It has been clear for some time that physicians don’t have a warm spot in their heart for the dramatically growing number of retail medical clinics — staffed by nurse practitioners and physicians’ assistants, rather than physicians – that are sprouting by the hundreds around the country.  In the most recent expression of this antipathy, the American Medical Association has called for an investigation of clinics that are based in pharmacies and retail stores.  Apparently, its members have” “…complained that the clinics interfere with the traditional practice of medicine. [“Doctors Seek Probe of Pharmacy Clinics” Los Angeles Times June 26, 2007 (www.latimes.com)]

It is perfectly understandable that physicians should object to such clinics on grounds that they take away patients and revenue from physicians, since they certainly do, and since such clinics are far more convenient to use than are traditional physicians, they are fierce competition.  Physicians have also objected on grounds that such clinics may miss important signs and symptoms when seeing patients, and focus solely on whatever problem prompted the visit.  Moreover, clinics lack access to patients’ medical records, and continuity of care suffers.

While these are “legitimate” concerns, they mix so many different rationales that the question is bound to arise as to which is most important to physicians and based on their own financial interests, in contrast to concerns that affect the best interests of patients.  Patients clearly prefer getting medical care as soon as they need it, for example, rather than waiting days or even weeks to be seen.  Some physicians have responded to this understandable patient preference by offering same-day appointments, or next-day at worst.

The continuity issue could be easily addressed if physicians arranged for patient-controlled retail clinic access to their electronic medical records on patients’ past medical history, since few physicians can rely on their own memory of each patient, given that most see two or three thousand patients, at least primary physicians do, so they rely on the same records for continuity.  Because electronic medical records are rare among physicians, this same discontinuity risk is present with most referrals to specialists and care rendered by hospitals, as well.
It is frequently the case that patients seeking care at retail clinics have no personal physician, at least as they define the term, even though there may be physicians who have seen them before.  They more often would have gone to an emergency room, or an urgent care clinic run by a physician, where the same discontinuity would be present anyway, in most cases where they lack a personal physician.  And while urgent-care physician clinics offer a wider range of services, they also cost more, and run equal risks because of not knowing patients’ histories.

One area in which some retail clinics deserve to be preferred over most physicians may be their relative emphasis on prevention and proactive care, in contrast to sickness care.  As consumers’ share of the sickness care burden increases, more patients are looking for ways to protect or improve their health, and to manage their chronic conditions.  But physicians can usually not afford to deliver the most important proactive interventions, which require time and interaction that falls into the category of “cognitive services”, and are not even billable to insurance.

Because retail clinics often bill patients directly, and are used to collecting cash or credit at time of service, they can afford to deliver a wide range of preventive and proactive services, that physicians rarely offer, given the lack of insurance payment for them.  The RediClinic chain, for example, begun in Texas but spreading, offers two distinct kinds of care: “Get Well” services aimed at diagnosing and treating simple medical problems, and “Stay Well” services aimed at protecting and improving patients’ health.  They charge affordable rates for both.

The only physicians that come to mind that are equally in the Get Well and Stay Well businesses are “retainer” practices such as the 150 or so MDVIP practices already operating in 16 states.  These offer proactive personal health planning and cooperative action to all their patients.  And evidence strongly indicate that such patients require dramatically less, in most cases, only half as much or less hospital and ER sickness care than do patients in traditional primary practices. (www.mdvip.com/newcorpwebsite/valueinprevention/healthcarestatistics.aspx)

One concern that the AMA expressed could be strictly a patient issue, namely whether retail clinics that are located in pharmacies or retail stores that include pharmacies “steer” patients to those sources of prescription drugs, vs. let patients make up their own minds.  Realistically, such “hosts”, and occasionally owners of the clinics probably need not do any more than be in the same place as patients are when needing such drugs to enjoy beneficial market effects.

A spokesman for the Walgreen Co., when asked to comment on the AMA call for a probe, said that clinic customers are not steered to its clinics when getting care at those clinics located at its stores.  The AMA did not cite any evidence of such steering, though it would be a legitimate concern if it were practiced.  The only “steering” that I am personally aware of is that by employers and insurers who have suggested to employees and their dependents that they might prefer going to retail clinics, and even offer to waive the usual physician visit co-payment if they do.  That merely reflects the fact that going to retail clinics is usually in patients’ financial interests anyway.

While I am by no means a follower of Adam Smith who believes that the “free market” will take care of everything, it would seem that physicians might better look for other options beside condemning retail clinics.  They could easily work on developing both record access and referral arrangements with them, as many have.  After all, physicians could comfortably refer their own patients to retail clinics for prevention and proactive services, and get referrals of patients needing more advanced care in return.

And physicians could certainly refer their patients to such clinics, once record-sharing is arranged, for evening and week-end needs, for which most physicians lack an acceptable source as far as patients are concerned.  In any case, it would be nice to see physicians working to embrace and improve the operations of retail clinics and the benefits that patients gain thereby, rather than confusing their own financial interests with the interests of their patients.