This morning, two stories caught my eye. KevinMD is pointing to another article on Grady's plight in Atlanta; another public hospital struggling to survive.
The other story was one of several reports on CVS' MinuteClinics being cleared to operate in Massachusetts: WSJ, David Harlow's Health Blawg, White Coat Notes at the Boston Globe, and Paul Levy at Running a hospital.
So hospitals are dying while corporate money mills with very little value-added are thriving. This evening, I spotted another post, reporting that 6 - 8 storefront, limited-service, retail clinics are going to open per day in 2008, over and above the 1000 already in existence.
There is a greater need in one area, but a greater profit to be had in another. Public hospitals fail while retail clinics grow.
I am a great believer in free markets, but fair markets rarely occur naturally. The current conditions are, in fact the result of regulations that provide perverse market incentives. Half the practice of medicine involves NOT PRESCRIBING MEDICATION!!!!
(Sorry, I'm yelling!)
Now, retail giants like CVS, have succeeded in developing vertically integrated style operations in which they control everything from the distribution channel to the provider's incentive. By most informed people's standard, quality is not defined by the highest possible prescriptions per encounter, but that is the natural incentive when a pharmacy chain controls the providers. Bonuses will be paid and employment decisions will be made according to the provider's ability to generate prescriptions.
And a public health authority voted for this? In Boston, with an incredible network of publicly controlled, not-for-profit community health centers? That makes absolutely no sense and without an adequate explanation of their logic, somebody please look for corruption or corporate threats on the face of it. As David Harlow points out, the diversion of resources will ultimately be damaging to the population's health. People need medical homes, not McDocs and McPA's. Nobody is coming to work for me, given that all I have to offer is a more difficult job and lower remuneration.
We must compete on a level playing field. The question is who is getting the more difficult patients and not being adequately remunerated for it. Who is getting easy encounters and getting the dividend of the prescribing revenue?
I can see 50 healthy people with coughs and colds with a good nurse and someone to answer phones and I can do it in 4 hours. In the same amount of time, I can properly do two complete geriatric assessments. The reimbursement differential per encounter cannot possibly cover the differences in resources, so I can't afford to do them properly. I cannot allow my physicians to do complete assessments and so will encourage them to refer out. MinuteClinics didn't worry about pushing those patients to me because they do not provide the service. Will you, dear reader, require me to have a different moral standard than MinuteClinics?
If retail clinics can push certain patients to me, then I can push those patients to someone else.
Health care facility managers segment their markets and subtly poach the patients that represent the best profit margins. Why hire a nurse practitioner with pain management background? Those patients are time-consuming, frustrating and unprofitable. Rheumatologists sometimes deal with elderly patients and time-consuming multiple medical problems, frequently more than they can compensate for in procedural fees from joint injections. In fact, poor people are generally a good bet to represent losses, sometimes even with Medicaid.
In a city like Atlanta, hospitals and ER's adopt the view that the "county hospital's" job is to take "those" people off their more productive hands. Some public/county hospitals do not recognize that this is the kiss of death.
Public and county hospitals must be in a competitive mood in order to recognize that their existence is threatened. Despite not having lived in Atlanta for three years, I am convinced that a major portion of Grady's trouble stems from the mind-set that "they" will never let Grady go under (meaning the counties and the state would always bail Grady out, no matter how much trouble they got into.)
Being sheltered from competition is part of Grady's problem.
Here, in the Great American Desert, I am in a community with three hospitals; one is county-funded (and trying to expand based on a public appropriation), one is critical-access (therefore subsidized by enhanced Medicare and Medicaid payments) and a stand-alone for-profit. It is only the for-profit that is knocking everyone's socks off. The others are trying to protect or expand their federal or local subsidy, rather than competitively expanding product lines, improving service levels or quality-of-care.
So we have contradictory forces regarding competition. In the case of MinuteClinics, competition harms the public health. In the case of public and county hospitals, the lack of competition is at the root of the problem.
In a free market, public and county hospitals must realize that they have to compete for the same kinds of profitable patients that MinuteClinics is after. But MinuteClinics must not be permitted to get away with such an artificially limited scope of service, by which they effectively block access to complicated patients, leaving the costs for others to bear. And damn the consequences that the rest of us who will have an even greater trouble recruiting competent providers to do the slugging in the trenches where it counts.
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31 comments:
the expansion of minute-clinics will effective super-saturate ERs with elderly patients sick-as-dogs with multiple chronic conditions, and medicaid patients without a regular primary care doctor.
I'm guessing "code blue" will be heard with greater frequency in ER waiting rooms & hallways than in ICUs today.
They'll also be overwriting antibiotics & ultimately worsening the patterns of antibiotic resistance in the community, screwing hospitals & nursing homes even further.
These clinics wouldn't exist without MDs willing to sell out, (oops..I meant supervise) them. Really, the mistake was made years ago when docs decided, for the sake of their own bottom line, that supervising a PA or NP was a good business decision for their practice. The cat is out of the bag, and now you can't control it. A little late to change things now.
Additionally, it would be nice if the qualifications of the "practitioner" were explicitly and clearly displayed at these minuteclinics (years of schooling, training, etc.) so the difference in education and training compared to a physician is transparent for the customer.
You're right, MD's sell out and we know why. They are going to where the money is, reacting to market forces.
Honestly, I think that's OK as long as the market is fair and designed to improve the greater good.
But pharmacies control the majority of retail clinics today and that introduces a perverse incentive.
Of course that could be mitigated by allowing physicians to sell drugs directly to the public, but that is generally frowned upon.
Also don't forget that part of the reason people gravitate to urgent care and retail clinics is the way they are paid according to rates set by central government fiat (i.e. CMS reimbursement rates makes the world go 'round).
Fantastic post. You articulate what I have been trying to say in the doctors lounge for sometime.
It is somewhat analogous to the acne clinic in derm. I could easily see 8 acne patients in an hour or say 3 chronic urticaria patients in that same time. I would be paid the same for 1 acne patient as for 1 urticaria patient. I don't mind the challenge, but if all the easy patients are soaked up by nurses and PA clinics, that leaves all the difficult patients for me.
Oh you poor, poor doctors! Just take a drive around the block in your 700 series and you'll feel better...I promise. Each of these posts demonstrate the fact that physicians are a bunch of babies with no business sense. Toughen up and join the ranks of the rest of us that actually work for a living!
What's a 700 series?
Sorry, my wife says she thinks it's a car. I presume it must be a luxury model.
I really wouldn't know. I'm trying to fix the bumper that just fell off my '01 Xterra.
I think it's my referring cardiologist who drives a luxury car. Unlike you, I don't begrudge it to him.
Having said that, if we did toughen up, I would advise my colleagues to screw every patient possible. But that's just not our game, so everyone else gets to screw us.
That's the point. If it were a level playing field and we were tough business types, we would cream you.
Fortunately we do better at ethics than most of corporate America.
You really don't get it, do you? The whole appeal of "limited service clinics" is that they offer limited, focused services. Do you think that its appropriate to evaluate and treat everything that one sees in a traditional setting in your local pharmacy clinic??
If you took some time to do actual research than rant on blogs, you'd find that clinic practitioners DON'T overprescribe antibiotics (http://www.marykatescott.com/pdf/HealthCareInTheExpressLaneRetailClinics2007.pdf).
The most vocal opponents of retail health are physicians worried about their wallets. They will attack the model, the nurse practitioners, the pharmacies, the insurance companies, etc. They are worried about losing the "cream" - the easy 5 minute patient who only has a sore throat - as so many physicians have eloquently put it. All you will hear is talk about reimbursement and dollars. The problem with these tactics is that the public sees right through this and makes you look that much more greedy and close-minded.
Let's just put it this way, if I call your office and say I'm a new patient, have no insurance and need to be seen today for my ear ache, will I even get a response from your secretary as she laughs and hangs up the phone on me?
The clinics are serving a need becuase the system is beyond broken and patients are suffering in the process.
Nurse Practitioner,
I have been impressed with my NP's intelligence, perspicacity and above-all their ability to read, properties apparently not universal amongst nurses, if I were to judge from your comment.
I do get it, but you fire too quickly and so mis-fire.
Let me be blunt: I don't give a dang about someone with an earache when I have 6,000 patients with chronic diseases and no one to see them in a timely fashion.
The ears will get better on their own. My diabetics will get sicker. Where do I put my front line practitioners, if I want to maximize population impact?
Did I say anything about NP's versus docs? More than half of our chronic disease management is done by NP's or PA's. Who cares about the designation, I only care about what is happening to our primary care providers. If we divert them to wasteful, low-value cough and cold treatments, they are not doing something else which may create more value. A nurse practitioner out of high-value activities is just as bad as physicians doing the same. Moreover I don't propose completely eliminating retail clinics; but I do think it should be considerably more difficult than was done in what is arguably our most progressive state. Don't forget that the cream is exactly what allows our physicians to stay in business. Take it away and more will close up shop, making it all the more difficult to get an appointment anywhere.
The burden of proof is on the one advocating the change, not on those advocating a status quo. Your reference indicates that research is progressing, but does not provide the parameters, especially when it comes to pharmacy-controlled retail clinics.
The jury is still out, but this has made my job just a little more difficult. But then, you don't seem to know what my job is, do you?
My my..have I struck a chord Zagreus Ammon?
First off, I love your reference to "your" nurse practitioners - I bet they are so proud to be "yours."
Again, if people took time to research this young model, they would know that patients without PCP's are always encouraged to establish a relationship with one and those having PCP's should follow up with them. The clinics support the "medical home" concept. Thus, they are not driving folks away from PCP's, they are encouraging them to HAVE one. (maybe I should spell this one out - physicians benefit from getting new patients. However it appears that you don't want any new patients from your ill-informed comments).
Please tell me why I need to know what your job is and why I should care that it is now "a little more difficult"??
The value of this exchange is in inverse proportion to the size of the chip on your shoulder.
I am hiring ARNP's, PA's, FP's, IM, Peds and OB/GYN.
Leave a note with contact info and I'll send you an e-mail...
Interesting post and even more interesting comments.
As a consumer, I welcome retail clinics for they provide convenience and from the reports I have read, certainly adequate care. It is unfortunate that many physicians and their lobbying group the AMA are fighting this tooth and nail and as in the case of Massachusetts, even the Mayor of Boston has joined the AMA in their fight.
Reality is though that the number of uninsured is only increasing, access to primary care physicians is difficult, wait times in ER has seen a dramatic jump (today's Health Affairs journal), and the list goes on.
Simply put, the healthcare system we have today is broken and we will need to be more creative in finding new ways and modalities to deliver care as the problem will only get worse with this big baby boomer bulge that is hitting retirement coupled with an epidemic on obesity.
The challenge I see that we really need to wrap our collective minds around is how to deliver continuity of care and insure that accurate health records are readily available. Such new technologies as Personal Health Records (PHRs) may be a solution but they are very immature today. More on PHRs and other topics at www.chilmarkresearch.com
you can e-mail me at SteveFNP@aol.com
I couldn't disagree with you more.
You're assuming that these clinics are going to be staffed with providers that have limited ethics or morals.
Do you really think that these providers wouldn't do whatever is in the patient's best interest?
You're also assuming that the number of extremely ill patients will change as a result of these clinics taking business (patients) away.
I believe these clinics are a great idea. However, it remains to be seen if they can be profitable over the long haul.
Forgive me Mike, I never said anything of the kind and the assumptions are patently wrong.
I am saying there is a limited amount of resources and they are being misused, misapplied and mal-distributed.
Keep reading and maybe it'll make sense.
This posting is humiliating and just tells me that MD who wrote this has no idea about retail clinics and how they run. Where did you get the idea that providers will be reimburst as per number of prescriptions they write? This assunption is simply stupid. Why would CVS wanted to share profits with providers? Furthermore, retail clinics do not hit PCP's as much as they hit ER's. Your fast-track ED patients are being taking away, not your regular reliable patients. EDs get hit for the right reasons: long waits and poor quality of service. If your practice would be trully patient and provider freindly, you would not suffer at all. That means hiring more providers and extending your hours of operation, so you would remain compatible. You might loose some money at first, but you will gain in the long run. Also, as much as retail clinics are spreading, I do not think they are here to stay. For them to make profit, they have to see over 40 patients daily, which is not a reality, unless the area where they are is very populated.
I know I have to be careful clearly articulating my argument, but I do not understand where you get your information. You protest against things which I have not said and indicate that you did not read or digest my comments. I stand by the content of my post. I am amazed by your inability to read.
"ability to read, properties apparently not universal amongst nurses, if I were to judge from your comment."
"Keep reading and maybe it'll make sense."
"You protest against things which I have not said and indicate that you did not read or digest my comments. . . . I am amazed by your inability to read."
OK, I think I get it.
If you have not commented on some facet of retail clinics, then you don't want anyone else commenting on that facet. Also, people who disagree with what you do say must not have read you correctly or, (in your words), demonstrate "inability".
And physicians sometimes wonder why many people think they are arrogant. Why, even I have wondered that on occasion. But surely the answer lies in my "inabilities". My bad.
Stella Baskomb
So much for that e-mail huh, zagreus?
Actually Steve, I'm looking for people who won't make my life more difficult. Our urgent care is always well staffed, but it is harder getting family practice covered.
Oops, something else, you didn't know. We run an urgent care track.
Stella: I'm sorry. You will have to try again. In English this time, but I can do French, Spanish and Greek too. Just let me know what language you are going to be incoherent in first.
BTW, I have searched across many blogs. You do appear to misinterpret and misrepresenting other people's words.
Please address my concern that pharmacy clinics divert precious resources away from areas that can have a greater population health impact. My facility (like other subsidized environments) have difficulty recruiting primary care practitioners to deal with sick people because they are going to "easier" environments, like pharmacy clinics, which skim healthy patients with minor problems, a source of margin with which we could improve the care of the chronically ill.
Moreover this exposes practitioners to the subtle influences and incentives of being employed by a pharmacy.
That is just too bad for you, isn't it? You want your providers to see 60 patients a day, but pay them for 15 with impossible 5-6 days a week schedule. Sorry, no dice. By the way you did mention in your original blog that providers will be reimbursed as per number of prescriptions written. Dear PMD, you need to get a grip on reality, no one in their right mind is going to work for you, if they can choose Retail clinic. Although, I do not believe that retail clinic will survive, I do not think you should capitalize on sickness either.
No I said they would be incentivized according to the number of prescriptions they wrote.
No, I expect 20 patients a day, with an appropriate case mix for scope and interests.And we pay overtime for more than 40 hour work weeks (midlevels only).
Capitalizing on sickness? Are you sure you work in health care? These are the only professions in the world which are dedicated (theoretically) to their own end. In the absence of sickness and injury, there would no need for health care. But we are not talking about sickness are we? We are talking about convenience. Quick, convenient care carries a cost, not the least of which is a maldistribution of important resources from where they are truly needed. In the name of what? The absolute worst side of medical consumerism: I want my cold treated now on my schedule and I don't give a damn what it costs to the rest of society.
Un-American, I say. Inhuman and short-sighted.
We are a long way from oblivion, I agree, but don't tell me you didn't take a couple of steps in that direction.
Who put you in charge? Who says that a dying cancer patient has more rights and needs than the kid with ear infection? And by the way: yes, I want my cold treated on my terms, and not a week or 2 later when you will grant me your presious 3 min. Why don't you look around the Net what consumers are saying about these clinic. Maybe this will open your eyes finally.
I am a nurse practictioner and I hate MDs. I want to own my own clinic someday and hire all MDs to work like a slave for me.
Without me working for her there is no MD. I go to school too you know.
Thank you for your valuable input. I should note that at this late stage, I am still looking for FP's but cannot get my hands on enough CV's. I have filled all but one of my mid-level positions. They are great, with strong clinical skills, always asking questions (which boosts everyone's confidence that they work within the limits of their skills) and a great attitude regarding their community mission of improving the public health.
I'm gratified that they are also making the effort to see add-ons (established patients with minor problems) who would otherwise go to external facilities like ER or urgent care.
We're not there yet, but we are moving in the right direction.
Hello, just stumbled on to this blog. Funny enough, I started the retail clinic movement with my patient in 1998 (MinuteClinic originally Quickmedx). Our intent was never to replace family doctors, I am one myself, but rather to provide a service that was lacking in the Twin Cities area of Minneapolis/St. Paul. That was easy access to immediate, walk in care for a limited scope of practice. While you say you could see 40 patients in a half day with colds, etc, I certainly don't see my colleagues here doing the same, in fact I doubt that there are any doctors who see that volume of patients. Even in my rural practice days, I never saw more than 45 people in a day! Now that the hyperbole is out of the way, the fact is that patients like this, the scope is limited, the practice protocols are based on national guidelines with a hint of medical experience (mine from 20 years of practice). The arguments, such as they are, come off as self-serving and are clearly more about economics than about patient welfare. If doctors saw these patients when they wanted to be seen, then there would be no need for MinuteClinics. I would rather these patients be seen by physicians, they just weren't seeing them.
I love how a doctor who is trained to the extent as you all are would quibble over who sees the lowest acuity of patients. You don't see this behavior in the ER where Mid-level Providers see the fast-track patients to leave the more critical patients to the doctors in most cases, not that Mid-levels don't see their share of trauma, CVAs, MIs, etc.
As put to me by a Physician colleague who deemed me "the devil" for developing a plan for a retail clinic, why should he get stuck with the diabetic patient whilst the providers who work for me see the "easy money, five minute catch-up patients"? I think that pretty much sums it up. Jealousy exists because someone built a better mousetrap that serves its clientele more affordably and efficiently.
Which ever blogger wrote that antiobiotic prescriptions will rise and of course cause adverse affects needs to perform a little peer review within their own clinic and see that the most prolific anti-viral remedy being prescribed by every walk of practitioner out there is still a Z-pack. This trend has been going on long before the advent of NPs and PAs.
All this debate is for nothing when you think about it. Sooner or later the government will step in and try to save the ailing healthcare system by socializing it and eliminating competition. I believe the retail clinic will be the last bastion for people to get quality care because business will always tout customer service, which is completely lacking in todays hospitals and clinics. If you treated patients like they had a choice, which is what most businesses do, you'd be more competitive and would have to worry less about your own inevitable failure. Enough Said!
P.S. I'll finish my business plan now! God Bless.
I am a PA and still wondering how PAs are working in these clinics. We have never declared autonomy like the NPs. We need a supervising MD at all times. The PA profession does not want to replace anyone. We enjoy our team model. As the PAs have warned MDs many years ago, nurses would eventually do this. They have taken over anesthesia already. The MDs dont challenge it or correct it so let them deal with it. The PAs saw it coming a long time ago.
The rapid growth of retail clinics is a result of the need for accessible, low-cost basic care provided in an environment where one is treated as a person. This demand is simply the result of a very defective and unfair health care delivery system.
I am doing a story on this subject for a college course, I was wondering if you could contact me for permission on quoting your blog in my story. Thanks!
Erica
masseye1@nku.edu
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