Medical Device Daily Washington Editor

ALEXANDRIA, Virginia — On the second day of the Chronic Care Congress held here just outside the nation's capital, a panel discussed a subject of great interest to providers, even if the topic receives little attention on Capitol Hill. The title of the discussion was "Should Retail Clinics Manage Chronic Disease?"

While retail clinics are not new to healthcare, they are once again on the healthcare agenda as costs and patient frustration with access drive attempts to forge a model for care that falls outside the doc-in-a-box concept.

Arguing in favor of retail clinical treatment of chronic diseases was John Bachman, MD, a professor of medicine at the Mayo Clinic (Rochester, Minnesota), and making the contrary case was John Butterly, MD, of the Dartmouth Hitchcock Medical Center (Lebanon, New Hampshire).

Bachman told the audience that he first heard about these clinics three years ago, and referred to a consumer survey by Deloitte & Touche (New York) of 3,200 consumers that indicated "16% have visited a retail clinic."

Bachman said that the rise of retail clinics showed clearly that "we're going from patient-centered care to consumer-directed care," but he also took a moment to play myth-buster.

"Patients like the traditional model [of healthcare]. That's a myth," he said, citing the Deloitte survey. He also asserted that the idea that the vast majority of Americans are not worried about their own health insurance is a myth. "Only 10% are not concerned about their insurance," he said.

"Healthcare is very expensive, not a very good value," Bachman continued, posing the not-entirely hypothetical question: "What if Wal-Mart could deliver value at low cost?" The question "then becomes 'should we use retail clinics to cut costs?'" He reminded the audience that three-fourths of all U.S. healthcare expenditures are for chronic diseases, but while one in four Americans are said to have only one chronic disease, another 25% have more than one.

Bachman mentioned the so-called "Iron Triad" of healthcare, comprised of access, improved quality and cost containment. He also pointed out that interest in primary care as a specialty has fallen way off in recent decades and that physician practices of five or fewer MDs are very unlikely to be wired for healthcare information technology.

However, retail clinics are generally wired.

As we all know, timing is everything and Bachman stated that most patients typically decide to call their doctor at night. "You have to wait as your call is put on hold and you're told to call back. And this is open access care," Bachman quipped.

He said that the patients get to the doctor's office only to find themselves in the paperwork mill yet again, and then "[w]e read magazines and watch the goldfish." The patient typically endures a "66-minute wait for a six-minute visit, and that was just the time in the office." All this to see a doctor who is "probably over-qualified to deal with a lot of things" seen in primary care, Bachman said.

Bachman argued that others, such as nurse practitioners (NPs) are qualified to deal with a lot of things that land in an MD's lap, and that "numerous outcome studies show very good results" for NPs compared to doctors in delivering much of primary care. He said that retail clinics are estimated to number at least 1,100 in the U.S., but said the real number was probably significantly larger.

Bachman said Mayo operates some retail clinics in Minnesota that are accredited by the Joint Commission on the Accreditation of Healthcare Organizations, and that bill most insurances.

In any case, the typical retail clinic could handle chronic-care basics such as eye exams, measures of blood sugars with the HbAc1 assay, and foot care. "How hard would that be to do?" Bachman asked, pointing out that the rates of patient compliance with doctor's recommended check-ups across the U.S. "is pitiful" and calls for greater convenience than is afforded by the typical doctor's practice.

"Do we need an MD to do this basic stuff?" Bachman asked. If the patient is in bad shape, yes, but otherwise, "I'm not so sure." He stated that "what we will now watch is whether they will change healthcare."

Butterly said that retail clinics have a place. "I have no doubt at all that if you have a sore throat or a sprained ankle ... they can do it well," adding that nurse practitioners are "very good" at a lot of things typically handled by MDs.

"The real question here is ... can retail clinics manage chronic care?" He said of clinics operated by Wal-Mart (Bentonville, Arkansas), Target (Minneapolis) and CVS (Woonsocket, Rhode Island) that it is "very hard to find their mission statements," which he said is primarily "to provide returns to their stockholders.

"Hundreds of these clinics have closed down" due to lack of return on investment, Butterly said.

"This really is about access, and we are doing such a poor job of this," he reminded the audience, but nonetheless asserted that "management of chronic disease is a complex problem," and "for a complex problem, there is a simple solution and it's usually wrong."

Butterly asserted that chronic care is "best delivered by primary care providers," who he said possess "a core mission ... a core knowledge base" that is lacking in retail care. "Medicine is a team sport," hence the need for nurse practitioners and physician assistants, but "you just can't do it intermittently," he said.

"In summary, I think the major issue is access," Butterly said, adding, "I think the retail clinic will have difficulty with familiarity" with the patient and family. "The question that is really raised here is why are these clinics popping up? The answer is that we failed. We need to get the message and do a better job."