        It was the total charge, and in both cases insurance would have paid.

        • hennorama

          OPC — thanks for your response.

      • Paul Gerrard

        I don’t see how it matters. Even if I had insurance, I’d pay the $10 cash and also save the hours difference to get the shot.

        • hennorama

          Paul Gerrard — thank you for your response.

          Part of the intention of the post was informative, and the remainder was to determine the difference in how these particular providers charge for their services.

          As to your “hours difference” point, one could imagine the health care provider combining the flu shot with a regular visit. Remember, OPC was already at the provider’s location in his example.

          • Paul Gerrard

            Ah, yes, you are correct. In this case the time is not a factor. And the vast difference in cost is really a concern and factor in our current system.

          • hennorama

            Paul Gerrard — TYFYR.

            Indeed, the significant difference in cost in the example could also overcome any time differential. Certainly if one is informed that both the time and cost are greater for one provider, the choice is quite clear.

            A large part of the issue is a lack of price transparency, as other commenters have indicated.

  • Scott B

    This could potentially save billions of dollars, both for the gov’t and people, if done right. People still show up at ER’s for things better suited to a clinic, and that costs billions of dollars a year. The people show up because that’s all they know, and they know they can’t be refused. Apply some of those same rules and you have easier access for treatment, since a CVS, Walgreens et at, are closer, and a better way for people needing regular monitoring and treatment for things like diabetes to stay out of the ER’s, or need hospitalization. If the people do need more treatment, they can be referred to the hospital.

    It would have to come from both sides. The store clinics could provide their services, and agree to provide records so results can be tracked person to person, area to area, and the insurers (be they private or medicaid//medicare) pay a set amount for a certain service and make the payment to the clinic in short order.

    • Don_B1

      This transition of patients from using ERs to clinics, or, better yet, a regular patient of a doctor, is part of what the PPACA was intended to begin.

      For clinics to even approach the service level of having your own doctor, the health care forms must be consistently and thoroughly filled out be every provider and must be online and in a common format. There probably must be ways for the doctor seeing the patient with a problem to contact any doctor or facility that has provided care in the past.

      But there is a distinct possibility, almost a certainty, that this will be a big improvement for many who have never had a doctor.

      • Scott B

        I was thinking something kind of analogous to when a church would build a place of worship right on top of where the pagans were used to going.

        Right now many of the people showing up in ERs go there because that’s where they’ve always gone, clogging up needed beds, taking up time more needy patients require, and costing everyone time and money. They have to be retrained, and odds are that they already go to many of these places for everyday things, including OTC meds, as well as food and goods.

        Records will have to be shared. The store clinics might not like it, but they can be encouraged by some incentives like, say, quicker reimbursement, just for one example.

        • Don_B1

          Exactly!

          And because the government payments to cover the cost of treating indigent patients is drying up with the increases in Medicaid coverage (where Republican-controlled states don’t prevent it), the hospitals have every incentive to encourage ER patients to seek other care providers.

          The pressure on Republicans to accept the Medicaid expansion will get real intense as the hospitals start to close down for financial reasons. This has already started.

          Of course, most of the closing hospitals are in poor areas that Republicans just ignore already. But in small towns, there probably are not more than one hospital, if that.

      • OnPointComments

        The transition of patients from using ERs to clinics and a doctor may be the plan, but it is yet to be seen if the plan will come to fruition.

        Oregon had a lottery in which some low-income adults were admitted to Medicaid. It tracked those Medicaid adults against non-Medicaid adults, and it showed that having Medicaid increased the probability of using the emergency department by 7 percentage points (an increase of about 20 percent, relative to a base of 34.5 percent). Medicaid increased the number of emergency department visits over the 18-month period by about 40 percent (0.41 visits, relative to a base of 1.02).
        http://www.nber.org/oregon/index.html

        • hennorama

          OPC — thanks for pointing out that it’s too soon to make the call.

          Changing human behavior isn’t easy, and education takes time.

          • HonestDebate1

            I just find the whole notion, and defense of it, of the government manipulating its citizens behavior regarding things they have no business in, disgusting and un-American.

          • Don_B1

            So you are for paying 1%, 2%, 5%, or 10% more to cover healthcare for those too poor to buy it with insurance companies denying coverage to anyone with a pre-existing condition as was the case pre-2009. Note that the number in that sequence will be determined by the amount healthcare costs go up without the minimal constraints built into the PPACA.

      • brettearle

        I underscore that Connectivity, in a variety of ways, remains paramount.

  • RolloMartins

    Tom, as a pharmacist I can tell you that there is no profit to speak of in drug dispensing. We are here to get people in the store–we function as a loss leader. So these clinics are not there to get people to get their rx profits within the store, but they are there to get a volume increase, to get toothpaste sold etc.

    • RolloMartins

      The newest area to find a revenue stream in pharmacies is in disease management, which these clinics will feed.

  • Shag_Wevera

    I wonder if anyone has considered getting insurance out of medicine. A middleman who skims money from the system without contributing anything to good medical outcomes.

    • hennorama

      Shag_Wevera — good one.

    • Rick Evans

      And, should you have a catastrophic claim how would you pay for it. Oh, wait, you’re obviously Silicon Valley billionaire who can write a check.

      • Shag_Wevera

        I dunno, how do they handle it in France, Italy, Taiwan, Japan, England, Spain, Norway, Canada, and the rest of the civilized world?

        • Rick Evans

          All those industrialized countries have some form of insurance. Some OECD’s have single payer insurance and some like Germany private insurance mandates.

          My point is few people can afford a catastrophic medical case sans insurance.

  • Oh bummer

    Give the career politicians in D.C. time, when they see how many people are legally avoiding Obamacare, the kleptocrats in D.C. will enact legislation to shut the ‘minute clinics’ down.

  • Stephen706

    While may be good for minor things and simple things (UTI, strep, flu shot), not good for chronic long term conditions that require more in depth thought and analysis (diabetes, cardiovascular, GI, pulmonary issues)… And this won’t stop people from abusing the ER where no money is needed up front–in the eyes of many, it is “free” care covered by all of those who filed their tax returns yesterday and who rarely come back to pay the outrageous bill generated for non-ER issues

  • RolloMartins

    When the typical person goes into a doctor’s office anyway, who do they see? A physician’s assistant or a nurse practitioner. This is just about someone else competing with mds.

  • myblusky

    Obviously people aren’t going here for serious illnesses like cancer, but they are great for UTIs, sinus infections, etc. They are usually staffed by nurse practitioners and they are much more conservative when it comes to dispensing medications. They are also empathetic and listen to what you are saying. I have had good experiences at these clinics so far.

    They are also convenient. My friend and I were having lunch one Saturday and she had a sinus infection that had been brewing for a few days. I suggested we stop in at Walgreens so she could see a nurse. In 30 minutes she was done and picking up her medication. Why wait for an appointment with your doctor for days regarding something like this?

    • Paul Gerrard

      exactly!

  • Jeremy Callahan

    I already see a Nurse Practitioner when I visit my General Practitioner! I see my doctor on rare occasions!

  • Citizen James

    Hey I am all for :

    1. The convenience of a CVS visit.
    2. The usage of cheaper resources such as a nurse practitioner instead of an MD
    3. The usage of electronic medical records that can easily be transferred to my primary provider.
    4. The ‘chipping away’ of the current model that is so expensive.

    Some times I eat an expensive restaurant. Other weekends I eat at a local diner. I want the same choice in healthcare. I want my personal healthcare to enter the 21st century.
    What allows this to happen is the electronic medical records which feeds all my medical ‘transactions’ to my primary care MD

  • peterntreed

    There is great concern in the pediatric community about minute clinics — pediatricians worry that these clinics will detract from the ‘medical home’, disrupting continuity of care. For example, pediatricians work hard to keep their patients up to date on vaccines. If vaccines are given at the minute clinics, will records of those vaccines get back to the child’s pediatrician? Pediatricians also rely on regular visits with children and their families to track development and psychosocial wellbeing. If minute clinics disrupt that continuity, it is likely that some children with developmental delays or psychosocial stressors will slip through the cracks, whereas they would have been detected in a medical home setting. (I am a pediatric resident.)

    • brettearle

      Is this not an example of a necessary requirement for online medical records to be accessible through a universal network–with patient’s permission?

      If someone is out of town, or even abroad–and must suddenly go to an ER, for example–such accessibility could be essential.

      I would see the same opportunity–to keep track of records–to be essential, for a parent bringing a child to a clinic, for a vaccination.

      In other words, make it mandatory for a Minute Clinic to have records’ accessibility–in cooperation with practices, group practices, and hospitals.

      Maybe impractical now–but perhaps not in the future.

      • hennorama

        brettearle — here’s what CVS says on their website, directed toward “Clinic Practitioners”t:

        Electronic Medical Records (EMR)

        At MinuteClinic, you’ll have all the tools you need to confidently manage your clinic and provide the highest quality care. Our proprietary EMR system, for example, was created specifically for our practice model, and provides our clinic practitioners with:

        evidence-based clinical guidelines — built into the system — that can help you make better clinical judgments

        the latest clinical information, delivered in real-time, so you can have the most up-to-date protocols and treatment recommendations at your fingertips

        accessibility to patient records from any location, ensuring continuity of care, no matter which location your patient has previously visited

        an automated chart review process to ensure continuous improvement

        e-prescribe functions that allow you to send prescription information to the patient’s pharmacy of choice, and automatically records it in the patients’ records, promoting greater drug safety

        an easy process for payment and insurance information — built right in — so that you can spend your time taking care of your patients, not paperwork

        Whether these records are accessible by other providers is not specified, but since it is a “proprietary EMR system … created specifically for our practice model…,” it seems unlikely.

        See:
        http://www.minuteclinic.com/careers/clinicpractitioners/yourrole/emr/

        • brettearle

          Thanks…

          So this is only a `Network Provider’, so to speak?

          ….where Records are accessible throughout the Clinic network only?

          The pediatrician had an essential point, I would think….

          • hennorama

            brettearle — TYFYR.

            I can’t speak to the details of EMR sharing between different providers, but that sharing and accessibility is one goal of such systems.

            It’s a difficult thing, however, to balance access and privacy, and the legal concerns of all parties involved.

    • hennorama

      peterntreed — when your residency ends, do you plan to be an independent provider, or work for a health care provider?

      The concerns you express are of course legitimate, but can also be part of the lives of individuals and families who move frequently, and/or who “provider hop” depending on insurance coverage or lack thereof, are they not?

  • hennorama

    Anyone interested in more about the concierge/subscription model for independent health care providers can read more here:

    http://www.accenture.com/us-en/Pages/insight-new-business-models-new-era-healthcare-summary.aspx

  • SjMills

    Reply – my GP is not working the ‘concierge’ model. He is a small town doctor who knows his patients. He is NOT getting wealthy with his practice and I would not be surprised if he is taking chickens as payment. (Seriously!) This may be an outdated model, but that’s a statement about lack of fundamental medicine utilizing many GPs as the front line of health care.

    • hennorama

      SjMills — I think those health care providers who are still independent are interested in the concierge/subscription model primarily due to the complexity and cost of dealing with insurers.

    • HonestDebate1

      Unfortunately they are a vanishing breed and it will only get worse.

      I’ve been racking my brain all morning to remember the term concierge model. Thanks.

      • J__o__h__n

        Is there an additional fee to tip the concierge model?

        • HonestDebate1

          It all depends on how long they allow your beer mug to remain empty.

          • J__o__h__n

            Sadly I think the current medical pricing model might be spreading. I went to a bar on Sunday and they didn’t have prices on the beer list.

  • Paul Gerrard

    I have a great PC doctor! He is concerned and talented. I also have insurance. But I use Walgreens because I simply can’t wait for an appointment to get a flu shot or a strep test. And, I just pay cash.

    • Paul Gerrard

      Sometimes I take my car to the dealer for an oil change. It costs more but they have a nice waiting area with wifi. They will also check my car for major problems and recalls. But, if my car is running fine and I just need an oil change and not a lot of time, I just go to a QuickLub place. Same oil, not as nice waiting area, but cheaper and less time.

  • J__o__h__n

    My insurance changed from a plan with a copay for an office visit to one with a high deductible (changed before Obamacare) and I tried to find out what a routine office visit would cost and the office couldn’t tell me. The medical industry is blaming the patients for outrageous costs but then won’t tell you what things cost before you get them. This minute clinic model can only increase consumer knowledge and price transparency. I can’t see CVS charging a patient $80 for a Tylenol.

    • TFRX

      Somehow when you say “before Obamacare” part of me wants you to tell the truth and say “because of Obamacare”.

      But then, I have been watching Fox and Friends all week.

      • J__o__h__n

        I was trying to ward off the blame Obamacare for all problems with health care crowd.

    • HonestDebate1

      I think a big problem with the dynamics of health care is people have become completely disconnected with the cost. If they pay nothing but a deductible then it’s easy to disregard the fact that someone else is paying the difference. In that sense I agree with you. I think it’s outrageous if you can’t find out the cost of an office visit. On the other hand they themselves may not know. It has gotten very convoluted and bureaucratic.

  • creaker

    People need to know they are in charge of their own care when they use resources other than their doctor. These are kind of like going to Autozone instead of your car dealer.

    That said it can save a lot money.

  • creaker

    If this really takes off, doctors may have to change their pricing models – if all the bread and butter stuff leaves their offices, more and more of their compensation will have to be made up on visits, which could get much more expensive – or they’ll just be much harder to find.

  • Stephen706

    The other problem is NPs and PAs, mid-level providers, are not intended to be independent uncollaborative care providers. How will the retailers solve this? they won’t.

    • parentisfrustrated

      Many states have regulations that allow NPs to set up independent practice for the express reason of having them fill the need. Many are trained in primary care and multiple studies show they provide exemplary primary care. Retail won’t solve the problem because it is not based on prevention but is based on financial gain. This has nothing to do with who staffs it.
      PS- I am not a “mid-level provider” (insulting term). I am a provider. I have my own panel of patients in a Primary Care practice. Many of these patients have seen me for >10 yrs without ever seeing the Physician. When I changed to a new practice many of my patients sought me out and followed me despite my not telling them where I was moving to (I did not feel that would be ethical to do so while still working for the old practice). That is continuity of care!

      • hennorama

        parentisfrustrated — congrats. That no doubt reflects well on your skills and “exam tableside manner.”

        “If you like your Nurse Practioner, you can keep your Nurse Practioner.”

        • brettearle

          Thanks for reading that comment, above.

          I actually think it has, theoretically, life-saving implications, as does the MDs comment, even more.

          • hennorama

            brettearle — YW, of course.

            Given that the practice of medicine is both art and science, and it involves fallible and vain humans, there will always be errors made, errors ignored and denied, and differences of opinions.

            This is also true with the practice of law.

            In both fields, no one individual can know all the information. However, it is helpful to have ongoing feedback regarding one’s performance, so that it can be improved over time.

            This feedback seems more frequent and routinized in the medical profession compared to the legal profession. As time goes on, both systems and individuals will improve their performance based on the routine analysis of results.

            This can only be a good thing.

            One question: did you give the first attorney any feedback?

          • brettearle

            Check Graham Bell, for other things.

            As far as your question is concerned, as the Russian Ambassador said to Stevenson at the UN, back then,

            “You will have your answer in due time.”

          • brettearle

            Can’t give him any.

            We’re too politically and practically embroiled with him…..it’d alienate him.

            That’s the ironic nub of it…

            We’re between Iraq and a Hard Place

          • hennorama

            brettearle — understood, completely.

            One holds one’s tongue until business is concluded, then …

            It’s unfortunate when one feels such a need to hold back, else the service provider take offense, and perhaps purposely muck up the works.

            Best of luck with that.

          • brettearle

            He’s done some things….

            It’s a lesson in the radical twists and turns of professional-client relationship.

            And, at some point, you’ll likely hear about something rather incredible…..that transpired

            He’s also, if you can believe it, a semi-pro hockey coach.

            To boot,, he’s a micromanager. Big Time.

          • hennorama
      • Stephen706

        Yes that is continuity of care! And yes you are good–glad you take excellent care of your patients.

        PS–BUT you are not a physician. Mid-level is not an insulting term.

        • parentisfrustrated

          I consider it insulting. Considering it is a term people have decided to label me with I can have that opinion. My patients consider me their provider. I do not provide mid-level care. I provide appropriate care. If I need a consult I get one but that occurs at the most 1-2 times a week.

          • Stephen706

            My apologies… That is awesome and cool! Again my apologies… I will work on striking it from my lexicon.

            Trust me, I would love to be in practice with you as your style, care, compassion and dedication are OUTSTANDING and the example set that we need. Too many patients and not enough providers to go around…

      • HonestDebate1

        It sounds like your patients are lucky to have you but I am curious. There is a movement for nurses to become doctors after so many years of experience, Have you heard of that and do you support it?

        • parentisfrustrated

          Not at all. They do not consider any of your experience when you enter school. I don’t know anyone personally who has taken that path

          • HonestDebate1

            Thankfully, I don’t think the path yet exists but there is noise being made and a looming doctor shortage on the horizon. I can’t imagine it happening though.

      • brettearle

        In the last couple of days, I had an attorney, with Probate expertise, answer a question, related to Property Law, that he thought he knew the answer to.

        I checked with another Attorney–with an even more focused expertise, on Property Law– and he gave me an exact opposite answer, from what I received, with the first attorney.

        This has also happened, in my experience, with Medicine a number of times.

        Why wouldn’t this go on, not only between MDs, but between NPs and MDs–but perhaps not with you and your practice and your expertise?

        I do not see that I am asking a question that should be taken personally or defensively–by any practitioner, by you or anyone else.

        I am making my comment, based on my experience.

        My question, it seems to me, is a legitimate question in the interests of patient protection.

        Had I taken some of the advice that a variety of MDs have given me, over the years, I could have been in more trouble.

        I would feel the same way about any other kind of practitioner.

        And, too, I think that it is Patient Beware–if a Patient is not appropriately cautious.

        • parentisfrustrated

          I have no idea what the question is. Can you clarify?

          • brettearle

            The MD, above–that I posed the same question to–seemed to have understood my question, to some degree.

  • Don Kollisch

    Snce Primary Care is such a small part of the health care dollar, this movement won’t have a significant impact on overall healthcare costs. The immediate debate is about convenience vs continuity. There is very little evidence re: quality. My question is whether ACO’s will use Urgent Care Centers as a cheap and easy way of building a primary care base?

  • TFRX

    So, when will Texas (and their ilk) start regulating the hell out of these clinics because of no good medical reason whatsoever?

    • jefe68

      No health care for the working classes.
      Seems like Oklahoma is a competition with Texas on who can write the most draconian laws.

      • TFRX

        (If someone like you missed my pivot on minint-clinics v. womens’ health clinics and TRAP laws then I really did not write my original post as well as I thought.)

  • Dab200

    These mini-clinics are a bit crazy to me but it’s all the result of badly working health system. You make an appointment with your doctor and you still have to wait and often a long time. You need an appointment with a specialist – it’s going to be 3-6 month away with even a longer wait once you get there. Add to it the fact that it’s not often that you are seen by the specialist but more often you are just seen by some training assisting staff so what’s the point? BTW the bill will be for the specialist visit. In such surroundings mini clinics won’t make much negative difference or any difference but shorten the wait time.

  • parentisfrustrated

    Commenting on the tele-doc scenario- I am an NP- saw a patient the other day who used a service like this. Had an illness for less than 3 days. Was diagnosed with sinusitis and treated with an antibiotic. (guidelines state should be febrile and have sx for more than 10 d before considered a bacterial infection). Came to me 3 days later, not better. Of course not. The patient had a viral infection. The Doc had prescribed medication without meeting any guidelines for the diagnosis. The patient was not asked if she was febrile, had sx for 3 days and wasn’t particularly sick. For 38 $ she got an antibiotic for a virus. I took the Dr name on prescription and reported the incident.

    • hennorama

      parentisfrustrated — thank you for this direct experience story. Do you have any anecdotes about positive experiences with “the tele-doc scenario”?

      • parentisfrustrated

        Not yet. So far it seems to be about making the patient happy. Unfortunately that means they want a quick fix and the antibiotic means a ‘happy’ patient until it doesn’t work. This is a nightmare for those of us who hold the line and do not prescribe inappropriately. It is way more time consuming to say no than to just give the med. Having to then deal with the patient telling you, “Well, when I called X they gave me an antibx” implying that I should know they are different and NEEEEED the antibiotic. .

        • J__o__h__n

          Doctors have been over-prescribing these too for years.

        • hennorama

          parentisfrustrated — thank you for your response, and for sharing your experiences.

          One imagines similar battles with requests for “TV-prescribed” medications as well.

          Good on ya.

  • Markus6

    Missed the show. Too bad, sounds like a good one.

    I heard of a study, years ago and can’t remember the source, so feel free to be skeptical (I am). It stated that using a computer for diagnosing problems and prescribing treatment was significantly better than having a doc do this. I think they looked at records of symptoms, the prescribed treatments, their outcomes and compared them to what a computer program would prescribe. It was arguing that there were just too many variables and too much new information for a doc to stay up on. It also argued that docs too often jumped to conclusions based on a few questions.

    I could see a situation, where these minute clinics supplemented by such tools would be very effective for a high percentage of cases. Those the combination couldn’t handle would go to specialists. Overtime, as this combination got smarter, fewer would be referred outside.

    Leaving the validity of the study aside, I could see these minute clinics, as well as other modes, being very effective. And similar to search algorithms that learn what we want (ok, not the best comparison), overtime these would get better if there were a feedback loop.

    • hennorama

      Markus6 — you’re probably referring to IBM’s Watson.

      See:
      http://www.research.ibm.com/cognitive-computing/watson/watsonpaths.shtml#fbid=-2RGA7xY244

      As to the remainder of your post, here’s what CVS says, directed toward potential “Clinic Practitioners” (in part):

      Our proprietary EMR system, for example, was created specifically for our practice model, and provides our clinic practitioners with:

      evidence-based clinical guidelines — built into the system — that can help you make better clinical judgments

      the latest clinical information, delivered in real-time, so you can have the most up-to-date protocols and treatment recommendations at your fingertips

      an automated chart review process to ensure continuous improvement

      e-prescribe functions that allow you to send prescription information to the patient’s pharmacy of choice, and automatically records it in the patients’ records, promoting greater drug safety

      See:
      http://www.minuteclinic.com/careers/clinicpractitioners/yourrole/emr/

      • Connie Lentz

        I note the term “proprietary EMR system”. One huge problem is that these systems do NOT communicate or coordinate with each other. In my clinic practice which I recently left, we had separate EMRs for the medical records, the lab reports and the xray reports. The Xray reports were printed out and scanned into the medical record – ridiculous. In theory EMRs are fine, but compatibility of systems is a major impediment, and in my opinion would not be solved unless there was one unifying system.
        I have found the EMR most useful for prescribing. It can find interactions that could be harmful. However, ALL of a patients meds, including OTCs with correct dosages need to be entered accurately. This can be a problem, especially when adjusting dosages. It is easy to enter the wrong information into the computer. Who has never made a typo, or clicked on the wrong link on a computer?
        As part of the stimulus package, providers were offered up to $10,000 each to install EMRs. So what happened? The companies that make them just jacked up the prices to take advantage of the stimulus money.
        Another issue is HIPPA. While insurers can get all of the information they want, patients and their providers cannot. Proprietary EMR software compounds the problem.
        In my opinion, EMRs as they currently exist are not the solution to the problems for which they have been promoted for the above reasons.
        Decision support software can be useful but it can be just as wrong as a human being.

        • hennorama

          Dr. Lentz — Your valuable input and perspective are appreciated.

          Indeed, the proprietary aspect likely means “doesn’t play well with others.” Similar issues are evident in various goverment information systems, and there are fiefdoms dedicated to preserving the funding of legacy systems. It’s maddening and ridiculous, as you described, and one can compare it to the “stovepiping” of intelligence information with various local, state, and Federal agencies.

          Regarding the various digital options you deal with: as with any tool, the ultimate results are user-dependent. Likewise, neither the tool nor the user is without its limitations.

          Do you think your views and experiences are fairly representative of your colleagues?

          Thank you again for your time and input.

          • Connie Lentz

            I don’t know if I represent most or all of my colleagues but certainly a significant proportion, at least in primary care. If I didn’t say earlier, I am a general internist and have done a variety of things including emergency medicine, hospital and ICU medicine and young adult care with a lot of gynecology and even some pediatrics. I recently retired from a position I held for 25 years in a university setting
            We had an urgent care aea within the clinic that we all rotated through and I could easily follow up patients who needed it. I am taking a breather and considering future options.
            I would take some issue with your comment that the ultimate result {of EMR} is user dependent. With the EMR I was often reduced to a data entry clerk. I found the time I spent looking at the computer screen instead of the patient to diminish the quality of care I was able to give. When listening to a patient it is not just the words they say that are important but their facial expressions and posture. I want to look into the their eyes and not at the computer screen. I suspect that the EMR my clinic chose was not the best but other colleagues using different systems that are supposed to be “better” have similar complaints. I think the doctors who can make the best use of EMRs are those who do very specific things, such as dentistry or dermatology. I shudder to think what EMRs will do to mental health should they be used there.
            I’m finding this discussion very useful. Thank you.

          • Kevin Burber

            I am a Pharmacist who works on developing an EMR for a large hospital – building Orders and Order Sets and doing a variety of development on several of our systems. I agree wholeheartedly with you…including that it is not user dependent. The thing that I find most frustrating is the lack of vendor accountability. As health care providers, perfection or near-perfection is expected of us, but no such expectation exists for those building these systems. It seems that even when we bring up a serious concern, we consistently get a response akin to, “Woopsie…we made a mistake. We will put that on our (long) list of things to fix”?? It is truly exasperating.

            On the bright side, these systems are only in their infancy….expecially when being used to the extent that they are today. Additionally, I have seen how complicated it is to connect all of these things. If you take banking as an example, they send a handful of “segments” (Name, account number, amount of credit, etc). In health care, you have to send literally hundreds of these bits of information and it is not linear – you need to send allergies to the Pharmacy system, Dietary, Radiology, but not to lab, billing, etc. You need to send billing information to 4 systems that send charge files on their own and for the others, the charge files are sent to the financial system that then sends the bill on their behalf.

            I do wish there was one system that could do it all…for all of us. It would have streamlined the entire process and would have provided the capability for systems to link in a way we simply can’t…yet.

            Good luck.

          • hennorama

            Dr. Lentz — thank you again for your response, and you’re welcome for any value you may have garnered from this discussion.

            My comment regarding “the various digital options you deal with” was intended as a reply to your observation that “It is easy to enter the wrong information.” I would imagine, for example, that one would get a different result if one entered a daily dose of 5 mg alprazolam rather than 0.5.

            Reflecting on your overall comments, it seems that the EMR helps with the science aspect of the practice of medicine, and detracts somewhat from the art. It can routinize the search for the exotic and uncommon possibilities, which supplements the practitioner’s brainpower and experience, but on the downside, it divides your attention between your patient and your tool.

            Perhaps at some point in the future, voice input would help to overcome that objection.

            Thank you again for you ongoing attention and engagement.

    • brettearle

      I’m wondering whether Family History can be programmed.

      Seems to me this could be one variable that could be of hidden importance.

      • Markus6

        You’re right, family history would be a huge issue. Given the requirement to have electronic medical records, seems possible. Very difficult given all the possible linkages, but doesn’t seem impossible.

        • HonestDebate1

          Yikes! I think family history is crucial to help doctors and patients determine best options and what tests should be given. For instance, many women with a family history of breast cancer are opting for prophylactic mastectomies. That being said, if that information somehow becomes available to the government or worse yet to the public via insurance companies, employers, etc. then it could be a disaster.

      • hennorama

        brettearle — two things electronic systems are very good at are memory and pattern-finding. Working backward from this point would be massively resource (time & $$) intensive, and likely prohibitive, but moving forward, it will be easier and beneficial to analyze individual family health patterns.

        • brettearle

          Stop Dave….Dave Stop….Stop Dave from taking Statins….

          Dave…..I’m afraid….I can’t have you….take them, anymore, Dave….

          Time….for….Omega 3….Dave

          By….the….way….Dave….could you refill my silicon prescription….?

          Reciprocity….Dave

          Now Dave…..

          Daisy, Daisy

  • Nadia

    Is it possible to hear the discussion from this morning?

    • hennorama

      Nadia — I believe they post the audio at about 2 PM Eastern. There are also other stations nationwide that carry OP at different times. You can find them here:

      http://www.wbur.org/syndication?program=onpoint

      • Nadia

        Thanks!

        • hennorama

          Nadia — you’re welcome.

  • brettearle

    I wrote the following comment–a few comments down on this thread, to an NP.

    I thought I’d pose it, here, as well–because I think it has some relevance to your comment.

    [It is both instructive and, to some degree, even unnecessary, to see the context of this comment's first placement, below]

    Thanks…the comment is reprinted here….

    “In the last couple of days, I had an attorney, with Probate expertise, answer a question, related to Property Law, that he thought he knew the answer to.

    I checked with another Attorney–with an even more focused expertise, on Property Law– and he gave me an exact opposite answer, from what I received, with the first attorney.

    This has also happened, in my experience, with Medicine a number of times.

    Why wouldn’t this go on, not only between MDs, but between NPs and MDs–but perhaps not with you and your practice and your expertise?

    I do not see that I am asking a question that should be taken personally or defensively–by any practitioner, by you or anyone else.

    I am making my comment, based on my experience.

    My question, it seems to me, is a legitimate question in the interests of patient protection.

    Had I taken some of the advice that a variety of MDs have given me, over the years, I could have been in more trouble.

    I would feel the same way about any other kind of practitioner.

    And, too, I think that it is Patient Beware–if a Patient is not appropriately cautious.”

    • Connie Lentz

      Patient Beware is an imperative. Despite all the “miracles” of American medicine, many of the things we can do are often dangerous and not always effective. A second, and even a third opinion are always worthwhile.
      I am suspicious of the profit motive in these clinics, as I am suspicious of the profit motive of the pharmaceutical industry. My motto is to never put anything in your body or do anything to your body that profits someone else without careful consideration.
      The point I was trying to make is that experience and collaboration by doctors and mid-level providers are important. Doctors have a minimum of 7 years post college education and training. The least experienced person is the patient, but they are the only accurate witness of their own symptoms. I find that people usually know what is best for them but they can be spectacularly wrong.

  • brettearle

    I think it’s important to underscore MDs resentment to computer technology being part of their decision-making process.

    I’m sure adjustments have been made by a number of MDs, by now.

    But I’m wondering if there still isn’t a great deal of resentment & resistance flying around, among MDs….

    Which, to my mind, in the final analysis, IS deplorable……

  • hennorama

    Dr. Lentz — thank you for sharing your real-world experiences.

    As I asked of another health care provider in a slightly different context, do you have any anecdotes about positive experiences with “a mid-level practitioner, an NP or a PA (physicians assistant) [picking up symptoms, diagnoses, etc., that other providers] missed that were life threatening?

    • Connie Lentz

      I have many positive experiences. In fact, my personal “doctor” is a nurse practitioner. But she practices in a collaborative practice that includes both other NPs and doctors. I find that the best Nurse practitioners were often hospital nurses first and had many years of clinical experience before becoming NPs. My concern with minute clinic type settings is that there is little first-hand consultation. I consult with my MD colleagues all the time. There is a long tradition of more experienced physicians mentoring younger ones and of collaboration. Nobody can know every thing. NPs and PAs can start practicing with much less experience than the minimum of 7 years of post-college training that MDs have.
      About 30 years ago there was a movement in New England where I live for walk-in clinics that were free-standing and opened by physician entrepreneurs, a few of whom made a lot of money. I worked in 2 such centers for other doctors. One went out of business and the other morphed into a conventional practice. I left out of frustration with the episodic care and difficulty following up on patients.
      I worry that the minute clinics are being opened for the potential profit- both in the visits and the supplementary purchases, from tylenol to antibiotics. They can’t help but add to the fragmentation of medical care.

      • hennorama

        Dr. Lentz — thank you again for sharing your real-world experiences, and for your response.

        Indeed those are legitimate concerns.

        There is obvious value in collaboration, and a team approach to care, assuming there is a willing acceptance of information and feedback both up and down the hierarchy.

        To a limited extent, experience can be substituted for and supplemented by interactive electronic guidelines and diagnostic tools, and the pooled resources of large organizations.

        There is also significant value in the automated review and feedback that can be provided using these and other tools. (I referenced the CVS MinuteClinic’s online pitch to potential Clinic Practioners, which describes its EMR system, in other posts on this topic. See the link below.)

        As you wrote, “Nobody can know every thing.”

        Thank you again for your time and your response.

        See:
        http://www.minuteclinic.com/careers/clinicpractitioners/yourrole/emr/

  • Sy2502

    Eye care physicians work from shops that sell glasses and contact lenses. Does anyone see something strange with that? I don’t see much difference really.

  • brettearle

    Pharmacists can easily enhance MD expertise on medications; their contraindications; their side effects to watch for; and drug-drug interactions.

    They may also be, in some cases, privy to new medications that MDs are not.

    My guess is that MDs, all too often, give pharmacists short shrift.

  • civisisus

    The leading retail clinics, like those Tine Turton’s organization represents, provide (mostly un-primary-care-doctored) patients a written summary of each treatment visit AS A MATTER OF COURSE. Standard operating protocol.

    Quick show of hands of those whose “real” primary care doctors do the same thing.

    Yeah. That’s what I thought.

  • hennorama

    Melody Schniepp — thanks for your real world perspective.

    Some of what you describe is the usual conundrum: fast, good, cheap — you only get to pick two.

  • creaker

    Why limit it there? What about bringing back home visits? I’m sure people would pay a good premium to have someone come to their sick child’s bed rather than bundling them up with fever, vomiting or worse and dragging them into a doctor’s office.

  • Gunther

    Given how dysfunctional the American health care system is, anything that may increase competition and empower patients is a step in the right direction. I personally am embarrassed with the fact that the US is such a wealthy country and spends so much for health care and our health outcomes are so poor.

    • ExcellentNews

      Me and my republican buddies are all for low-wage competition – as long as it does not affect the 100 million dollar compensation package of insurance company CEOs, or the bottom line of the trillion-dollar corn-syrup processing industry.

      • Gunther

        CEO pay and corn syrup are not the root problem. The problem is that consumers are not empowered to make the right choices because the pricing signals are not there. How is it possible that it is cheaper to fly to Belgium to get a hip replacement and stay 10 days in a first class hotel than to buy simply buy implant in the US? Answer = Belguim places a cap on what can be charged for the implant and the surgery, which is a fraction of the cost in the US. Why is the price of an appendectomy anywhere from $2,800 to $180,000 in the US? That is the sign of an inefficient, dysfunctional market.

        • ExcellentNews

          But of course they are at the root of the problem!!! For starters, about 1/3 of the cost goes to support the private insurance system. In other words, from each $100 spent by consumers, $33 go to support a function that has nothing to do with health or care. And this money, adding up to hundreds of billion per year, does not go to pay the salaries of the peons working in the call centers and back offices…

          Second, in Belgium – and throughout much of the Western Europe – people tend to be healthier owing to better diet, more physical activity, and less stressful lifestyle. There is less use of expensive treatments for common complications from diabetes and obesity.

          Of course, our healthcare system is far more complex and screwed up than that – but it is not a sign of a dysfunctional market. On the contrary – it is a sign of a fully functioning “free” privatized market. As shown in industries ranging from banking to energy, “free” markets are great for leeching value from consumers and workers into the pockets of executives, owners, and political cronies.

  • Diana C. White

    dear Civisisus – actually, not contraary

  • HonestDebate1

    After hearing the show, I don’t see the downside. As long as people don’t believe they can replace their doctors with Walmart (I have more faith in my fellow man) then it’s all good. If doctors have to compete and end up lowering (or even posting) prices for minor medical treatments, what’s not to like?

    • ExcellentNews

      I’m sure you didn’t see the downside either of invading Iraq or outsourcing unionized American jobs to China…

  • mumtothree

    Whether you think walk-in clinics are good or just good-enough medicine may depend on your attitudes toward single payer health insurance.

    In one European country where I lived in the mid-1980′s, the local pharmacy was often the first stop when you were sick. It was not CVS-like, and for the most part not self-service. You spoke with the pharmacist, who made a quick diagnosis and recommended an over-the-counter treatment. Antibiotics still needed a prescription, which meant a doctor or NP visit, and the pharmacist did not overstep his/her authority or expertise, but would refer you out. Antibiotic overuse was not as much of an issue for that reason. Thus the doctors’ caseloads were often lighter, and they all worked essentially 9-5 jobs. It also kept the overall costs down. Patients didn’t run up a $125 office visit bill to have someone treat flu symptoms.

    • ExcellentNews

      While living there, you might have noticed that people were not obscenely obese, did not drink a gallon of soda a day, and walked when the destination was nearby.

  • ExcellentNews

    After winning the WAR on American Workers, WalMart seems poised to undertake a war on American Doctors. Welcome to our Walmartized medical system – a production chain clinic staffed by underpaid nurses, right next to the soda and chips aisle.

    • Gunther

      American doctors make twice what doctors in other developed countries make. The prevailing wage for doctors is at the top of the wage spectrum. According to the Bureau of Labor Statistics, in Massachusetts where On Point is recorded, the six occupations with the highest salaries are all in the medical profession, all above the salary of CEOs. I wouldn’t cry for physicians’ salaries. http://www.bls.gov/oes/current/oes_ma.htm#00-0000

  • Gunther

    What is the source of your wage statistics about 5x average wage? Not sure what a term like “third world peons” has to do with the US health care system. Where are your statistics regarding salaries of physicians in the US compared with Europe? I don’t see it. GDP PPP is higher in the US, and I don’t see how that is possible, given they account for a higher share of health care spending than they do in Europe. Here is the NY Times article regarding inflated prices in the US, particularly with regard to implant manufacturers who charge substantially more for the same implant in the US: http://www.nytimes.com/2013/08/04/health/for-medical-tourists-simple-math.html?_r=0

  • Gunther
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