Pointy Stick Prodding For Quality Health Care Access: The Case For Retail Pharmacy Clinics
Posted May 26 2012 10:01pm
Posted on | May 24, 2012 |
This past week, I heard my effort to offer “constructive insights” on a Board described by a fellow member as being jabbed with a pointy stick. Geeze, I thought I had mellowed!
All I said was that retail pharmacy clinics deliver a good product, that “virtual minute clinics” as extension arms of the retail based sites might come to your home in the future, that home care for older chronically ill patients could easily be mixed with well-care like sports physicals or strep cultures for grandchildren at home, that home health care companies should consider themselves to be a “comprehensive virtual clinical practice” not a pay for hire service, and that the competition (doctors’ offices and hospitals) provided uneven service if you were able to get an appointment for standard care issues.
Regardless of my stylistic issues, I felt somewhat vindicated this week when two of my contemporaries with decidely “un-pointy” dispositions, Christine Cassel from the American Board of Internal Medicine and Thomas Bodenheimer of UCSF penned articles on the same topic that got me in trouble in JAMA(1) and the New England Journal of Medicine(2) respectively.
Dr. Bodenheimer opined on how to improve access to primary care, while Dr. Cassel reflected on the expanded use of retail clinics in pharmacy settings to address the need for improved access to care.
Dr. Bodenheimer and his colleague, Amireh Ghorob, spend most of their time defining the problem. They note current wait times in Massachusetts for a primary care appointment are 36 days for family medicine and 48 days for internal medicine. In their words, “The reason for the access problem is an imbalance between demand for care and capacity to provide care…. One answer is for physicians to share care with an empowered health care team….In most primary care practices, non-clinician team members – registered nurses(RN’s), medical assistants, health educators, and others – are not empowered to share the care.”(2)
No sharp stick here, just a gentle reminder that many physicians are asleep at the “changing world” wheel. (Note however the implied inclusion of nurse practitioners and physicians assistants as clinicians- not mentioned above. Is this the new status quo?)
On the final page, the authors prod a bit deeper. “Some practices empower RN’s or pharmacists to provide all care…for certain patients with uncomplicated hypertension, diabetes, or hyperlipidemia, thereby adding substantial capacity without new demands on clinicians’ time…The most significant barrier is the discomfort that many physicians feel about giving up decisions regarding preventive and chronic care, which, though seemingly routine, are often complicated by patients’ various coexistent conditions, preferences and goals.” And if physicians took insult, they could find comfort in the final paragraph, “Creating teams to share the care is not an end in itself. The purpose of this practice change is to address the national demand-capacity imbalance while enhancing quality and reducing clinician stress and burnout.”(2)
Dr. Cassel’s comments were considerably more direct beginning with the unapologetic opening line, “Easy access to medical clinics in retail settings is gaining momentum in the United States.”(1) Numbers are joined – 200 retail clinics in 2006 and 1400 in 2012 with an additional thousand on the way.(1,3) What follows is a consumer sensitive analysis touching on three main issues – access, cost and coordination.
On access: “For a working person with a sudden onset of febrile illness, the retail clinic provides a solution: the person can be seen quickly the day the problem arises and most often is able to receive a simple and straightforward evaluation and treatment or recommendation to seek specialist care if indicated.” On cost: “…the visit would be less than $100 and the pricing would be transparent. In contrast, the same minor problem could cost hundreds of dollars for an emergency department visit.” On coordination: There is acknowledgment that retail clinics are not yet linked widely to hospitals or doctors office. But that could change. “The retail clinic phenomenon could be transformative for a vast number of patients in the United States.”(1)
Dr. Cassel goes on to cite studies that show that retail clinics provide “equal quality care and lower costs”, high patient satisfaction scores, with “first-line roles for advanced practice nurses and pharmacists who bring with them unique clinical expertise” and a huge patient pharmacy database. What’s missing? Better information connectivity and flow between retail clinic caregivers and primary care and hospital networks, and expanded ubiquitous presence of retail clinics nationwide.
Dr. Cassel pragmatically concludes, “There are challenges, but this is happening already. The question is whether this phenomenom will grow and flourish in the ways described here or whether 20th-century attitudes about physician and hospital dominance in health care will prevent market based solutions to health care access and cost crises.” Ouch. Guess I’m not the only one with a pointy stick.