Not directly about retail clinics, but neat, and about primary care, so….(Click on the map image below to open the “real” interactive map). Cap tip to Medgadget for alerting us to this nifty tool.Tweet
Practically as soon as HHS announced plans to get data on the ease of scheduling appointments with physicians, they have called them off (Administration Halts Survey of Making Doctor Visits, Robert Pear, NY Times, 6/28/11). (Is it quibbling to note that no actual visits were ever going to come of the department’s survey activities?)
Opponents noted there already is considerable reputable evidence on the ease or difficulty of obtaining timely appointments with physicians, and Administration officials could certainly have managed planning and execution of the survey with greater transparency.
On the other hand, the letter from Republican Senator Mark Kirk to HHS Secretary Kathleen Sibelious requesting information on details of the survey plan contain howlers like this one:
…we request details of how this survey would be conducted, how investigators would be punished for misconduct or extortion and how patient/physician confidentiality would be maintained….How will patient and doctor confidentiality be maintained? If your researchers report bad information or use this survey for extortion, bribery or other bad acts, how will they be disciplined?
“Or extortion“? Senator, they’re calling to arrange a doctor’s appointment.
“Bad acts”, indeed; Senator your feigned outrage is leaving teeth marks on the stage props.Tweet
We really really really don’t mean to be “that guy” so frequently who, confronted with the 1,027,391th article about “the complexity of the US health care (non)system”, counters with something like “well, it’s really not that complicated if you look at ___ key defining features which, if appropriately adjusted, would fix ___% of all that ails it”.
We’re not clinicians, we’re businesspersons who have been tasked with grappling with the asystematic (we dislike the overused term “dysfunctional”) nature of American health care for 20something years now. We KNOW there are plenty of things clinical about said system that we are either completely unaware of or that we excessively discount in our contemplations. (And then we read something else by Dr. Nortin Hadler, and we wonder…).
Still, we feel that The ER, 50 Years On, by doctors Arthur L. Kellermann and Ricardo Martinez in the New England Journal of Medicine’s Health and Policy Reform (6/15/11) are 1200+ of the most thoughtful and thought-provoking words you may read about health care’s future that you could read in all of 2011.
We’ll excerpt the thoughtful portions first, which means taking them out of the order in which they appear in the original opinion piece:
The quickest way to assess the strength of a community’s public health, primary care, and hospital systems is to spend a few hours in the emergency department. If public health is under-resourced, you will see more patients with vaccine-preventable illnesses, smoking-related health problems, preventable injuries, and foodborne diseases than you otherwise would. If primary care is fragmented or weak, the ER’s waiting room will be full of patients with problems that should have been prevented or treated by primary care providers. If the hospital’s administration is not adept at managing the flow of patients, the ER’s exam rooms, resuscitation bays, and hallways will be packed with ill and injured patients, many of whom were stabilized and admitted hours earlier but now have nowhere to go.
In essence, the authors modestly propose that the ER is a pragmatic point of entry for evaluating health systems, and appropriate reforms of same. We are quite inclined to agree.
Now are a couple of eyebrow-cocking excerpts, provided almost in passing by the authors:
Although emergency care consumes only 3 cents of every health care dollar and employs 4% of U.S. physicians, emergency departments handle 11% of all outpatient visits, 28% of all acute care visits, and half of all hospital admissions. Hospital-based emergency care is the only treatment to which Americans have a legal right, regardless of their ability to pay. This probably explains why emergency physicians provide more acute care to Medicaid patients, beneficiaries of the Children’s Health Insurance Program, and the uninsured than the rest of U.S. doctors combined.
We’re not sure these numbers add up – and we’re too lazy right now to tackle that project – but just consider one passage among them for a moment: “emergency departments handle 11% of all outpatient visits”. One needn’t be a devoted student of health care economics to know that ERs are not the most economical venue in which to treat many conditions, and that some meaningful fraction of that 11% of outpatient visits – which by our estimation is about million treatment visits – had no business BEING handled in an emergency room (our guess would be many more than 8% of that 11%, the authors’ optimistic figures notwithstanding).Tweet
We’re really chapped by the potshots Dr Roy Benaroch took at retail clinics in his recent post at KevinMD. Dr. Benaroch’s post, titled If You Want Good Pediatric Care, Stay Away From Retail Clinics (Dr. Roy Benaroch, KevinMD, 4/11/11), asserts that no responsible parent would ever take their ailing child for care at a retail clinic:
Everyone knows that if you’re looking for good, wholesome food, you ought to stay away from McWendyKing. If you want good pediatric care, you ought to stay away from these quickie retail clinics, too. They’re the “fast food” of health care providers, offering exactly what your children don’t need.
Everyone knows, Dr. Benaroch? Really? You know who uses “everyone knows” as if it actually served as confirmation of a remark’s validity? This guy:
But wait, there’s more:
What’s “good pediatric care”? Care that looks at the whole child, the whole history, and the whole story. To do a good job I have to review the history, the growth charts, the prior blood pressures, the immunization records, and more. Good care means I’m available for every concern—not just the sore throat, but the “Oh, by the way…” worries that are often more significant than the current illness.
We’ll forego sniping at the internal inconsistencies and, well, physical impossibilities of Dr. Benaroch’s brief observation for a moment, and congratulate him for realizing that “good care” can mean a variety of things to a variety of people, even to a medical professional like himself. Not to put too fine a point on it, Dr. Benaroch, but the parents of your patients occasionally have their own ideas of what “good care” consists of, and it may mean, on any given day, “competent professional care I can access right now”.
and finally these 2 fact-challenged tidbits (we, dear reader, added the brackedted item #s for your benefit):
 You can be assured that your doctor isn’t suggesting something or prescribing a medication just because he’s selling it at a profit.  At the retail QuickityClinic, families get their prescriptions, march over to the pharmacy, and pay for their white baggie of pills.
Let’s take our reservations in order:
 Dr. Benaroch, you know full well that doctors’ prescribing habits are strongly influenced by pharmaceutical manufacturers’ messaging. The physician may not be “selling it at a profit”, but too often they are “selling it” thanks to skewed information from their friendly pharma rep.
 While the prescription fulfillment scenario Dr. Benaroch suggests does take place, its “odiousness” is, by Dr. Benaroch, greatly exaggerated. Once again the available evidence suggests the prescribing habits of retail clinicians are clinically comparable to those of conventional doctors following their conventionally unsystematic care-providing habits.
Among the problems with Dr Benaroch’s post is he does not exhibit even a glimmer of understanding of what Christensen, Grossman & Hwang might refer to as “the job parents of ill children need to have done.” Of COURSE “responsible” parents would ONLY want to have their children attended to by the rightful heirs of Dr. Spock
(no, not Mr. Spock –
Glad we got that cleared up).
But here in the real world, responsible parents DEFINITELY would seek out a nearby retail clinic for professional assurance that their child’s condition is routine and manageable. For us, a significant comfort is that a competent clinical professional has led evaluations of the care provided by retail clinics, and found they are capable in most instances of providing the standard of care they promise.
As for Dr. B – well, all he has are his anecdotes, cutesy nicknames for the retail clinic chains, and his anxieties about his professional future.Tweet
American Medical News reports that over half of respondents to a recent Harris Interactive poll said “it’s hard to find basic information about a doctor online”.
The article (How To Help Prospective Patients Find a Practice Online (Pamela Lewis Dolan, American Medical News, 2/7/11) goes on to quote several marketing authorities who suggest physicians focus on providing searchers pertinent information about them and their practice, such as where they are.
Hmmm….yeah, we can get behind that.Tweet
Mad medicine (Steve Shaw, Louisville Eccentric Observer, 2/1/11)
One of the most rancorous battles of the 2010 Kentucky General Assembly is expected to restart this week with the filing of a bill that allows nurse practitioners autonomy to prescribe non-narcotic drugs such as antibiotics, insulin and blood pressure meds…..
….Now-retired Sen. Gary Tapp, R-20, of Shelby County, the sponsor of Senate Bill 75, the measure under siege [noted]….
“There are too many specialists,” Tapp added, “and not enough family physicians.”
If you are confident that transformation of US health care – even something simple, like the expansion of retail clinics – will come without hard-fought disputes over fundamental issues like “what are the “right” standards of quality for primary care”, we suggest you follow the course of Kentucky Senate Bill 75. Or others like it that could well crop up in other states.Tweet
Robert Wood Johnson Foundation Clinical Scholar and ER physician Dr. Zachary F. Meisel and his colleague, George Washington University’s Dr. Jesse M. Pines (also an ER doctor) address our national disdain for waiting for – well, anything, but specifically for medical treatment, whether or not we might be better off for the wait, in McDonald’s Medicine: Too Impatient to Wait for Care?.
The essay appears, appropriately enough, in Time magazine online (1/26/11).
it’s clear that convenience has become an important part of the way people think about health care
the doctors suggest
Perhaps the root problem isn’t Americans’ impatience for care, but the fact that many are stuck navigating a system that has done a poor job making sense of time and health. The current system for many people (depending on who their doctor or their insurer may be) is not really set up to help triage acute medical-care needs.
and add that doctors
need to communicate more clearly the key difference between two concepts: severity and urgency.
They conclude that considerably more attention needs to be devoted to the intersection of time and health if we are to move in the direction of a more rational health care system.
Gee, where have we heard that notion before.Tweet
Retail clinics provide convenience, but doctors see problems (Laura Unger, Louisville Courier Journal, 1/19/11)
If you’re in the market for an article on retail clinics that appears to strive for balance, comes short of that mark, but does a yeomanlike job of laying out, at some length, salient features of clinics as well as some of their potential shortcomings – and DEFINITELY generates a lively conversation among the commenters – you could do much, much worse than the one we’ve supplied a link to here.Tweet
Here’s another way this kind of innovation happens. We hate the term “co-optition” but this is probably an example of it:
Instead of seeing retail based clinics as a threat to one’s practice, perhaps we ought to focus on finding ways to rethink our value proposition and embrace change.
Colorado-based Dr. Marc Ringel avers that they just may be in this public radio interview (7/10/2010, station KUNC, Colorado).
Audio clip is available at the top of the article.
Dr. Ringel sums things up this way:
As we proceed into the brave new world of post-healthcare reform, where there will be lots more people with health insurance but no more primary care doctors to attend to them, we’re no doubt going to have to receive a greater share of outpatient medical services outside the traditional setting of the doctor’s office. Retail clinics will certainly be in the mix.
We should be no worse for this change of venue, if we can keep our eye on what’s good enough care.