BLOG Medicine

All That and a Bag of Chips

Walk-in clinics in retail outlets and drugstores like CVS, Duane Reade, and Wal-Mart continue to grow in prevalence, with people flocking to them because they tend to be cost-effective, convenient, no appointment necessary, and many have wait times of less than 15 minutes.

Retailers got more aggressive about staking their claim in the fast-growing business last July when CVS Corp., the largest drugstore chain in the country, acquired Minneapolis-based MinuteClinic, the pioneer and largest provider of such retail-based health clinics in the U.S.  MinuteClinic had already grown from 19 clinics in 2 states to 83 clinics in 10 states in just one year.  With 175 clinics in 20 states, CVS broke new ground last week in Chicago, opening 5 clinics, the first of their kind in the area, with plans for 30 more in the next year.  CVS has also asked Massachusetts health officials for approval to open the first of 20 to 30 planned MinuteClinics in Boston-area stores.  CVS is in negotiations with Blue Cross and Blue Shield of Massachusetts, Harvard Pilgrim Health Care, and Tufts Health Plan to cover their members' visits.

Other retailers are also expanding.  Wal-Mart had plans to expand their 12 existing clinics to include another 50 by end-of-year 2006.  Wal-Mart has allowed several companies to run their clinics.  One of them is RediClinic, run by InterFit, a private company backed by AOL founder Steve Case.  InterFit has plans to add another 500 clinics by 2009.  The other big competitor is Take Care, which runs 16 clinics in Rite Aid, Osco, and Walgreens and has plans to open 1,400 clinics by the end of 2008.

The clinics are typically staffed by certified nurse practitioners and physician assistants and can offer treatments at a fraction of the cost for the same treatment provided in the average visit to a doctor or at the emergency room.  Patients are understandably enthusiastic.

Physicians, however, aren't embracing the retail clinics.  In June 2006, the American Academy of Family Physicians, stated that they don't endorse any particular retail health-clinic business model or company, reiterating that the clinics can only complement the work of family doctors and other primary-care physicians.  The organization also recommended that its member physicians adopt a system of "open access" scheduling and provide same-day appointments to keep patients happier and healthier and state medical societies are pushing legislation that would regulate retail clinic operations and marketing.

In Massachusetts, although there has been no organized opposition, yet, health officials are moving cautiously.  Concerns range from a CVS request to waive some medical clinic certification requirements, to disrupting existing patient and referral relationships, to the potential financial strain that may arise if the MinuteClinics siphon off the easier cases to leave only the more complex, and more expensive cases, to existing physician practices.■

A Business of Caring

Early in my career, I had the opportunity to participate in a "guest relations" program at an academic medical center in Cleveland.  As a newly-minted physician relations manager, I knew I could only grow, professionally, from the experience and readily volunteered.

The program paired non-clinical hospital management with the family members of patients who were long-stay or terminally ill.  The idea was to provide a brief respite from the obvious stress involved with such situations, and, as non-clinicians uninvolved with direct patient care, we would be seen as non-adversarial to the patient's family.  We were to have dinner, at the hospital's expense, in the senior staff dining room which came with an elegant setting and an equally high-caliber chef.  Conversation was to be directed by the patient's family and specific talk about the patient and their stay was discouraged, but not forbidden.

I ended up paired with two mothers, each with their own child (one a tween, the other a teen) in the cystic fibrosis unit.  If you are unfamiliar, cystic fibrosis is an inherited chronic disease that causes the body to produce unusually thick, sticky mucus that affects the lungs and digestive system.  At the time, the predicted median age of survival was significantly less than today's 37 years and with some 70% of cases diagnosed by age two, these mothers had already lived with their children's disease, and the consequent and frequent inpatient stays, near to its expected term.

After a brief introduction and assurance that this fresh-faced young man was indeed the hospital manager they were meant to meet, we sat down to dinner.  What followed was one of the most exceptional and fulfilling experiences of my professional career in healthcare.

Initial talk had been about why their children were inpatients at the hospital, the facts about the disease, the length of the current stay, and what number visit this stay made for the year, so far -- a matter-of-fact, dry monologue that was far from hopeful, let alone a distracting respite for these weary women.

At this time, I had been at the hospital just over a year-and-a-half, having recently finished setting up the physician referral program for the health system.  In order to manage my newly hired staff of 15, I had to know about, and had entered into our database, every piece of available information about every program, service, attending, and admitting physician affiliated with what is the largest academic medical center in Northeast Ohio.  The project had taken over 16-months to complete and, at the end, I could and did write entire sections of the physician directory from memory -- if the service was provided by our hospital, I could tell you at which building, on what floor and who headed up the program.  I could talk the talk; however, I hadn't walked the walk.

Already in a negative frame of mind, when the mothers found out that I had never actually been to the cystic fibrosis unit, I prepared myself for disapproval and recrimination.  Instead, their focus immediately shifted from reliving their children's illness and pain to one of superiorly-informed docent.

For the next several hours, they took me, floor-by-floor, through the children's hospital, showing me where the patient's of the programs I had written about, and facilitated referrals to, experienced their care (some of the best in the nation, some would say world).  They had walked these halls numerous times over the years, and various inpatient-stays of their children, and would introduce to me, by name, almost every charge nurse.  They put a face to each service, patient, and family; they made real what had only been academic.

And, during this, they weren't thinking about the suffering of their own children, or how long this stay would be, or how much longer they may have with their child before finally losing them to their disease.  They allowed themselves, instead, to be distracted for a short while; to re-energize themselves, ironically enough, through the process of better informing me why they brought their children to this place for care; proud to educate me about the hospital I thought I already knew, making me understand why they entrusted us with the care and comfort of their sick and dying.

I walked away, that night, having accomplished the goal of the program, yet having received much more than I had given.  Every service now came with a face; I saw who we treated and where.  What had been a business of information had become a business of caring.

In the end, although not exactly as expected, I understood that I had been right; I had grown from the experience.■