[NPInfo] California Minute Clinics

[David Mittman]

Bread, milk -- and a diagnosis
As the nation's healthcare system struggles to provide affordable care to
all who need it, store-based health clinics are springing up around the
country.
By Shari Roan, Times Staff Writer
January 22, 2007
California's laws strict on clinics

WHAT a Monday morning this was shaping up to be. Carrie Clemens' head
pounded, breathing through her stuffy nose was difficult and her symptoms
were worse despite a weekend of bed rest. But work beckoned ‹ and she had no
time to visit the doctor.

And so, before checking in at her job, Clemens stopped by a small walk-in
clinic at a Costa Mesa Rite Aid. There, she received a sinusitis diagnosis
from a nurse practitioner, filled a prescription for an antibiotic to treat
it and was out in 15 minutes.

"I can pop in here and get on with my day," says Clemens, 32, of Huntington
Beach. "And I won't have to wait for hours in my doctor's office with a
bunch of other sick people."

As the nation's healthcare system struggles to provide affordable care to
all who need it, store-based health clinics are springing up around the
country. By using mostly nurse practitioners instead of doctors, and
operating in a corner of an existing business, the clinics are able to
provide some basic health services for around $40 to $70 per visit ‹ in less
time than it takes to eat lunch. Most are even open evenings and weekends,
when the lights are out in private doctors' offices.

Some doctors and health experts worry that the clinics may not always
provide quality medical care ‹ and that they could prevent a patient from
forming a relationship with a primary-care doctor. But clinic operators say
their services are an innovation whose time has come. The emphasis on
convenience and low cost fills an unmet need in today's healthcare system,
they say.

"Consumers are increasingly finding that access to their primary-care doctor
is problematic," says Mary Kate Scott, a Los Angeles-based healthcare
consultant who wrote a report on the trend last year for the California
HealthCare Foundation. "Either you don't have a primary-care doctor or it
takes a very long time to get an appointment."

With deductibles and co-pays ever increasing for doctors' visits, many
consumers find the flat fees charged by retail clinics a bargain, says
Scott. When not covered by insurance, the cost for a doctor's visit can cost
$70 and up. Even with insurance, co-pays of $35 are commonplace. Add that to
additional premiums charged if the yearly deductible hasn't been met and
walk-in clinics' fees become comparable.

For uninsured Americans or those without primary-care physicians, such
clinics can help avoid crowded hospital emergency rooms and the resulting
long waits.

"A large number of uninsured people are hourly workers," says Michael Howe,
chief executive of the Minneapolis-based chain MinuteClinic. "If these
people have to go to an emergency room for care, it's not just the cost they
are bearing, it's the lost wages as well."

Walk-in clinics, which are usually set up in drugstores, groceries or
big-box stores such as Wal-Mart, are expected to grow from more than 200 in
2006 to as many as 2,000 by the end of this year, according to a report by
the California HealthCare Foundation, an independent philanthropic
organization based in Oakland that focuses on improvements in healthcare
delivery.

No more doc-in-a-box

The premise behind quick, after-hours medical care is not new. Two decades
ago, walk-in clinics ‹ often referred to as doc-in-a-box ‹ were opening in
almost every city and suburb.

Almost as quickly, it seems, the clinics were shuttered ‹ victims of low
profits despite their popularity with consumers.

Today's walk-in clinics are different, clinic operators say, and thus stand
a better chance of surviving. Doc-in-a-box clinics were typically
free-standing centers, staffed by both doctors and nurses who provided a
broad range of primary-care services, even X-rays and lab tests. Such
clinics accepted insurance and charged fees similar to those of primary-care
doctors.

But the centers ‹ with all the expenses of a regular doctor's office but no
regular patient base ‹ simply weren't cost-effective.

"What they found was that if you're trying to provide vast needs in primary
care, this was not the best way to do it," says Dave Mandelkern, founder and
president of QuickHealth, a chain of walk-in clinics based in Burlingame,
Calif.

In contrast, the retail-based clinics opening today are usually staffed by
nurse practitioners or physician assistants, both of which can prescribe a
wide range of medications within their specialty area (such as pediatrics or
primary care). The clinics are tiny ‹ usually 500 square feet or less. Nurse
practitioners or physician assistants are authorized by the clinic operator
to treat and prescribe medications for 25 to 40 simple conditions, including
colds and flu, pinkeye, minor skin burns, bug bites, poison ivy and urinary
tract infections. The clinics also offer a limited range of inexpensive,
on-the-spot diagnostic tests such as pregnancy, mononucleosis and strep
testing. Most provide flu shots and other basic immunizations.

The staff follows guidelines set by the clinics' operator or physician
supervisor on what types of conditions they are allowed to treat and what
medications they may prescribe. Patients with symptoms or conditions that
are beyond this limited range are referred to a doctor or hospital. Many
clinics employ doctors who can be reached by phone if questions arise.

Because the clinics encourage walk-ins, a receptionist is not needed to book
appointments. An estimated 60% of walk-in clinics don't take insurance,
which eliminates billing costs, although patients can ask their insurer for
reimbursement. Patients who belong to preferred provider organizations are
most likely to receive reimbursement; HMO patients are unlikely to do so.

"These centers work because they are limited," says Tine Hansen-Turton,
executive director of the Convenient Care Assn., an association trade group
that formed late last year. "The overhead is lower. The practitioner is
seeing the patient for 15 minutes max. From a business perspective, it makes
more sense."

At the Lindora Health Clinic, nurse practitioner Janet Schmitt, who treated
Clemens, did not ask for a health history other than to inquire about
allergies to medications. "We only ask questions relevant to what is going
on," says Schmitt. She also phoned the adjacent pharmacy with Clemens'
medication need so that time wasn't wasted writing out a prescription.

"Every other consumer retail service has figured out that you have to be
more customer friendly," Mandelkern says. "You need to treat the customer as
king rather than treat the provider as king."

Doctors have doubts

But many doctors aren't so sure the customer is being treated well ‹ even if
he or she feels like royalty.

Last year, several national medical organizations ‹ including the American
Medical Assn. and the American Academy of Family Physicians ‹ issued
recommendations that they said would help ensure patients are well cared for
at such clinics. The recommendations include using treatments proven to be
the best approach for a particular condition, having a system to refer
sicker patients to doctors, specialists or hospitals and informing patients
of the providers' qualifications so that patients wouldn't mistakenly
believe they were seeing a doctor.

Although the American Medical Assn. and the American Academy of Family
Physicians appear mildly supportive of walk-in clinics for minor acute care,
both groups say consumers should also have a primary-care doctor.

"The key thing from the standpoint of the AMA is that patients receive good,
quality care," says Dr. William Hazel, a trustee of the American Medical
Assn. "Good, quality care traditionally has been in a situation where there
is some continuity of care; where you establish some relationship with the
physician."

But the appeal of such clinics is not lost on the traditional medical
establishment, Hazel notes.

Walk-in clinic operators "perceive there is a gap they can fill in terms of
offering convenience," he says. "If these clinics prove to be safe and
effective, and there is data to substantiate that, then there's a
possibility they'll help. We just don't know yet."

The American Academy of Pediatrics issued a statement in December, however,
strongly opposing retail-based health clinics for the care of children and
adolescents. The group said such clinics undermine the concept of having a
"medical home" where one practitioner oversees all healthcare needs. Walk-in
clinics may also lead to fragmentation of care, may not keep good records or
encourage follow-up, the group charged, and could enable the spread of
communicable disease because of the lack of an isolation area.

Further, the group said, pediatricians often use minor acute care visits ‹
such as treating a sore throat ‹ to check the child's overall health,
provide immunizations or to advise parents on other health issues.

Howe dismisses such fears. Most walk-in clinics do not treat babies, he
says, adding that the concerns about quality and disruption of a medical
home are overblown. MinuteClinic, he says, has 145 centers in 18 states and
has not had a malpractice lawsuit in more than 700,000 patient visits. The
clinics, he say, err on the side of caution, referring elsewhere those
patients who do not clearly have a minor illness.

"You hear concerns about quality of care," says Howe. "The facts don't
support the histrionics. The practitioners are perfectly trained for these
conditions."

Clinics meet a need

Executives and consultants working in the healthcare field agree that such
clinics have the potential to relieve some pressure on overburdened
primary-care doctors and prevent the unnecessary use of hospital emergency
rooms. According to a recent report from the American Academy of Family
Physicians, 39% more primary-care doctors will be needed in the coming
decade. Between 1997 and 2005, however, the number of medical school
graduates who entered primary care decreased by more than half.

Moreover, a poll of emergency room users published in October by the
California HealthCare Foundation found that 46% admitted their problems
could have been handled by a primary-care doctor. Two-thirds of those
patients said they would have gone to such a doctor instead of the hospital
if an appointment had been available. Almost half said they couldn't get a
same-day appointment.

The report also found that uninsured people often chronically use the
emergency room even for minor acute-care problems. One convenient care chain
has focused its services on the uninsured.

Uninsured workers, says Mandelkern, of QuickHealth, "have incomes and money
to spend, they just don't have health insurance. They can't afford the $90 a
primary-care doctor would cost and they sure can't afford the $400 an
emergency room would cost."

Emergency rooms are required to treat everyone, regardless of their ability
to pay. States end up paying for the care of those who cannot pay.

QuickHealth has six clinics located in the Bay Area and Fresno and hopes to
expand this year with another two dozen clinics throughout the state. The
clinics, which are staffed by doctors, charge $39 for a standard visit; lab
tests and immunizations start at $19. Services, along with the price for
each, are posted on a large menu board at the clinic entrance. Doctors are
instructed to discuss costs with patients.

"Customers love the fact that pricing is transparent," Mandelkern says. "The
one thing people hate about the current medical experience is when they ask
how much something is going to cost, they can't get a straight answer."

Many clinic operators have also partnered with their host drugstore to offer
patients a limited number of generic drugs for $4 to $10 per prescription.

All walk-in clinics offer to fax or e-mail patient records to a primary-care
doctor, says Hansen-Turton of the Convenient Care Assn. They will also help
customers find a regular doctor.

"These clinics can refer patients who don't have a medical home," she says.
"They are very interested in being a connector to primary care."

At least one healthcare group, Sutter Health, looks at walk-in clinics as a
natural partner to traditional healthcare. The group, a nonprofit
organization made up of hospitals and physician groups in Northern
California, opened its first walk-in clinic last month and plans to expand
to six clinics in the Sacramento area this year. Both Sutter patients and
those who see non-Sutter doctors can be treated at the clinics, says Dr.
Thom Atkins, medical director of Sutter Express Care.

"I think the demand for services shows a demonstrated need for this," says
Atkins. "I hope doctors see we're not trying to build something that
competes with them."

Lindora Inc., long known for its medically supervised weight loss programs,
also recently decided to enter the convenient-care field. Primary-care
providers aren't well equipped to quickly or conveniently handle minor
illness and lifestyle problems such as obesity, says Cynthia Stamper Graff,
president and chief executive of Lindora Inc. The company will soon have
Lindora Health Clinics in three Orange County Rite Aid stores.

"We know our patients want convenience," says Stamper Graff. "The nurse
practitioner is right there in the [drugstore] aisles."

Clinic operators dismiss fears that consumers will bypass necessary medical
care. Consumers intuitively understand when quick, walk-in care is
sufficient and when they should make an appointment to see their doctor,
they say. Clinic operators say that 5% to 10% of their customers are
referred to a doctor or hospital for specialized care.

The advent of health savings accounts, in which consumers manage their own
healthcare dollars before their insurance kicks in, encourages people to be
savvy shoppers, says Scott, the L.A. consultant. Health savings accounts are
tax-sheltered funds consumers can set aside to pay for healthcare. The
accounts are usually linked to high-deductible insurance plans.

Because they are spending their own money, consumers want to make sure they
are getting the most for their dollar, says Scott. "Consumers today are so
much more involved and engaged in their healthcare and are able to make
smarter choices for themselves."

For Clemens, that meant returning to work ‹ a Monday morning disaster
averted.


shari.roan at latimes.com

*

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When to walk in

About 5% to 10% of people who use walk-in medical clinics are referred
elsewhere for more sophisticated care. How do you know if a walk-in clinic
will suffice or if you need to call your primary care doctor or seek
emergency care?

One rule of thumb for using a walk-in clinic is believing that the illness
is minor and that you already suspect what it is, says Michael Howe, chief
executive of MinuteClinic, the nation's largest chain of walk-in clinics.

"Retail clinics are more about confirmation of the diagnosis," he says.

Also, remember that most clinics treat illnesses in four categories: urinary
tract infections, problems with the eyes and ears (pinkeye, swimmer's ear),
upper respiratory infections and skin conditions.

Other tips:

Don't take babies younger than 18 months to walk-in clinics. Most clinics
won't take babies and some won't take children younger than 5.

Don't go if you're highly contagious or think you may be contagious (such as
with chicken pox).

If it's going to require disrobing, forget it. Clinics don't have gowns or
facilities for disrobing.

Don't go if you may need X-rays. These clinics don't have the equipment.

Go elsewhere if you are having mysterious or severe pain, particularly chest
pain. If there's a chance you're having a heart attack or stroke, call 911
or go to an emergency room.

Walk-in clinics aren't for disease management. You need to see a primary
care doctor on a regular basis, for example, to determine whether your
diabetes or cholesterol medication is working or your asthma is under
control. Walk-in clinics can be used for initial screenings, however, to see
if you have high blood pressure or high cholesterol.

Some clinics offer sports, back-to-school or employment physicals as well as
basic immunizations.

Source: Convenient Care Assn., MinuteClinic