How The General Practitioner
is Changing His Spots
Not long ago my wife said, over dinner, that she had recently taken the kids to get their vaccinations at a MinuteClinic. I thought to myself: “Wait! What? Aren’t they those drugstore doctors!? In fact, come to think of it, are they even doctors!? I think they’re actually nurses! Like my wife! … Oh.”
Now, I was in a quandary. As far as I was concerned, these MinuteClinic people are what many of my physician brethren would identify as “The Enemy.” Some of my doctor friends would probably even say that they’re nurses just masquerading as doctors.
My wife went on to explain that she had gone to MinuteClinic because she couldn’t deal with the concept of waiting two hours or more to get the kids their shots. And every other adult at the table, except me, was already nodding his or her head vigorously. “Yes!” “Yes!” They, too, had had it with the long waits in doctor’s offices and thought the MinuteClinic idea was perfect for this kind of thing.
It’s pretty ironic that my wife and I, who, as a nurse practitioner and doctor, respectively, are the ultimate medical insiders, would ever need to resort to something like the MinuteClinic to get flu shots for the kids. But that’s why the company’s business model makes so much sense and why CVS bought what was originally called QuickMedx in 2006. It has subsequently installed these nurse-run clinics in many of its stores around the country.
My wife’s visit to our local CVS-based MinuteClinic typifies most such encounters. She needed seasonal flu shots for our three boys, and she knew from long years of experience with our pediatric practice that any attempt to engage in anything other than a scheduled appointment less than six months in advance would involve entering into what sounds like a bullfight.
The MinuteClinic is more like a beauty salon. There’s a menu of services. The client chooses the desired service, gets it, and leaves. My wife selected three seasonal flu shots at $30 a pop, the kids got them, and she left 10 minutes later. Completely painless, except for the kids of course, and my wife was able to buy hair and dental products while they were getting stuck.
MinuteClinic offers a menu of services under the heading “minor illness exam” for about $60 or a co-payment with the patient’s insurance company. This includes the diagnosis and management of things like flu symptoms, sore throat or earache, nasal congestion, and urinary tract infections. “Minor injuries” such as blisters, burns, bug bites, splinters, and lacerations are priced similarly. Covered “skin conditions” include cold and canker sores, chicken pox, scabies, and shingles. MinuteClinic can also screen for high blood pressure ($30), diabetes ($40), and asthma ($95). The practitioners will perform a variety of specialty examinations for camp, school, college, or sports that cost between $30 and $40. Pregnancy testing is $50. Ear-wax removal, oddly, is a little bit of a bargain, costing three dollars less than most other procedures. Almost every service costs less than $100.
MinuteClinics are designed to run lean. The patient enters relevant information into the clinic’s electronic medical record software via a touch screen while waiting to be seen. The clinician then follows a series of logic-driven questions once she’s in the room with the patient. The company compares this to a pre-flight checklist, and the logic is designed to arrive at a diagnosis and a focused treatment plan. Most importantly from a liability standpoint, the computer’s software is designed to determine whether or not the client’s problem lies within a suite of common, readily characterized illnesses and, if so, to recommend a treatment course that’s consistent with nationally accepted clinical practices. These best-practice algorithms are drawn from professional societies like the American Academy of Family Physicians, the American Academy of Pediatricians, and the Institute for Clinical Systems Improvement. MinuteClinic also makes it very clear that they know when to refer a patient for issues that fall outside their defined scope of engagement.
Almost 90 percent of retail medical clinic visits are for one of 10 common conditions that would otherwise require a visit to a primary care physician or emergency room. A typical visit requires no appointment and takes 15 to 20 minutes. The transaction costs one-third less than an urgent care appointment and three-quarters less than an emergency department evaluation. And because most of these visits are goal- oriented, the patient typically leaves with a solution and is therefore a satisfied customer who will probably return. Like many medical transactions, these represent a set of clear-cut, uncomplicated problems that could be addressed in a brief encounter but typically aren’t at traditional medical facilities because of the tremendous inefficiencies of the latter in delivering sub-acute care.
Harvard Business School Professor Clayton Christiansen and Dr. Jason Hwang co-authored a 2009 book entitled The Innovator’s Prescription: A Disruptive Solution for Healthcare. They suggest three alternative approaches that business executives might adopt to reduce health-care costs to their companies. The first is to encourage their employees to use health-care retailers like MinuteClinic, the second is the formation of partnerships with integrated health systems like Kaiser Permanente, and the third is to set up their own clinics based on a retail model. Christiansen is best known for his studies of innovation, in particular, “disruptive innovations”—ones that enter a market at a relatively low cost and with modest goals but eventually go on to transform that market entirely.
Christiansen and Hwang (a former Kaiser Permanente physician and Harvard Business School graduate), as well as a growing number of companies, believe that retail medical care represents an efficient, effective alternative to the traditional, oftentimes dysfunctional, alternative. Several seemingly unrelated trends suggest that there is good reason to pay attention to the evolution of retail medicine. Rising deductibles, for example, are likely to make consumers more conscious of the price differential between an emergency department visit, with the invariably lengthy wait, versus a convenient, much less expensive visit to a retail medical facility. As much as 20 percent of routine primary care visits are for diagnoses that fall within the limited number of conditions on which retail clinics concentrate. This includes the evaluation of flu-like syndromes and minor skin conditions as well as routine medical evaluations.
Handled properly by retail providers, a significant volume of business could get siphoned away from primary care physicians, urgent care centers, and emergency rooms. And as with many disruptive innovations, there is a niche for the innovator’s entry into a market that doesn’t appear, at least at the outset, to present a big threat to the incumbent. Because of the typically low reimbursement rate for care provided to patients with these issues, most physicians don’t see the loss of these patient visits as a problem. The problem, as with all disruptive innovations, is mission creep.
Retail medical care is already showing signs that it wants to grow beyond its modest initial scope. Whereas the company initially confined itself to the management of acute conditions and vaccines, it added cholesterol, blood pressure, and diabetes screenings in 2003 and now provides ongoing monitoring of those conditions as well as of asthma. Although the American Academy of Family Physicians was an ally at one point, co-signing explicit formal relationships with several retail health providers, it saw enough of an evolving threat that it issued a statement in 2010 saying that it “opposes the expansion of the scope of services of Retail Health Clinics and, in particular, the management of chronic medical conditions in this setting.”
Medicine has plenty of examples of innovations from within that have disrupted traditional treatments or service models. For example, coronary balloon angioplasty was initially used only for a very limited subset of patients with coronary narrowings or blockages and therefore didn’t appear at first to represent a threat to cardiac surgeons. But, as we’ve seen, subsequent innovations, such as improved catheters, stents, and techniques, eventually led to the emergence of a whole new sub-specialty. And coronary lesions are now being treated pharmacologically with statin-class drugs, which may, in turn, eventually eliminate the disease and the need for interventional cardiologists altogether.
Emerging data about retail care suggests that these nurse-practitioner-run clinics do well with acute medical conditions. In an evaluation of nearly 60,000 cases of sore throat over a one-year period, 99 percent of the time, retail providers did not prescribe antibiotics to the two-thirds of the patients with a negative strep test. More importantly, they did prescribe appropriate antibiotics for the one-third with a positive test. Another study looking at the management of earache, sore throat, and urinary tract infection at retail clinics showed that visits for these conditions cost substantially less compared to costs at doctor’s offices, urgent care centers, or emergency departments. The preventative care and quality scores were comparable at retail clinics, doctors’ offices, and urgent care centers but lower in emergency departments.
One of the key attributes of truly disruptive technologies is the fact that they enter the market at the bottom, where profit margins are small and the threat to the incumbent technology appears to be minimal. A cycle then ensues in which the disruptor innovates continuously, while the incumbent retreats up-market to retain higher-end and more profitable customers. The disruptor is driven to improve to enhance profits, while incumbents are fighting a series of retrenching battles until they are finally marginalized into a small corner, or gone.
To truly disrupt, retail medical clinics can’t just be plugged into existing health networks; they must develop their own direct connections to employers, insurers, and patients, bypassing hospitals and doctors. Christiansen notes that one key lesson from successful revolutions of the past is that the energies of the incumbents are typically focused on improving the top end of their products. They complacently disparage seemingly simplistic technological innovations. Physicians who are trained to use the literature and their intelligence to diagnose and manage their patients find it inconceivable that a simple computer algorithm might perform as well as or better than they do. The threat, however, is very real.
There is a war underway in medicine to take the once highly individualized and intuitive diagnostic and treatment algorithms that were unique to each physician and codify them into best practices. If you think of a medical best practice as just another widget, like a cell phone, a computer, or a digital camera, you can imagine a process through which it evolves. Widgets, be they algorithms or products, can be subjected to ongoing study and continuous improvement, and best-practice widgets, once defined, can be tested for accuracy, efficacy, and efficiency.
One can even imagine that through this evolutionary process, once-clunky best-practice widgets will eventually evolve to become as sleek and functional as today’s smart phones and cameras. As they’re formalized, they can get coded into software as decision-support tools that can be administered just as readily by a doctor, or a nurse practitioner, or even by the patient herself. It is entirely feasible that much of the cognitive work now performed by medical providers will eventually become so objective, precise, and encodable that the doctor himself might become obsolete.
I don’t personally believe this mechanized version of the future will ever become real because I think the most important element of the interaction between the doctor and the patient is fundamentally human. Medicine evolved from altruistic activities like mutual grooming and feeding that are common to species throughout the animal kingdom. However, we do need to find our way to some model of medical care that balances the opportunities provided by advances in medical technology with what’s best for the patient.
We’re in a cutthroat era of medical evolution. Change will be fast-paced. Individuals or specialties that are slow to adapt will fall behind. Medicine is indeed entering its own brave new world.
William Hanson is a professor of anesthesiology and critical care at the Perelman School of Medicine, and director of surgical intensive care at the Hospital of the University of Pennsylvania. From “Smart Medicine” by William Hanson, M.D. Copyright © 2011 by the author and reprinted by permission of Palgrave Macmillan, a division of Macmillan Publishers Ltd.
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FEATURE: The Other Health Care Revolutions By William Hanson
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