• If you don’t like retail clinics, do what they do better

    Some days it’s hard to be a blogger. Yesterday, I told a story about how the local Minute Clinic filled a niche by providing timely care on off hours for a simple acute issue. Nevertheless, I got a lot of email accusing me of being a shill for Walmart and selling out the medical profession. Please.

    Look, I clearly said at the end of my piece that I don’t think retail clinics are good for everything. I think longitudinal care through a medical home is proper for primary care. But there are limits. There are times when you need to see a health care professional early in the morning, or later at night. Have you tried to get an appointment lately when you’re sick? It’s hard! That’s not all. You often have to wait a while:

    So almost 20% of people need to wait at least a week to see a doctor when they are sick. Try getting a same day appointment if you can. Or, even better, try getting an appointment before or after work. Or on a weekend:

    Yeah, we beat Canada. But we lose to almost every other country. Almost two thirds of Americans have trouble getting care on nights, weekends, and holidays. You know what? A significant amount of the week is filled with nights, weekends, and holidays. Especially if you don’t want to miss work.

    It’s fine to believe that people should try and see the doctor in the office. But if you want that to happen, then you need the office to be available. If retail clinics do a much better job in that respect, you can’t complain when people make use of them. In my example, my kids could be seen at 8AM, before school, without an appointment. That’s useful. If physician offices want that business, they should do the same.


    • Around a year ago, our kid’s pediatricians began to offer exactly that: A walk-in service from 8 to 9 am on Mondays and Fridays. It’s for established patients only, and it’s for acute illnesses only. I think we’ve only made use of it once, but it was a godsend that day.

      Perhaps not coincidentally, there are three CVS Minute Clinics within a ten-mile radius of their office. It won’t surprise me if the service eventually expands to five days a week.

    • And I bet the retail clinics charge more.

      Primary care is hosed unless they call themselves an urgent care clinic, then they can charge more and pay the docs more as well.

      • Actually, they don’t cost more. I was without insurance last year and had strep and conjunctivitis. I went to the CVS minute clinic and saw a APRN, got a rapid strep test, and an exam for $67. I work in a hospital now, and thank God have insurance because that visit around here would cost $200+.

        I’m all for the easy walk in clinics, but maybe thats because I’m not a doctor losing $$ to them!!

    • I’m curious, is that wait how long it takes to get an appointment or how long people wait to decide to actually get an appointment? or some combination? I’m guessing the latter, but would be nice to know to inform the discussion.

    • When I was insured through Kaiser Permanente, I could get urgent appointments at odd hours (and I had to on a couple of occasions). The results were communicated to my PCP. The downside was that I had to get to one of their centers, which aren’t very conveniently located in DC, but the fact remains that I could easily get off hours appointments.

      With all due respect to Dr. Carroll’s profession, it seems to me that American physicians as a whole have been reluctant to organize into large groups or to work for hospitals (to be fair, hospitals haven’t played nice with physicians, either). I’d suspect, though, that the sort of staffing model necessary to give patients access to a provider at off-hours while maintaining reasonable hours for the providers is only possible with a large practice.

      • Well, I would think large clinics can do that easier. I used to have late hours one day weekly, starting at 11 AM and work until 8 PM, but I started getting lots of patient complaints about not offering AM hours on those days. I even did Saturday AM hours, but couldn’t fill the 8-10 AM appts, which meant patients wanted to be seen late AM and early PM, which destroys the Saturday for me. That was when I was solo in rural Indiana.

        Sometimes you have to pay for convenience. But few patients are willing to do so.

    • I’m prone to bronchitis. My doctor knows that. Last year, when I had a bad attack and needed treatment, her office (clinic at a hospital, part of a large network) told me they could get me in to see in a month and a half. I told them I was having trouble breathing and needed to see her within a few days. They said if I thought I needed to see a doctor, I should go to the ER.
      I asked for a referral to go to the Walk-In Clinic on my HMO plan and was told I couldn’t get a referral without seeing the doctor first … in a month and a half.

      I went to an independent walk-in, paid $90 and got appropriate care within 30 minutes without cluttering up the ER.

      I realized that the reason my HMO cost so much less was that I was unable to see a doctor at all using it. Needless to say, I’m switching out of the HMO and changing doctors.

    • My family and I recently moved to Sydney, and I want to share an experience from down-under on this. My 18-month daughter got really sick last Saturday night, and into Sunday morning.

      That’s when we found out that there is (at least in Sydney—I don’t know about other parts of Australia) an amazing public after-hours/weekends/holidays medical service. We called an 1-800 number, and less than two hours later a doctor was at our door. The cost? Fully covered by Medicare.

      The interesting thing about this, is that I suspect it may even save the system money—back in America, we would most likely have rushed our daughter to the ER.

    • Being from Canada, I want to mention a few things that the chart doesn’t show…

      Our family doctors always tell us that if we have a problem off hours, go to Emergency (meaning Emergency at any hospital). So you can always see a doctor if you want to (though you might have to wait around for a couple of hours if you’re not in distress).

      And in every city there are walk in clinics (though they probably aren’t open at all hours).

      The only real problem is that people in rural areas don’t have as quick and easy access to health care as those in cities (though that’s probably true in every country).

      Our system isn’t perfect, and you can find some horror stories if you dig, but… don’t believe anyone who tells you it isn’t generally good.

    • Last February I had severe allergic skin reaction. It had happened before, but not this bad. I was out of town, near my hometown, and 3 hours from my PCP. Ironically, most of the time during this event was spent in a hospital due to my father’s stroke, however ER would not have covered it. I logged on and looked up my crappy Aetna coverage, and there was an urgent car clinic on the list. Turns out it wasn’t covered after all, so I had to pay out of pocket.

      But my point would be, this urgent clinic was in a typical highway strip commercial building, I think it was a former Dunkin Donuts. Check in was quick and speedy, and I got some steroids to calm things down. The amazing thing was the degree of technology in the office. The doctors and all the staff had tablet computers, and I only had to fill out one relatively simple form once and they had all my info captured. My experience with the past few PCPs I have had is that the first 15 minutes of a visit is filling out forms over and over. My current PCP is nice and all, but the office is a mess. Paper files everywhere, spilling into the halls, all over the reception area, etc. etc.

      It baffles me that the benefits of information technology have revolutionized almost every industry in the past decade, and indeed made a lot of work(ers) obsolete, yet it doesn’t seem to have carried over to medicine. Everything is still on stacks of paper files, and I go to my PCP and the first thing then do is make a photo copy of my insurance card and ID.

      Meanwhile, this little operation running out of an old Dunkin Donuts was state-of-the-art and top notch. This year I got a flu shot at a Doctors Express franchise, and it was the cheapest around, and I was in and out in 15 mins.

      I would use these kinds of facilities more, if my insurance plan covered them. I can make rational economic choices, and can deal with a few rules, and I don’t need to have my hand held by an MD every time. My plan doesn’t cover the cheaper option, yet my plan just went up an additional $39 a month, the second increase in a year. I’m ok with helping to contain costs, but I wish Aetna would not raise my rates while concurrently denying coverage for a lower-cost service delivery.

      • And what did you pay the clinic compared to what your PCP is paid by insurance? How do you know the “Dunkin Donuts” clinic is a lower cost operation? I had to pay $2500 for my laptop–and we’ve had 3 stolen from this office so far after hours. Our health insurnance for our employess went up $100 per month for the family plan, and it would have been more than $200 per month if we had not changed companies. Being a PCP sucks.

    • Hello Aaron,

      I came to your blog via Andrew Sullivan. I think you are correct that these “Minute Clinics” are fulfilling an important niche in American health care.

      We have to come to grips with the reality that medicine is becoming moving away from a paternalistic model and becoming more consumer oriented. Why should anyone go through the trouble of scheduling an appointment at their doctor’s office, take time off work, and sit in a waiting room for an hour just to get a flu shot when they can walk into a CVS and get one for $20? When someone is not feeling well and needs medical attention, why should they have to wait a week to see anyone? Consumers wouldn’t tolerate this from other businesses. When my basement flooded this spring, I was able to get a plumber to fix my sump pump the same day, and a cleaning service came the day after. We both know medicine works on much different business model than plumbing, but consumers don’t see the difference.

      So as PCP’s, how do we keep up? The good news is (as your chart clearly demonstrates) the law of supply and demand works in our favor. I have been able to greatly expand my practice by hiring PA’s, which has allowed me to schedule more patients, reduce wait times, and stay open on weekends. It’s just no longer economical for me to see every single patient for every visit. If you can’t beat ’em, join ’em, I say!

      • I think you’re taking the right approach. We need to recognize that there are more patients than physicians can serve. We need help. We need to accept that mid-level practitioners can serve an important role in health care.

        I think we will reach a point when customer service will matter. Seeing patients in off hours and in a timely manner can matter!