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In the US, a health clinic increasingly may be in the back of a store
American doctors are up in arms about retail based clinics. Hundreds have opened, located in about half of US states. Last week, the American Medical Association House of Delegates beat back a proposal by some worried members to call for a ban on the clinics. They did, however, adopt a resolution asking state and federal authorities to investigate whether these low price, convenient competitors were putting patients at risk.
Most retail clinics are located near the prescription counter inside large grocery stores or pharmacies. They are open long hours seven days a week. They are staffed by nurse practitioners or physician assistants who diagnose and treat common illnesses, give immunisations, do physical examinations, and perform a limited number of procedures.
Unlike in the UK, where some GPs have set up walk-in centres in retail settings, the US clinics are usually not full-service surgeries staffed by doctors. Nor are they owned by doctors or hospitals. Most are owned by one of a dozen for-profit companies with up to 200 clinics each.
As Richard Bohmer pointed out earlier this year (N Eng J Med 2007;356:765-8), the organising principles of these clinics are taken right from the fast food industry: convenient locations, long opening hours, limited menu, low prices, and consistent (if not always the highest) quality. As opposed to sorting by urgency (as an emergency department does) or by body part or system (as doctors do), retail clinics stratify by complexity. Anything that can be done by mid-level practitioners based on well accepted guidelines is in. Anything that involves too much judgment, ongoing chronic care, or serious consequences is referred out.
Patients love them. A recent national poll found that between 80 and 90% of users were satisfied with the quality of care, convenience, and costs of the centres. The leading factors behind patients' selection of a retail health centre over an emergency room or doctor's office in an Arizona poll were (in order) convenient location, walk-in (no appointment) policy, and short waiting time.
One Sunday afternoon, I visited my local Minute Clinic to check it out. I drove five minutes to a large pharmacy in Bethesda, Maryland, parked in the free lot, walked in, and headed to the back of the store. I found the small waiting area empty, with a sign saying that the nurse practitioner was in one of the two examination rooms with a patient. I signed in and sat down.
While I waited, a large flat-screen video display flashed promotional material alternating with the menu of services: common illnesses (ear and eye infections, bladder infections, allergies) $49 (£24; €36) to $59; skin conditions (minor sunburn, poison ivy, athlete's foot) $49; vaccines $30 to $110. The clinic takes cash and credit cards, and accepts most health insurance plans. Thus, you pay either the listed price or (if your insurance is accepted) a smaller co-payment.
After about five minutes, a pleasant middle-aged nurse practitioner came out and greeted me. I asked her to check if my insurance was honoured. It wasn't. I told her I'd think about it, and she turned to the customer (patient?) who had signed in after me, greeted him, and took him into an examination room to determine the appropriateness of his complaint. I tried to overhear what was going on but couldn't. I picked up some literature and left.
These clinics clearly work for people who have an acute, limited problem or need an immunisation or other offered service, as long as they also have the means or insurance to pay for it. Perfect for the recurrent ear infection on Sunday for a child or an assessment of dysuria in the evening. Quick examination, diagnosis, treatment, and the prescription can be filled without moving your car. Or if you're on vacation and develop conjunctivitis or a sinus infection, nothing could be more convenient.
But legitimate clinical questions exist. Where's the medical back-up? What do they do when a true emergency walks in? How do you sort out the simple, minor problem from the serious problem presenting with common symptoms? The clinics answer that they hire certified, experienced nurse practitioners who know what they are doing and when to get help. They follow recognised guidelines in the diagnosis and treatment of the disorders they treat. They triage all patients to make sure that their problem is within scope; if it's not, they refer them to their own doctor or another doctor, with no charge for the visit. All the clinics have telephone backup with a doctor, although sometimes that doctor is in another state. As for emergencies, they really don't see many. Most patients understand what these clinics can do and can't do and triage themselves accordingly.
Economic questions also exist, of course. Are these clinics providing quick, competent, convenient care, relieving busy doctors from having to deal with mild acute illnesses so they can focus on more complex and important problems? Or are they “cream skimming,” taking all the lucrative brief visits by insured patients and leaving the miserable poor to fill up doctors' waiting rooms? The answer depends on who you ask.
Certainly the retail health clinics are a threat. But they are providing a useful service, from which conventional practitioners could learn a thing or two. In that sense they provide additional impetus for medicine to reinvent itself to become more patient focused and responsive.
The clinics provide additional impetus for medicine to reinvent itself to become more patient focused and responsive