The “Mall-ification” of Health Care

 by Danielle Ofri
New York Times

Last week I was dashing through O’Hare Airport in Chicago to catch a flight back to New York. Fifty feet before my gate I noticed a stand offering flu shots. I’d been considering getting a coffee before the flight, but maybe I should get a flu shot instead?

            It sure looked tempting. I’d been meaning to get my flu shot at work, but whenever I had a moment the nurse was busy with patients, and whenever she was available I was locked in mortal combat with the electronic medical record system. The pleasant young woman at the airport clinic offered to check my insurance plan to see if it would be covered, and I was about to pull out my insurance card when the paperwork logistics gave me pause.

            Because I’m a doctor and am required to get vaccinated, I’d have to get documentation from the airport kiosk, remember to bring it to my hospital, and figure out how to get it incorporated into my official medical record. And who was this white-coated person anyway, I wondered. Was she a nurse, a pharmacist, an airport employee? Who was certifying this kiosk? Were they storing the vaccine in the proper manner? Did they have equipment available to handle allergic reactions?

            When retail health clinics started springing up in the early 2000s, many thought it was a passing fad. But these clinics have exploded over the last 10 years, and now it seems like every other big box store, supermarket and shopping mall has its own clinic. Apparently airports are now getting in on the action.

            Between 2007 and 2009, the number of visits to retail clinics quadrupled. Almost half the visits were after-hours visits — on evenings and weekends when doctors’ offices are usually closed. Most visits were for minor acute conditions like flu symptoms, ear infections and back pain, or for simple preventative care like vaccinations and sports physicals.

            There are nearly 2,000 retail clinics in the United States. Typically they are staffed with nurse practitioners or physician assistants. For patients, the convenience of easy location, after-hour availability and walk-right-in policies are appealing. It’s hard to argue with this, since traditional doctors’ offices fail miserably on these measures.

`            There’s also an actual price list. When a patient asks me in my office how much her CT scan is going to cost, I can’t even give her a ballpark figure, nor can my finance department. My patient will have no idea what the cost will be, and she certainly can’t comparison shop with any another hospital. But two clicks online and you can see that the hepatitis B vaccine for kids costs $60  at Walgreens but $79 at Target.

            Many physicians worry about the quality of care these clinics provide, and perhaps the competition they pose. Dr. Ateev Mehrotra, an associate professor of medicine at Harvard University, has researched the topic extensively and concludes that for the minor conditions treated by retail clinics, the quality is generally “as good as the care at regular doctors’ offices. Or should I say ‘as poor as’ because these clinics over-prescribe antibiotics as much as doctors do.”  But the patients he interviewed at retail clinics love the convenience, easy access and clear pricing. They also love the standardization. “Just like Starbucks is the same in Seattle and in New York,” he said, “so is CVS’s Minute Clinic.”

            Doctors also express concern about the fragmentation of care — patients getting bits of medical care here and there that aren’t coordinated by a central primary-care physician. “Retail clinics have the potential to disrupt longitudinal doctor-patient relationships and undermine the ‘medical-home’ model of primary care,” says Dr. Dave Chokshi, an assistant professor of medicine at NYU and a colleague of mine at the Bellevue Medical Clinic. For healthy patients, the stakes are not so high. But for patients with multiple chronic illnesses, disruptions in care can be particularly detrimental, he noted in a recent article in the New England Journal of Medicine. This is increasingly a concern as retail clinics begin to venture out from basic medical care to more complex care.

            The American College of Physicians, the professional group that represents internists, recently released a position paper on retail clinics. They recommend that retail clinics stick to low-acuity conditions and act as the occasional backup to traditional medical care, not as a substitute for it. They stress that retail clinics have a responsibility to communicate with patients’ regular doctors. And if patients do not have a doctor, these clinics need to provide a referral to a new doctor as part of proper medical care.

            A number of large health systems have adopted the if-you-can’t-beat-‘em-join-‘em attitude and are partnering with, purchasing or creating retail health clinics. “The benefits of such an arrangement,” Dr. Chokshi observes, “could be extending the medical home into a more convenient setting for patients.” There’s clearly a financial incentive, as the nearly 17 million patients newly insured via the Affordable Care Act represent a tantalizing new market.

            There is one problem, though. “When we make things more convenient,” Dr. Mehrotra notes, “people use them more.” When getting an appointment for a doctor may take a week or more, many patients with bronchitis or the flu or back pain wait it out at home with chicken soup and a heating pad — often getting better on their own. But now, with around-the-corner, around-the-clock access, these patients might zip over to the nearest retail clinic to get an evaluation that they really didn’t need. Even though retail clinics are touted as low-cost alternatives, they run the risk of driving up utilization and overall health care costs.

            In the end, I grabbed a cup of coffee instead of a flu shot on the way to the plane, then got a flu shot back at work, where it was recorded in my medical record. But now I have to get my three kids vaccinated. Organizing a bipartisan vote in Congress has nothing on trying to find a day where the pediatrician can take all three kids at the same time, but that doesn’t conflict with the schedules of three different schools and after-school programs and also doesn’t require a day off from work.

            Unfortunately, New York State does not allow pediatric vaccinations at retail clinics. If they did, I’d be there in a New York minute.   (from the New York Times)