The Covert Rationing Blog

The AMA Takes on In-Store Health Clinics

September 21st, 2007 by DrRich

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.

Posted in General Rationing Issues, Primary Care in America

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

1. Dan wrote on 09/21/07 at 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. wrote on 09/21/07 at 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 wrote on 09/21/07 at 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

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