Thursday, July 4, 2013

Retail clinics carry benefits, drawbacks: Column

Convenience is fine, but on chronic conditions, physicians should have an integral role.

Recently, I had a full schedule and was unable to see a patient for her cough. She instead sought medical care at a local drugstore, where she was treated for bronchitis. Normally housed in pharmacies and stores such as Target or Wal-Mart, such retail clinics have grown in popularity. While convenient for minor ailments, some of these clinics want to do more.
Walgreens recently announced that its clinics would manage chronic conditions normally handled by primary care physicians like myself, such as diabetes or asthma. Though retail clinics already monitor chronic diseases, they do so only after a first diagnosis by an outside primary care physician. Walgreens takes it a step further by having its nursing practitioners and physician assistants diagnose these conditions themselves. Competing clinics, such as those found in CVS, are consideringfollowing Walgreens' lead.
Access improved, but ...
Retail clinics accept most insurance, includingMedicare and Medicaid. But while expanding the scope of retail clinics improves access, patients should be aware of the downsides.
Consider the population most likely to have chronic conditions: Medicare patients. ANew England Journal of Medicine study found that these patients already see an average of seven physicians a year. Seeking care at a drugstore adds another provider and further fragments care. According to Jeffrey Cain, president of the American Academy of Family Physicians, "It is more difficult to comprehensively manage a patient's care if they are treated in multiple settings."
Indeed, I find managing chronic conditions more effective after developing a relationship with patients. Patients who go to retail clinics are more likely to see a provider they have never met. And retail clinics follow standardized medical protocols to abide by the American Medical Association's retail clinic policies.
Medical data lacking
Drugstores' lack of access to a patient's medical records also complicates treatment. People with diabetes, for instance, commonly also suffer from kidney or heartdisease, and they might be on a medication regimen fine-tuned over years. Without records, important details could be missed, or duplicate tests ordered.
Patients with chronic diseases are more challenging than those retail clinics typically see. In my office, a diabetes follow-up can turn into a lengthy visit in which a patient's recent hospitalization is discussed, medication doses are adjusted, and perhaps underlying depression uncovered and treated. These patients require close follow-up.
Finally, drugstore clinics could increase pharmacy revenues by sending prescriptions to be filled at the store. According to Consumer Reports, the price of generic drugs at large U.S. pharmacy chains can be as much as 18 times more expensive than wholesale chains such as Costco.
For retail clinics to be viable for primary care, they should not compete with doctors by siphoning off patients, but join local practices so that patient records can be easily shared and follow-up care coordinated. Patients should also have the explicit option to fill prescriptions at any pharmacy where prices might be cheaper. Until that ideal is realized, retail clinics are fine to treat your sore throat but should not substitute for your primary care provider.

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