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Competition or Continuity in Medical Care?

by Scott MacStravic

In the latest salvo of organized medicine in its war with retail clinics staffed by non-physicians, the American Medical Association has called for a probe of pharmacy-based health clinics, asking both state and federal agencies to investigate possible conflicts of interest involved. Apparently, members of the association felt there is an inherent conflict of interest when pharmacies or superstores that contain pharmacies host clinics whose providers write prescriptions. More people than should may have their prescriptions filled at the host pharmacy.

This is a strange argument, in light of the huge number of physicians’ practices located in “medical buildings” that also host pharmacies, often smaller and higher-priced ones than is the case for those that host health clinics. But it was apparently promoted by alleged reports of clinic operators having financial incentives based on the numbers of prescriptions they write and have filled at host stores. [S. Reinberg “AMA Wants Probe of Pharmacy-Based Health Clinics” WashingtonPost.com June 26, 2007]

Given the medical profession’s advocacy of “evidence-based medicine”, it might be better if the AMA had presented evidence of such conflicts of interest before calling for a national investigation of all such clinics. Given the profit motive that motivates all businesses, and scandals over pharmaceutical firms being swayed by their own interests over those of patients, the potential for abuse is clearly present. But where is the evidence that it is happening, as contrasted to “allegations”?

A spokesperson for Walgreens, the large pharmacy chain that hosts Take Care Clinics staffed by nurse practitioners in some of its locations, denied any conflict of interest. The Convenient Care Association, the trade group for such clinics noted that their growth reflects the desire of patients for access to high-quality, affordable care. It expressed surprise that the AMA has taken such a position, since many physicians and hospitals already have working relationships with this new model of care.

The AMA also wants to eliminate the financial advantage that such clinics have by forcing insurers to charge the same co-pay for patients, whether than obtain care in a retail health clinic or a physician’s office. While this is argued as merely a way to “level the playing field”, it may be seen by both patients and payers as simply a way to deprive consumers of a more cost-effective option.

Of course the comparability of retail clinics has already been attacked by some state medical societies, including Texas. Concerns were expressed that nurse practitioners and physicians assistants that staff such clinics could easily miss health problems other than those that prompt visits, and that they present an automatic risk because of the discontinuity of care created by patients’ using retail clinics for some problems, and personal physicians for others.

This continuity disadvantage, as well as much of the risk of failing to recognize other conditions that may be present, could both be significantly reduced if physician practices widely adopted electronic medical records, as have most retail health clinics, for example. Yet less than 20% of physician practices have EMRs, despite their widespread advocacy as valuable, if not essential elements of good medical care and practice operation. [B. Bysinger “Healthcare Crisis: EMR Non-Acceptance in the U.S.” Health Leaders News Features June 27, 2007 (www.healthleadersmedia.com)]

It seems most likely that more could be accomplished — for the good of patients and society as a whole, to say nothing of third-party payors who like the lower costs of retail clinics compared to both physicians’ offices and ERs – if organized medicine tried to work with retail clinics rather than against them. Considering the current battle over competition between physician-owned freestanding ambulatory surgery centers and specialty hospitals, where physicians favor competing with general hospitals over cooperating with them, it is clear that physicians, in general, favor competition over regulation.

It is true, as the old saying goes that “What’s sauce for the goose is sauce for the gander”, then perhaps medicine should accept the inevitability of competing ways to deliver health care, especially given widespread reports of physician shortages. A system in which all providers of health care cooperate to achieve the levels of access, quality, convenience, and outcomes for health care that most agree we should strive for would seem better than one looking more like dogs fighting over a bone.


  B. E. Rodin wrote @ June 29th, 2007 at 5:30 pm

I couldn’t agree more. Let consumers make the decision about how they will seek care. If they are dissatisfied with the services that retail clinics offer, the clinics will not survive in the long term. This introduces healthy competition to a marketplace that is sorely in need of it.

  Anandha Bhairavi K wrote @ July 3rd, 2007 at 9:07 am

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  John Ruffner wrote @ July 6th, 2007 at 12:55 pm

I have worked in the healthcare field for over 25 years and spent some time evaluating electronic medical record products. Perhaps the low adoption rate of this technology is driven by problems with the products, a fact you seem to have overlooked. Many business from large hospital based systems (VA, Kaiser) to samll individual MD offices have spent billions of dollars only to walk away from their investments. This was not a function of lack of interest or investment, it was due to functionality complications. This dynamic is well known to those that know anything about that market.

There are a lot of products with all the ‘bells and wistles’ including ‘award winning’ offerings that don’t deliver or have a user base of 2. This is a very imature technology and if you overlay compensation reductions to physicians, why would a rational physician purchase the products. Example, I worked with a fertility group in S. Calif that reviewed patient charts every day with all three MD’s. They could review the chart manually in about 7 minutes. They purchased the latest award winning EMR only to see their review time double. So, much for productivity in a small practice. By the way, when you look at some of these ‘awards’ you will not find much there.

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