HEALTH CARE JUNE 13, 2013
You have a sore throat, or maybe a rash. You could call your physician’s office and make an appointment, which could mean waiting for an opening and, then, schlepping across town. Or you could pop into the local Walgreens. You’ll probably see a nurse practitioner or medical assistant, rather than a physician. But you can go right away. You’ll get your prescription right there. And it might even be cheaper.
Is this is great idea? Or a terrible one? It’s time to ask that question, because more Americans are getting health care this way. And if a new report is correct, many, many more will in the future.
In-store clinics have been proliferating over the last decade or so. They started as stand-alone storefronts, but more recently the big pharmacy chains, like CVS and Target, have been opening their own. There are more than 1,400 such clinics today. That number could more than double by 2015, according to a projection from Accenture consulting. And it looks like they’ll be busy. By that time, the Accenture report says, in-store clinics will handle about one in every ten non-primary care outpatient visits. (In other words, one in every ten visits for routine care that’s not a wellness visit, a regular exam, etc.).
The clinics are expected to thrive because people will need more health care than the existing supply of doctors and more traditional clinics can provide. The rising demand will be a product, in part, of Obamacare. Many more Americans will have health insurance, which means many more Americans will be looking for medical care. But Obamacare won’t be solely, or even primarily, responsible for the surge in demand. Demographics—in particular, the aging of the baby boom generation—was already putting a huge strain on physician supply.
The health care system began accommodating this shift long ago, by allowing nurse practitioners, medical assistants, and other professionals to take on more tasks. It’s been a slow transition, in part because physicians have fiercely guarded their turf with so-called “scope of practice” laws limiting what other professionals could do. But with the demand for more services so strong, and the possibility of revenue so large, other professionals—and, now, the in-store clinics—have secured a place for themselves. One way or another, their presence is going to grow.
The promise of the clinics goes beyond convenience. A study of clinics in Minneapolis, where the MinuteClinic chain first established itself, found that they save $50 to $55 per episode. The study, which like all studies had many caveats and qualifications, didn’t specify the source of the savings, but it’s safe to assume it had something to do with lower labor costs. Nurse practitioners and medical assistants command good salaries, but they still make a lot less than physicians. But the same study, which appeared in Health Affairs, warned that in-store clinics could actually raise overall costs if, by making medical care easier to access, it increased the overall use of services. This is the constant danger of any change that makes it easier for people to get medical care: They might take advantage of it.
Quality is another question—and an important one. Physicians have long warned that dropping into your local drug store for medical care is no substitute for developing long, sustained relationships with doctors. And while the clinics might be perfectly capable of handling routine care, what happens when a patient needs something more? When somebody shows up with what looks like an everyday illness, but is in fact showing the early signs of something more serious? Some of these objections are transparently self-interested—it’s the M.D.s trying to protect their monopoly. But substantively the concerns are certainly credible. If you had asked me a few years ago, I would have been among those endorsing them.
Lately, though, I've warmed up to the idea. Partly that’s because I’ve become convinced that, armed with new tools to collect, analyze, and transmit data, other professionals can handle more duties—particularly if they are part of teams that provide care, constantly communicating with each other and with patients to promote good health and manage chronic conditions. And that’s what at least one of the drug store chains says it is trying to do. Walgreens recently got the green light, under Obamacare, to develop “accountable care organizations”—in effect, to create partnerships with doctors and hospitals that will manage the care of patients and, if they can save money, get bonus payments from Medicare. Sarah Kliff of The Washington Post explained the logic and how Walgreen's envisions it all working:
Up until now, hospitals and large physician groups were the only health care systems that had launched ACOs. Walgreen’s decision to move forward marks the first time a pharmacy has gotten into the new model and puts it among 250 ACOs created since the program began in 2011.
“I see this as a natural evolution,” says Walgreen’s Senior Vice President Jeffrey Kang, who leads the pharmacy chain’s work on health and wellness. “Over the last five years we have been moving more aggressively into health services. Historically our pharmacists were just filling prescriptions. We’ve moved them out behind the counter in a more consultative role.”
While a pharmacy-run ACO is not the traditional model, Kang argues it actually makes a lot of sense. Pharmacy stores are open every day of the year, making them a more accessible point of contact than most doctor offices. They have begun to handle basic health care, like vaccination and preventive check-ups, right in the store, which could prevent more costly diseases down the line.
“The way I like to describe it is as a physician-led plan where we’re an active partner,” Kang says. “They’re the quarterback who creates the treatment plan. We can be care extenders who help implement and execute the plan.”
The Walgreens experiment could turn out really well. Or not. When you read about changes in health care, you frequently hear bold predictions of great success or abject failure. Truth is, none of us can ever be that sure, and the most common outcome is something in between. That will probably be the case here, which means we should watch this development closely, expecting some good and some bad—because, like it or not, the transformation is happening.
Jonathan Cohn is a senior editor at the New Republic. Follow him on twitter @CitizenCohn