Retail health clinics here – regulation needed

CVS MinuteClinic has applied to the R.I. Department of Health once again for a license to operate a retail health clinic in Rhode Island, bringing home a national trend in this model of care. RHCs arose in the early 2000s and have grown to more than 1,600 clinics currently in operation in 42 states. In a recent study by Accenture, it is projected that retail clinics will double in the next three years to more than 2,800.
Weekday evening and weekend visits account for nearly half of retail clinic visits. No appointments are needed, and paperwork is minimal for patients. The wait times tend to be less than 30 minutes. RHCs primarily service a population age of 18 to 44 years of age.
Patients pay out of pocket and many do not have a primary care physician. They tend to be located in areas of higher income. Repeat visitors tend to be adults who lack health insurance or have unknown insurance status. RHCs claim to refer patients to a more appropriate setting such as a primary care office or emergency room if the problem is out of scope of practice. However, only 10 percent of retail visits result in a referral to those locations.
Patients consistently site convenience, short wait times and access as the main reason they visit an RHC. A 2013 survey by the Kaiser Family Foundation and the Health Research and Educational Trust found 56 percent of employers offer health benefits that cover retail health-clinic services and many offer financial incentives to visit RHCs over primary care offices.
The primary concern from the physician community is the quality, continuity of care and impact on their practices. There are claims that RHCs are disruptive to the primary care relationship, especially in light of the expanding model of the patient-centered medical home that provides comprehensive, accessible, longitudinal, quality and lower-cost care to patients.
There are concerns about missed opportunities for early diagnosis of more-complex medical problems, fragmentation of care, missed opportunities for prevention and continuity of care during off hours. Some states (Florida, Massachusetts, New Hampshire and Texas) have laws that limit the scope of practice, define clinical guidelines, regulate record keeping, physician supervision, referrals and limit repeat visits.
Various organizations – the American College of Physicians, American Academy of Family Practice, American Academy of Pediatrics and the American Medical Association – have policy around RHCs. The AAP is opposed to RHC usage for pediatric patients. The other organizations have the following common principles:
• RHC should have a well-defined and limited scope of clinical services and be consistent with state scope of practice laws.
• RHC should have arrangements for health care professionals to have direct access to and supervision by physicians.
• RHC should have standardized medical protocols based on evidenced-based guidelines.
• RHC should have an electronic record that is shared with the patient’s primary care physician/PCMH.
• RHC should have a referral system to physician practices for problems beyond the scope of practice and to establish continuity of care.
• RHC should not manage chronic medical conditions such as heart disease, hypertension, diabetes, asthma and others.
• RHC should clearly inform patients in advance of the qualifications of the practitioners and the limitation on types of illness that can be diagnosed and treated.
Retail health clinics have been a growing model of care for more than a decade. They provide convenience and access to care at potentially lower costs to patients and the health care system. They are also a model with potential for fragmentation of care, missed opportunities for early diagnosis of more complex medical problems and lack provisions for continuous team-based, comprehensive care. In our free enterprise medical-industrial complex, it is difficult to argue about their existence. But we can argue for the institution of the above principles to protect the health of our patients. •


Dr. Nitin S. Damle practices general internal medicine in a patient-centered medical home in South Kingstown. He is a past president of the Rhode Island Medical Society and past president of the South County Hospital medical staff.

No posts to display