Docs Split on Big-Box Clinics

Calls by the American Medical Association for a federal investigation into walk-in health clinics in "big-box" stores like Wal-Mart and Target have spurred a debate that could shape the way many Americans seek health care in years to come.

On one side are proponents of the clinics, who argue that they provide affordable and accessible care to those who might not ordinarily be able to get it.

On the other side are those who say such clinics fall short of offering a full spectrum of care, and that the medical professionals who work there could be tainted by conflict of interest.

"I think that it's a tough issue because we want to make sure patients get quality care," said Dr. Neil Brooks, former president of the American Academy of Family Physicians, who attended the AMA meeting this week.

"But we also need to make sure that the care is provided in settings that are appropriate and that it is within their scope of practice."

Attention Shoppers: the Doctor Is in

The clinics, which go by the names MinuteClinic, RediClinic and Take Care Health, are popping up in major stores, including Wal-Mart, CVS, Target and Walgreens.

And like the services offered by big-box stores or fast-food joints, they give customers an inexpensive and convenient alternative, in this case to the wait time of doctor's offices or the high cost of emergency rooms.

There are now 200 of these clinics operating in the country, and another 1,000 are projected to open by the end of the year.

Usually, these walk-in clinics are staffed by a nurse practitioner with physician oversight. They offer a menu of prices for treating a range of minor illnesses, such as sinus infections and strep throat.

If needed, the clinic can refer a patient with a more serious malady to a physician's office in the area.

But for many consumers, the main selling point of such clinics is that they offer affordable care.

In Minnesota, for example, seeing a doctor for a sore throat and getting a strep test costs an average of $109. A visit to a hospital emergency room for the same problem averages $328. MinuteClinic charges $48.

"Walk-in clinics offer a potentially promising alternative for people who have no coverage," says Dr. Peter Jacobson, director of the center for law and health systems at the University of Michigan School of Public Health.

"And therefore the burden is really on the AMA to show that poor quality health care is being practiced or that the clinics are not meeting the needs of the population being served."

Jacobson says that most people who visit these clinics either can't afford to go to physicians or don't have the time to see a doctor.

And, he says, these clinics may just force the primary care physicians to reconsider the way they do business, for example, by leaving open slots in their daily schedule for walk-in patients.

"I think before the AMA really attacks minute clinics, it would be appropriate to study the market niche they're serving," Jacobson explains.

According to one Canadian study conducted in 2003, the quality of care at walk-in clinics is actually higher than that of traditional physicians' offices.

Quality Concerns

But the AMA maintains that a host of potential problems exist with retail clinics.

Of major concern is whether or not these pharmacy-owned clinics urge patients to get their prescriptions filled on site, which the AMA says would pose a conflict of interest. The group also maintains that reducing the cost of co-payments for the walk-in clinics is unfair, as it could steer patients away from primary care physicians.

Another worry harbored by many physicians is fragmentation of care, or patients seeking health care on a piecemeal basis.

"There's no consistency, so patients don't develop a relationship with the person who is treating them," Brooks says, adding that such an arrangement could mean that chronic or major health problems may be overlooked.

The consistency issue may not be unique to retail clinics, however.

"The reality is that unless you're seeing the same doctor all the time, which is quite rare, the continuity of care is a function of record-keeping and how these clinics communicate with each other," says Dr. David Low, who manages a group of primary care physicians in British Columbia. "There is nobody who is doing this very well,"

But the fact remains that most in-store clinics may not have the proper facilities for drawing blood, taking urine samples or accommodating patients with disabilities or chronic conditions, which primary care physicians are trained to manage.

"When a patient comes in to see me just for just a small thing like an earache, I have to take into consideration if their vaccines are up to date, or if they need colorectal screening, or if they might have diabetes," says Dr. Rick Kellerman, president of the American Academy of Family Physicians.

"This is quick care, but not a substitute for having a physician who you know and trust and who is taking care of all your health needs."

Brooks adds that there may be public health issues involved with bringing sick people to a large store and encouraging them to shop while they wait to see the doctor. Moreover, many of these big-box retailers feature mini food courts -- a potential site for the spread of disease.

"If someone has the flu, you don't want them to contact a lot of people," he says. "In a doctor's office, they would be more separated from everyone else."

Sign of Unhealthy Times

Other physicians view the health clinics as evidence of the country's deteriorating health care system.

"The fact that retail clinics are here is just another sign that we have a failing primary care infrastructure," Kellerman says.

But for the uninsured, the clinics may represent something much more significant -- their only hope to receive whatever medical care they can afford.

For this reason, Jacobson says physicians must search for the best ways to work with these clinics to ensure that those seeking care receive all the services they need.

"We need to think about how physicians might actually take advantage of them in generating referrals from them, and how primary care can be organized so that people can have affordable access to preventive services and the like."

In the end, Jacobson urges a common sense approach, and advises potential patients to ask lots of questions.

"I think that the message is buyer beware," he says. "And on a broader scale, it is another move toward health care as a commodity in the marketplace.

"Increasingly, patients will be responsible for what they are buying -- as they would buy any other product or service in the market."