The AMA Takes on In-Store Health Clinics

Posted on September 21, 2007
Filed Under General Rationing Issues, Primary Care in America |

Despite the fact that covert rationing has systematically separated the interests of doctors from the interests of their patients, thus programmatically destroying the doctor-patient relationship, leaving patients to fend for themselves within a cruel healthcare system, and leaving doctors to wallow in frustration at their loss of autonomy and at the demolition of their once-proud, once-ethical profession, every now and again some doctors’ group will find the energy to raise its voice in protest over some new travesty.

This seems to be the case with the AMA today, which has bestirred itself into a genuine huff over the growing popularity of in-store health clinics. The AMA is deeply worried that these clinics, often located in large retail chain stores, will fail to provide American patients with the optimal medical care they so richly deserve.

The AMA’s concern, according to an editorial in the July 23 edition of the American Medical News, is related to how these clinics will “comport with medicine’s central dictum - First, do no harm.” The harm postulated by the AMA has to do with the in-store clinics’ “impact on physician practices - specifically, their potential to interrupt the physician-patient relationship and to undermine coordination of care.” (DrRich wonders: Doesn’t anyone at the AMA edit these editorials? Do they really want to complain, out loud, that their primary concern with in-store clinics is their impact on physician practices?)

Why are these clinics so dangerous? Well, a lot of reasons. First, they are usually staffed primarily by nurses and not doctors. Second, they are often run by companies (such as drugstore chains) that also sell medical products, so there might be a conflict of interest. (In fact, the AMA has called for formal investigations to look for such conflicts. DrRich believes this is called phishing.) And third, well, they might harm the doctor-patient relationship.

Why would patients allow themselves to be subjected to such risks? The AMA knows the answer to this, too. It’s mere convenience. The in-store clinics often have the same liberal hours of operation as the stores in which they reside. The waiting times are often minimal. (And, if patients find there is a wait, the magazine sections in many of these stores often have issues more current than 1993.) The nurses (yes, again, take careful note - these are often nurses and not actual doctors) sometimes seem more pleasant, unhurried, and caring than the patient’s own stopwatch-clicking primary care doctor. But it’s just plain wrong to sacrifice quality for mere conveniences such as these, and action must be taken to protect patients (simple things) who just don’t get it.

To limit the damage being suffered by unsuspecting patients (and, parenthetically of course, by physician practices), the AMA has proposed nine (nine!) principles that they would like to see legislated far and wide, and that will assure that in-store clinics meet the high standards the AMA would wish for them. (You can see these nine “principles,” which look a lot more like “rules” to DrRich, here.) It is probably mere coincidence that if the nine principles were all adopted, the in-store clinics would begin to look a lot more like the bureaucratic nightmares that many doctors’ offices have lately become.

It is all too easy to criticize the AMA for their actions regarding in-store clinics. Even the AMA’s invoking of the sacred doctor-patient relationship seems a bit sad, given that doctors themselves already have been systematically forced into abandoning that relationship. (If patients can’t have a doctor-patient relationship anymore, one wants to ask, can’t the AMA just step aside and let them at least have a nurse-patient relationship?) Capitulation to the central authorities who determine their viability as practitioners (thus relegating their patients to a place of secondary importance), even though done only under great duress, makes doctors’ protests against in-store clinics seem petty if not ironic.

But really, looking at things with the cold eye of reality, what else can the AMA do?

If the practice of medicine were an economic endeavor like any other, we would just tell the doctors, “Clearly, your patients are put off by the long waits, the inconvenient office hours, being rushed in and out of the exam room in 7.5 minutes, not being able to ask all the questions they want to ask, and scores of similar indignities that have become associated with seeing the doctor. No wonder they’re going to Wal-Mart for their healthcare. If you want to stifle these in-store clinics, which really do sound like a sub-optimal idea, then just learn to compete with them. Give the patients the convenience and the time they’re looking for - make them feel like they’re your chief concern and not an imposition - and you’ll run these guys out of town inside of a month.”

But that advice doesn’t work. Doctors can’t compete. They’re not allowed. The irrationalities, petty inconveniences, and low-grade indignities of visiting today’s doctor’s office are built in to the system (since stifling the demand-side of the equation is inherent to covert rationing). Limiting doctors to 7.5 minutes per patient visit has become a virtual mandate from the entities that are paying the bills; doctors have relatively little to say about it. Further, as we have seen, with the introduction of P4P even the content of these brief visits is increasingly scripted by some central authority. The patient’s needs have been purposefully and effectively marginalized. It’s become impossible for doctors to serve their true masters (those same central authorities), and satisfy their patients at the same time.

So when doctors begin losing their patients to a health facility that does not have to operate under the same constraints, the AMA really has no choice. If you’re not able to compete with in-store clinics on their own terms, then do whatever you can to bind them to the same kinds of constraints that bind you. Drag them down into the morass; truss them up with red tape; kill them. Do it.

Any enterprise that dares to challenge the infrastructure of covert rationing, by offering patients some small chance at self-empowerment, by giving them even the puniest opportunity for self-determination, will be treated similarly, and not merely by Wonkonian regulators and Gekkonian insurance companies. Even the doctors will act this way.

A resolute public demanding opportunities for self-empowerment is the only viable path out of our system of covert rationing. For this reason, DrRich is cheering on the in-store health clinics, as paltry a tool for patient-empowerment as it is.

Comments

4 Responses to “The AMA Takes on In-Store Health Clinics”

  1. Dan on September 21st, 2007 12:17 pm

    Dr Rich, oh wise one, you took the words right out of my mouth. That’s why I left behind the fly trap of conventional primary care practice for a trip in the way-back machine to the halcyon days of my past when I really felt as if (and I believe that I was)I could heal patients by changing to an urgent care practice. I think I’m several cuts above even the best NP or PA and I am having the time of my life.

  2. Vijay Goel, M.D. on September 21st, 2007 1:08 pm

    Dr.Rich,
    This is a terrific article. Having just had my annual “checkup”, which also lasted a total of 7 minutes, I’m not sure what type of coordinated, high quality doctor visits the AMA is talking about.

    However, tools for self-empowerment are coming that will take high-quality health care back from this insurance-based mess.

    Now playing in the health entrepreneur space, myself and a number like me are creating new means of purchasing care that will bypass the insurance companies, allowing Americans to get the right level of care to suit their needs, at the right price.

    The employer-based comprehensive insurance game is now a tragedy of the commons, and America is ready to move on to greener pastures.

  3. DrRich on September 21st, 2007 3:31 pm

    Vijay,

    7 minutes? They owe you 30 seconds.

    I read your article earlier today on your annual checkup, and thoroughly enjoyed it and the conclusions you drew from it.

    If patient-empowerment is ever going to be accomplished, it will require individuals making decisions that are now made “for” them by central authorities (on care, on purchasing insurance, on just about everything). That means: at some point they’re going to have to control the payment for at least some of this stuff themselves. Until patients become SOMEBODY’s customer, they’re just going to remain a money drain (a major inconvenience, a necessary evil, a pain in the *ss), to EVERY player in the healthcare system, even the doctors.

    Rich

  4. Quiact on December 8th, 2008 1:30 am

    Quick When You’re Sick

    Recently in the media, issues have been addressed regarding the specialty of primary care or family practice doctors and the shortage of them in the U.S. In summary, reasons for the shortage that exists are due to the specialty not being that profitable for a doctor compared with other specialties. As a consequence, the doctors view the specialty as not a desirable choice apparently quite often, although the specialty is greatly needed in the health care system and for the public health.
    As a layperson, I view primary care as ultimately a specialist in nothing in particular, yet knowledgeable in a large variety of medical areas, which I believe, makes them very valuable to those patients seeking restoration of their health. Furthermore, there is a comfort level with those in this specialty compared with other specialties, one could speculate. So the shortage of primary care doctors is in fact disappointing. Perhaps most disappointing is the atrophy of the doctor-patient relationship unique with such doctors.
    Yet one possible solution is what is known as retail care clinics, and their popularity was increasing not long ago for a variety of reasons. And their eventual need has yet to be determined and is only speculated by others at this time. Of particular note of most of these types of clinics is that are normally staffed with nurse practitioners, who are, like doctors, more thorough than others, but are favored by many as a vocation and sought as treatment providers progressively. The growth of such clinics may have slowed, but not necessarily the benefits of these clinics.
    First, I’ll offer a definition of a retail clinic: A retail clinic is a medical treatment facility that is usually located in a convenient location, such as a shopping area, and are smaller than most doctors’ offices in regards to geographical space. Usually, these clinics are staffed with a nurse practitioner that often have the ability and authority to provide the same quality care as a primary care physician, and do so with the same standards regarding accountability and autonomy. If you happen to go to one for what may be considered a mild ailment, for example, for such conditions as allergies or the flu, you will notice a unique and pleasant paradigm towards your care at such a clinic in comparison with present medical offices that are possibly demoralized if not largely apathetic:
    These urgent care light clinics are normally and amazingly quick for a patient treated at such a location. You are normally in and out of there within a half hour or so. This includes a thorough assessment and treatment regimen offered. Unlike typical doctor offices, these clinics are walk-in clinics, so there is no over-booking of patients, which is what typically occurs at current offices of doctors, as many are focused on daily volume of patients, as they are usually a member of a large health care system that instructs these offices in such a way.
    With these convenience care clinics, you actually dialogue with your health care provider more so than you have experienced in a traditional doctor’s office due to other doctor offices often being incredibly busy from seeing too many patients during a typical day for reasons described above. And this is not to imply that the health care providers at typical doctor offices do not care about you and one’s particular health issues, yet possibly is due to limited resources, possibly.
    The cost of going to such a retail clinic, which is sometimes termed an ‘urgent care light’ clinic or convenience care clinic, that have already been mentioned, is usually about ¾ or less than the cost of a typical primary care doctor visit, I understand
    You will likely notice no decline in the quality of care that you receive. In fact, likely you will experience greater quality on many different levels, both on a personal and clinical level, yet this premise lacks certainty due to the many variables involved.
    Critics of such clinics include the American Medical Association and various medical societies, yet in my opinion, they are simply vexed because of the invasion of these clinics on their turf and their infiltration into their group without being invited, perhaps.
    If it is discovered that you need greater medical care or attention than the retail clinic can provide for you during your visit at their urgent care light clinic, you will most likely be referred to a nearby location that can provide the care you are determined to need by the clinic’s heath care provider, who has likely has some familiarity and possibly some relationships with the hospitals and others in the medical community for which they serve.
    So most patients of these retail clinics are pleased with the care they receive from them, which is why they continue to grow in number under different names, as they have become franchises, yet the concept of this pay as you go health care is fairly new, only the future will tell if this method is preferred by those seeking minor restoration of their health.
    These retail clinics, it appears, provide possibly provide a response to the shortage of primary care doctors that some believe exist, and possibly are an answer to other problems that exist in the health care system in the U.S., which includes wait time and frequent distant relationships from their other health care providers. One could conclude that the retail clinics seem in a way more authentic than the dominant structure, and may be more beneficial ultimately for the public health, with exceptions, of course.
    Dan Abshear
    “Compassion is the basis of all morality.” — Arthur Schopenhauer
    Author’s note: What has been written is based upon information and belief. Furthermore, urgent care clinics are also progressively providing a solution to the cumbersomeness of receiving efficient medical care as well.

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