Thursday, June 4, 2009

Retail clinics no answer to medically underserved

UPDATE: I unfairly maligned Walgreens' nurse-practitioner for not doing any tests; in subsequent research I learned that my new illness is best diagnosed clinically in its early stages. On the other hand, the dosage of antibiotics she prescribed was too little, as I found out when I phoned my doctor. He told me to take the pills twice as often and twice as long, and graciously phoned in another prescription, so I was spared the price of an office visit. However, he said that if that doesn't clear up the symptoms, I will need to see a specialist.

(AP) — "Walk-in retail clinics in grocery and drugstore chains can help the uninsured find health care, proponents say. But a new study suggests most retail clinics aren't in the poorest neighborhoods.

"Like most businesses, they go where the money is — to more affluent neighborhoods, which already happen to be well-served by other medical resources....

"The study's results suggest financial incentives may be needed to lure the clinics to low-income neighborhoods, said study author Dr. Craig Pollack of the University of Pennsylvania....

"Open late and on weekends, the clinics use nurse practitioners to give shots and treat minor ailments such as sore throats and rashes. Visits typically cost $40 to $75, and prices are posted so consumers know what they're paying. People pay cash or use insurance....

"Industry leaders said retail clinics were designed to offer convenient care, not as the health care system's safety net. But they play a role, industry officials acknowledge. The clinics' own research shows 30 to 40 percent of patients say they don't have a primary care provider, said Tine Hansen-Turton of the Convenient Care Association, a trade group representing most of the clinics...."

Retail clinics like Walgreens' Take Care are quick and convenient. They're open evenings and weekends, and you don't need an appointment. If you don't have insurance, they're somewhat less expensive than a visit to most doctors.

Under our present health-care system, they do have a role. But they're a stop-gap, not a replacement for a primary-care physician. If you catch the flu or sprain your ankle on the weekend, they can save you a trip to the emergency room. But if your flu turns into pneumonia, or the ankle remains weak and needs physical therapy, they won't offer you followup care. For that matter, they can't x-ray your ankle to see if it's actually broken. If you have a chronic condition that needs monitoring, they don't do that, either.

* * *

Recently, I visited a Take Care clinic because of an illness I self-diagnosed ... with help from Dr. Google. Dr. G told me that it's one of those things that can get very bad if left untreated, so I thought I'd better get checked out. I didn't want to go to the Stroger Hospital emergency room, and the retail clinic seemed like the least expensive alternative.

The nurse-practitioner took a short medical history, did a very brief exam, listened to my description of my symptoms, said it looked as if I was right, and prescribed antibiotics. It cost $68.

She did no tests. She had to look up the correct antibiotic in a book. I asked about followup care, and she advised me to see a regular doctor once I'd finished the medication.

If Dr. Google and Take Care's APN are right, the pills will likely help me. If they're wrong, I'll have had — at a minimum — an unnecessary course of antibiotics that will do me no good.

Would my treatment have been different had I gone to the doctor I used to see when I had insurance? Perhaps not. But I bet he'd have ordered a test before writing a scrip, and I'd know for certain whether I had the disease I feared, or something else.

Of course, his price would have been higher, too.

* * *

Even for the limited ailments and injuries they diagnose and treat, retail clinics aren't a substitute for having a regular doctor who knows you and your history. If you rely on on such clinics for your medical care, it's very possible that underlying problems will go on unrecognized. And, as this new study notes, they aren't even convenient for the people who most need health care options.

To me, the existence of these clinics is just another symptom of our spotty, patchwork health-care system. Rather than offer financial incentives to create more for-profit retail health clinics in poor, underserved areas, it makes more sense to set up nonprofit or government-run clinics and offer incentives to doctors to work there.

Why don't we have a medical version of ROTC in the United States? In Australia, government scholarships subsidize the training of medical students who agree to spend six years working in underserved areas once they complete their schooling.

Somehow, it seems typical of the state of America now that our government trains young people to make war, but not health care.


  1. I couldn't agree more. These clinics are a stop gap measure and should not be considered any type of long term solution for someone's health care needs. Still, as a PCP in Chicago, I'm glad they exist, as I do think they relieve some strain on our crowded ER's. -Leslie

  2. I got my flu shot last fall at CVS. The first question they asked was for my insurance card. No different from the drs office except they are unlikely to be able to handle or perhaps even diagnose or notice something important or serious. I don't see the value to the uninsured at all. The argument that these services somehow expand health care is an argument that the poor or uninsured don't deserve real care.

  3. The only value to the uninsured is a somewhat lower cost than doctors' offices and emergency rooms.

  4. These places scare me because the lower cost likely translates into lower skill, higher volume and corporate control over getting patients in and out fast. There is something in the old fashioned medical profession they will never replace. I'm sure there is a medical term for it, but I don't know it. It's that diagnostic look see that doctors do every time a patient comes in for just about anything. For example, my doctor takes a light and looks into my eyes. A lot can be seen by a doctor when he or she looks into the eyes of a patient. Do retail docs or medical assistants do that routinely? Skin cancer can be detected at a regular checkup or even if you come in with the flu, will some people substituting a visit to the doctor with a visit to CVA or Walgreens benefit from an early cancer detection. Skin tone can indicate certain conditions with the kidneys and liver. Is looking for that something on the retail care menu? Will they notice bruising and bother to ask about signs of abuse. Do they have a legal duty to report it like a regular doctor would? The bottom line for me is that it may be cheaper care, but you probably get what you pay for and many people forced to substitute retail care for real care will not get early detection of serious conditions.

  5. Many places in the US offer to forgive student loans for recently graduated docs who work in underserved areas.

    Further, I don't think anyone is really trying to argue that retail clinics are more than a stop-gap measure. For complicated problems, yes, go see your primary physician. For easy things, an NP should be able to manage it at a retail clinic.

    It's true they have shortcoming, but I think the real point is this: For those who can't afford other facilities, isn't basic care better than no care at all?

  6. Abby, how do you know it's a complex problem until you get it diagnosed? The clinics themselves say that many of the people who go there do not have a primary care physician or health insurance.

    Yes, they're better than nothing, and for minor problems far better than the ER, but health-reform obstructionists try to say that EMTALA and retail clinics mean are adequate to treat the ills of the uninsured and that's just wrong.

  7. I manage a retail health clinic and the biggest obstacle is getting patients to understand that we are not primary care providers. Also, they want fast care 10 min or less. I tell my colleagues to spend the necessary time to gather all information to make the safest and appropriate treatment decision.
    Should we be in designated poor areas? Consider what the needs are for most on Medicaid or Medicare...they really should not be treated at a retail health clinic beyond minor services and minor acute illnesses.
    Daily pitfall: they know what they want but have no clue as to what they really need.


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