Retail Clinics and Telemedicine

June 19, 2012
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My reaction to the healthcare clinics being set up inside Walmart, Walgreens, CVS and other stores is that it sure seems like a continuation of what is driving up costs – episodic, uncoordinated care. So much for first impressions!

My reaction to the healthcare clinics being set up inside Walmart, Walgreens, CVS and other stores is that it sure seems like a continuation of what is driving up costs – episodic, uncoordinated care. So much for first impressions!

According to the article, “Retail Clinics and Drugstore Medicine,” by Christine K. Cassel, MD, in the Journal of the American Medical Association, there were 1,200 in 2009.  Factoring in growth the past three years, Dr. Cassel suspects the total is now nearly 1,400 and could be close to 2,400 by 2015.

I have used urgent care clinics several times.  Once on Sunday afternoon when I planned to fly to another city on Monday morning.  And once when an aggravating earache wouldn’t let me sleep at 10:30 at night. Still, I’ve always wondered if my visits were being communicated to my primary care physician (who also happens to operate an urgent care center in his office).  It’s something I should probably check on.

Something to consider is that the retail or urgent care clinics, especially those in pharmacies or connected to pharmacies, are closer to the “medical home” model than most primary care doctor’s offices.  As Dr. Cassel notes, pharmacists are underutilized if they are limited to just filling prescriptions.  Used more effectively within a team of healthcare professionals, especially for people with chronic illnesses, they provide clinical expertise in treatment plans.  She discounts critics who fear conflicts of interest when a clinic is in close proximity to a pharmacy.  She says they should be “managed by transparency, oversight, and payment incentives that reward value rather than volume.”  Anyhow, who said healthcare has to be inconvenient to be free of conflicts of interest?  Inconvenience to me is a conflict of my interest!

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As far as my…well, it isn’t exactly concern, perhaps interest is a better word… regarding integration with the rest of healthcare, Dr. Cassel says she has found that the retail clinics maintain relationships with primary care practices and refer patients to them.  Surprisingly, for those patients with a PCP, her research determined that most retail clinics fax or email messages to the patient’s physician immediately after the visit.  The larger chains are now working with medical homes or accountable care organizations.

To meet their potential, Dr. Cassel believes the retail clinics will need “electronic support, accessible specialty expertise and effective teamwork to ensure appropriate ‘triage’ of patients with complicated medical problems.”  All of this could be accomplished with telemedicine equipment and providers who would answer videoconferencing calls.

The AMA spent time over the last few days considering a resolution that would take the wind out of telemedicine’s sails by requiring a face-to-face visit with a physician to establish an “effective” doctor-patient relationship.  Look, nurse practitioners can already see patients in Arizona without physician supervision and prescribe prescription medication.  Even physician assistants working at a retail clinic can already do the initial visits with patients.  Why?  Because the people a PA sees become patients of his or her supervising physician.  The PAs are required to meet regularly with their supervising physicians and discuss the “important” cases.  According to the rules of the Arizona Regulatory Board of Physician Assistants, they can accomplish this meeting via videoconferencing.  Obviously, the PA could schedule a follow-up appointment with the supervising physician if appropriate, but not do so when it isn’t.  How much easier would it be for the PA to sit the patient down in front of a camera and have the doctor do a telemedicine visit.

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If PAs can see patients initially for their supervising physicians at retail clinics and establish the doctor-patient relationship when the doctor isn’t present, what’s the problem with physicians seeing patients for the first time telemedically?  If you’re asking “Mr.-I-like-convenience” here, you already know the answer.