MINNEAPOLIS, Oct. 14 – Time-squeezed patients can now get a strep throat culture, a flu shot, or even urinary tract infection treatment at some Wal-Mart or Target stores, CVS pharmacies, and local supermarkets. But don’t ask for the doctor.
Across the country, a small but rapidly growing number of convenience medical clinics staffed by nurse practitioners are sharing space in supermarkets, discount retail chains, malls, corporate offices, and pharmacies. They offer an array of basic primary-care services from immunizations to tests and treatments for common infections.
These mini-clinics are designed to treat the minor everyday ailments that often clog the waiting rooms and calendars of time-crunched primary-care physicians. The clinics promote themselves as the fast solution to the harried working parent whose child has a bad cough or the go-go professional who wants to have a sinus infection checked out during the lunch hour.
However, these quickie clinic companies will be the first to say they are no substitute for an established relationship with a primary-care physician or for hospital emergency rooms. For instance, they do not treat chronic conditions like hypertension, asthma, or diabetes.
Indeed, these clinics do not want regular customers, and any patient who returns repeatedly or shows signs of chronic disease is flagged and referred to a primary-care doctor.
Larry Fields, M.D., of Ashland, Kan., who is president of the American Academy of Family Physicians, characterized the clinics as “something to use in a pinch or in a hurry or when you’re not too sick.” They are not, he added, “a medical home.”
The intention of these facilities is to complement family physicians, not compete with them, said Jim Woodburn, M.D., chief medical officer of MinuteClinic, Inc., a Minneapolis-based company with convenience clinics in four states at Target, Cub Foods, CVS, and the corporate headquarters for the electronic retail chain Best Buy.
“We tell all our patients that they should have a medical home,” Dr. Woodburn said. “We use the words ‘complement’ or ‘adjunct’ to your current primary-care system.”
Some physicians welcome these clinics and see them as a chance to shift their focus from treating sniffling noses to more pressing concerns, such as difficult-to-treat blood pressure, said Kimberly Yarnall, M.D., an associate clinical professor at Duke University Medical Center in Durham, N.C., who has been watching the clinic movement develop.
“We’re trying to deal with all the chronic illnesses patients have as well as manage disease and provide preventive services, so having the simpler stuff handled by these clinics allows me to focus on disease, on the bigger issues in these patients,” Dr. Yarnall said. “I’m more freed up to do that.”
MinuteClinic, Inc., which was established five years ago, is one of the oldest of the clinic companies.
There is also Take Care Health Care Systems, LLC., a relatively new company based in West Conshohocken, Pa., that has announced partnerships with the grocery store chain Albertson’s Inc., Brooks Eckerd Pharmacy, and Rite Aid Corp. Through these partnerships, Take Care plans to open several clinics soon on both coasts and in the Midwest. Take Care is also in talks with Walgreen Co., the nation’s largest pharmacy chain. The company says its goal is to open 1,300 clinics by the end of 2007.
CVS says it is introducing clinics within its stores, staffed with nurse practitioners who can diagnose common ear infections, screen for high blood pressure, and give school inoculations. It is partnering with MinuteClinic, and CVS hopes to have 60 in operation soon.
Retail behemoth Wal-Mart also recently jumped into the fray by announcing partnerships with four medical-clinic providers: RediClinic, Quick Quality Care, Solantic, and Memorial Health. A total of 12 clinics will open in existing Wal-Mart Supercenters by the end of January, a company spokeswoman said. Currently, three are opened in Arkansas, Indiana, and Oklahoma, and three new locations will open by the end of this month in Florida. The clinic providers will lease the space from Wal-Mart.
“The reality is some customers are already coming into our stores to have their prescriptions filled,” the spokeswoman said. “We do think our customers will find the clinics a benefit since the clinics are open during hours that regular clinics aren’t.”
(Solantic announced today an arrangement with Wal-Mart in Florida to open four clinics, the first tomorrow, staffed by board-certified physicians rather than by nurse practitioners.)
Unlike physicians’ offices, these convenience clinics keep their doors open as long as their landlords’ doors are open, often from 8 a.m. to 8 p.m. Monday through Friday and on weekends.
And also, unlike physicians’ offices, there is no need for an appointment. The patient walks into a small sitting area staffed by a single nurse practitioner surrounded by a minimal amount of medical equipment.
Some clinics, such as MinuteClinic, post their services and prices like a cafe menu for all to see. Services and prices vary among different clinics. For example, a meningitis vaccine is $110, the most expensive item on MinuteClinic’s menu, said Dr. Woodburn. A flu shot is $30. An exam for strep throat is $49 plus the $10 for a rapid strep test and another $15 for a throat culture.
RediClinic, on the other hand, features a fixed-price menu where all diagnostic tests are a flat $45.
There are also differences between the clinics in whether they accept insurance. RediClinic, said Web Golinkin, chief executive officer of Houston-based Interfit Health, which owns RediClinic, is “purely a cash business” but is considering allowing third-party payments.
MinuteClinic bills insurers, which have welcomed these convenience clinics because of the potential cost savings.
Clinics also differ in the types of services they offer. Some clinics provide prevention screening, such as cholesterol and glucose checks. However, they do not treat any on-going conditions. Any patient with an abnormal screening test reading is referred to a physician.
While the nurse practitioners can prescribe antibiotics for a sinus infection, they can’t prescribe medications for on-going conditions, such as birth control pills, antidepressants, or cholesterol-lowering drugs.
The nurse practitioners often work in tandem with area physicians in case they stumble upon any problems or have any questions, said Y. Jesse Chang, M.D., a medical consultant to RediClinic and president of the Southwest Doctors Professional Association in Houston, which serves as backup for the RediClinic nurse practitioners.
“If they have any questions, they can call us,” Dr. Chang said.
Although nurse practitioners can practice independently in 27 states, other states require NPs to have a supervisory relationship with a physician. MinuteClinic says that irrespective of state laws, its clinics all operate with a physician consultant for all NPs — roughly one on-call physician for every five NPs who are on the job. (In Minnesota, MinuteClinic operations began with physician’s assistants, but it has switched to NPs as it expanded.)
Although calls to the physician are not required too often, said Dr. Woodburn, MinuteClinic NPs always have a physician they can consult with a question. Physicians are board-certified family physicians or emergency physicians, but not internists because of their relative unfamiliarity with pediatrics issues, said Dr. Woodburn.
Physicians in support of these clinics say the companies provide greater access to health care, especially for the uninsured or low-income patients who struggle to afford basic primary care.
However, critics question whether these clinics will make it too easy for patients to abuse this setup and avoid a primary-care physician. Golinkin said his company is prepared to prevent that.
RediClinic uses an electronic medical record system to keep track of who’s been seen when. If a patient comes to a RediClinic a certain number of times within a specific time frame, the computer will alert the nurse practitioner, who will then advise the patient to seek medical care from a physician. The nurse practitioner can also turn the patient away, Golinkin said.
“We’re not trying to replace primary-care physicians,” he said.
In fact, many clinic companies want to keep the lines of communication with area physicians as open as possible, Dr. Woodburn said. Sharing medical information with the patient’s doctor creates a win-win environment for both the physician and the patient. The clinics will also help find a primary-care physician for patients who don’t have one or may be new to the neighborhood, he said.
What is immediately clear is that there’s the opportunity for a lot of money to be made by both the clinics and the companies that lease to these clinics, said Dr. Fields, AAFP’s president.
“If you can charge someone $45 in cash and it takes two to three minutes to see someone with a cold and you don’t have to arrange follow-up tests…they hardly can lose,” he said. “The only way they can lose is if people don’t come.”
But, he added, malpractice issues could be a threat. It won’t take too many liability cases surfacing from these clinics to slow them down, said Dr. Fields.
“If it’s done right, it could actually be an advantage for physicians and patients,” said Dr. Fields. “Unfortunately, it’s a lot easier to not do it right because it takes more effort and money to do it right.”
