When Retail-Based Health Clinics Benefit Patient Care

April 21, 2014

Article

Retail-based medical clinics have their drawbacks, but they sometimes provide useful alternatives to patients.

The American Academy of Pediatrics (AAP) recently issued a strongly worded policy statement affirming its position that retail-based clinics (RBCs) are inappropriate places for pediatric care. In addition, many of my colleagues in pediatrics are also up-in-arms over the rise of RBCs as many practices feel they are stealing precious patients. I, though, cannot join in their fight; I have mixed feelings about RBCs and, while I do see significant potential problems, the truth is that RBCs are a good complement to the micropractice model that our practice is based on. Let me explain.

For us, the main benefit of RBCs is that they do what we do not want to do, namely they open on nights, weekends, and holidays. After being open for seven years I can confidently say that our patients enjoy many benefits from being a patient at our micropractice, including personalized, well coordinated continuity of care; same-day appointments; long visits; and no wait in our waiting room. But one major negative is that we cannot staff as many hours as the larger, multi-provider practices. Don’t misunderstand me: We are open most Saturday mornings, for both well and acute care, and we have a few 5 p.m. well exams each week, but we’ve consciously made the choice to close Sundays, most holidays, and after 6 p.m.

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A recent cover story at The Harvard Business Review said to forget about work-life balance and it explained that life is about hard choices; I wholeheartedly agree. I, and my staff, want to be home for dinner with our families and spend our kids’ days off from school having fun in the community. We like knowing that the RBCs are there to fill in for us when we are closed. It should be said that RBCs provide a convenience; clinically there is usually no reason why someone with symptoms can’t receive some over-the-phone care from the nurse or doctor on call and then wait for our office to open at 9 a.m. the next morning to be seen, but for those who choose not to wait, and, in some cases are willing to pay a premium for the convenience, why shouldn’t they go see an educated and licensed nurse practitioner at a RBC? Whether the strep test is run by us or them, as long as there is communication back to us, I don’t see a problem with RBCs providing mid-level triage for us.

They key for me, as with most issues impacting individual and public health, has to do with RBC regulations. I mean, how much can a patient really value the advice of a provider who works for a corporation that makes money when you buy over-priced over-the-counter snake oil? Government agencies have a duty to ensure that RBCs are not favoring customer satisfaction over good clinical judgment. Think about it: Patients seeking unnecessary antibiotics are more likely to buy over-priced items when they have happily received the drug they wanted (but probably didn’t need). While we’re on the subject, online “telemedicine” providers are also contributing to our current crisis of over-prescribed, and unnecessary, antibiotics. For just $49, you can speak with a doctor via a video Web chat and get the antibiotic your local provider won’t give you for that viral infection.

As a primary-care provider, one of our greatest values is our ability to diagnosis illness as early as possible in order to treat the patient for the best possible outcome. What I want our patients and public health regulators to understand is that common symptoms, the kinds treated by RBCs, are only one way in which providers diagnose illness. Although many of our patients will never experience these uncommon diseases, things like failure to thrive, autism, periodic fever syndromes, and celiac disease, can only be diagnosed when the primary-care provider has a complete medical history. Also, good diagnosis depends on the patient’s honesty with the provider; honesty is easier with a provider you’ve built a trusting relationship with over time. How likely is a teenager to tell a provider they’ve never met before about their unprotected sex or their suicidal ideation? Having an established relationship, for a patient in crisis, cannot be duplicated in the RBC setting.

Our next main value is our ability to help patients manage chronic conditions like asthma, ADHD, and obesity, before they experience symptoms or reach a crisis point requiring expensive and risky hospital care. The AAP is concerned that when patients visit RBCs with acute symptoms, it's a missed opportunity for providers to check in on chronic conditions. Again, in a micropractice setting, this is not a major concern. Our model, with only half the number of patients of a typical provider, has systems in place to ensure that our kids with chronic issues are checked on regularly. This is a luxury that large, volume-based practices with 20 short visits to 30 short visits a day can’t afford.

I’ve never visited a RBC myself, but if I’m being honest, I can imagine a scenario in which I would. In our experience, relatively few of our patients have visited RBCs and, for those who have, many only visit once never to return. It turns out the theory of walk-in urgent care is less attractive than the actual experience (long waits, high out-of-pocket costs, and usually a follow-up trip to our office anyway). Still, one size does not fit all, and for those patients who desire walk-in care or care when we are closed, we recommend the RBCs. And while our little patients are getting a throat swab at 7 p.m. at the RBC, my husband and I are home at dinner with our 10-year-old son. I wouldn’t want it any other way.