The Case for Drugstore Clinics
In The Atlantic, Richard Gunderman, MD, PhD, has delivered “The Case Against Drugstore Clinics“. It is a weak case. Let’s take his strongest argument first:
A woman with a sore throat went to a retail clinic and received a prescription for antibiotics. After a few days, she hadn’t gotten better, so she went to her family physician. The physician determined that the sore throat was probably due to a viral infection. He also, however, talked to her about her overall health and life. This conversation led to a previously unsuspected diagnosis of clinical depression. The patient is now in treatment and doing much better.
A case like this illuminates three important differences between the retail clinic and the physician’s office. First, the retail clinic prescribed an antibiotic, but in the physician’s judgment the infection was not bacterial. Overusing antibiotics can promote the development of antibiotic-resistant strains of bacteria. Second, the minute clinic focused exclusively on the sore throat. And third, the physician’s more comprehensive evaluation led to a diagnosis with important implications for the patient’s overall, long-term health.
Dr. Gunderman’s implicit assumption is that if the retail clinic were outlawed, the patient would have gone to her doctor first. However, there is a reason she did not go to the doctor first: The doctor’s hours were inconvenient; the patient could not get an appointment; or the physician’s fee was too high for such an apparently simple problem. Without the option of a retail clinic, the patient might not have been treated quickly at all, and when she did finally go to her physician he would not have known that the antibiotic had not worked. Dr. Gunderman implies that overprescribing antibiotics is a problem unique to retail clinics. On the contrary, it is a longstanding practice of U.S. physicians, confirmed by research published just last year.
It gets worse: Dr. Gunderman describes a clear benefit of retail clinics as a drawback:
One is the fact that they tend to siphon away many of the simpler, quick-to-treat conditions from physicians’ offices and hospitals — these common problems help keep costs down and keep hospitals in business. If retail clinics handle a growing percentage of the relatively straightforward cases, doctor’s offices and other facilities that offer more complex care will find their average patient becoming more complex, driving up their costs even further.
It is hard to over emphasize how wrong, wrong, wrong this accusation is. The “too big to fail” nature of general hospitals is one reason why they are so inefficient: They do not specialize. This is a major reason why costs are so opaque in U.S. health care. In a functioning market, no enterprise would try to mix easy and complex cases in order to average down its costs. An operation that specialized in high cost procedures would bring those costs down, rather than disguise them by cross-subsidizing from low-cost procedures. We see increased specialization in the practice of medicine itself. The family physician described above, who diagnosed his patient’s cough and depression, likely referred her to a psychiatrist. If she had a tumor in her brain, he would not have performed surgery. By Dr. Gunderman’s logic, neurosurgeons should spend much of their time in low-cost family practice, in order to “keep costs down” when they do a brain operation every month or two.
Few things would be better for U.S. health care than physicians forming collaborative relationships with retail clinics in their communities, in order to improve continuity of care. However, this relies on identifying and breaking down regulatory barriers, not professional turf protection.
I like how it works in Mexican pharmacies along the southern U.S. border. The drugstores are long and narrow. On one side, Cuban cigars, liquor, beer and wine. On the other side of the pharmacy, pills by the score — no prescription needed. Sometimes in the back — if not, then around the corner behind the pharmacy — is a doctor willing to write a script for controlled substances.
Dr. Gunderman’s case is indeed weak. Reports from Minnesota (original home of MinuteClinic) found that retail clinics were slightly better at not passing out antibiotics than traditional physician offices. Moreover, a lost of primary care doctors don’t have time to discuss other matters given the paltry reimbursements (and high office overhead) they must endure.
John and Friends:
This is one reason why there should be a collaborative effort to educate commentators, who so consistently mis-read the health field and make fatuous comments like the one here.
One trend is toward “Down-shifting” from high intensity care to low intensity care. In the case of minute clinics, the down-shifting is from both primary care physician offices and ERs! Surely we would not want to have ERs keep all the minor ailments that do show up! The other point to make is that the supply of primary care is dropping like a rock, as physicians leave the field, and fewer ones elect primary care. What then? Wait for weeks or months to see one?
Entrepreneurs frequently enter a field where supply is tight, and it is really good that these pharmacy chains expand their services, as it takes advantage of space they already pay for, uses staff less costly than physicians, and are usually located where there is a great deal of walk-in volume. What could be better?
As to the ignorance of the first care-giver here, it is true that doctors also over-prescribe antibiotics.
The other trend to note is the movement of medical information to social media. There are about 1500 aps, from Dr Phil’s own ap “Doctor on Demand” to sites for each type of symptom or condition one might be experiencing currently.
The macro-trend to watch is “Self-care” where people are choosing to change their lives so illness is rare. They stay out of doctors’ offices on purpose.
At the mid-point are Community Health Centers, some of which are Federally-funded. They tend to be located in inner city neighborhoods, and do the Lord’s work for the whole family, including OB.
There are areas that grow so fast that enough physicians simply have not moved in. One I visited was Vancouver, WA, where one medium-sized medical group–about 20 doctors–said they turned away 400 potential patients per day who called in. Many of those drove into Portland, to the Portland suburbs, or simply gave up and went to the ER at the local hospital.
Now, here’s the opportunity of the future–to remember that wen our forebears came across the country in Conestoga wagons, they had to take care of themselves. Mothers set their children’s broken arms. Took care of fevers. Presided at each other’s births…We don’t all have to be helpless in the face of illness. Go to Best Buy and see how many home diagnostic tools you can get. And, for heaven’s sake, buy a thermometer! (By study, only one-third of mothers who brought their feverish babies to the ER had one at home. This is just plain stupid.
Anyway==good topic to write about.
Wanda Jones, your continuing friend…
John, this was a great post, thank you.
if a lawyer stood before us and said he had to have some traffic ticket cases to overcharge, which in turn would let him defend serious crimes, we would be appalled.
People with minor traffic tickets should not be charged $3000, so that their lawyer can defend an poor person charged with murder.
Now my next statement may not be popular with all, but I will make it just the same.
It is much better to cover the high costs of complex medical care with taxes, rather than overcharging out patients.
If a hospital needs an extra $20 million to handle gunshot wounds or AIDS cases or Ebola cases, then raise taxes and give hospitals the money.
These would not be enormous tax increases. If a person making $200,000 a year had to pay an extra 0.5 per cent a year for more Medicaid, that would be $1000.
If an institution like the hospital ER benefits all the community, then all the community should pay for it. We are so wedded to user fees that we often forget this.
I went to a Minute Clinic and was shocked to see a menu on the technicians screen with check-off boxes to determine my illness. The technician while nice obviously did not know what they were doing. They did however direct me to their pharmacy to buy an anti-biotic which I think is the purpose of minute clinics. Just another cost center for the pharmacy.