They won’t take out your appendix, but if you have sore throat or need a vaccine, retail-based clinics are an increasingly popular option on the health care scene. With a nation-wide shortage of primary care physicians, CVS’s MinuteClinic and others like it are stepping in to offer the convenience and pricing transparency patients crave. We examine the appeal and the limits of retail-based health care and explore some doctors’ concerns about quality and continuity of care.

Guests

  • Nancy Gagliano Physician; Chief Medical Officer, MinuteClinic
  • Ateev Mehrotra Physician; Professor of Health Care Policy, Harvard Medical School; Researcher, RAND Corp.
  • Ernest Carter Physician; Deputy Health Officer, Prince George's County

Transcript

  • 13:06:41

    MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. They won't take out your appendix, but health clinics and stores like CVS and Wal-Mart offer everything from flu shots to strep tests to physical exams for summer camp. Physicians worry that retail clinics staffed by nurse practitioners don't offer the same quality of care you'd get at the doctor's office.

  • 13:07:15

    MR. KOJO NNAMDIBut clinics say they're not trying to replace your primary care doctor. They just want to offer a meet-the-people-where-they-are entry point for health care, especially on nights and weekends when the doctor's office is closed.

  • 13:07:27

    MR. KOJO NNAMDIAs more people signing up for health insurance under the Affordable Care Act and some communities struggle with a shortage of doctors, retail clinics are receiving new attention for their role in the changing health care landscape. Joining me to explore their impact locally and nationally is Dr. Ernest Carter. He is a physician and deputy health officer of the Prince -- within Prince George's County. He joins me in studio. Ernest Carter, thank you for joining us.

  • 13:07:53

    DR. ERNEST CARTERThank you, Kojo.

  • 13:07:55

    NNAMDIJoining us by phone from Rhode Island is Dr. Nancy Gagliano, chief medical officer of the CVS MinuteClinic. Nancy Gagliano, thank you for joining us.

  • 13:08:06

    DR. NANCY GAGLIANOThank you very much. I'm looking forward to our conversation.

  • 13:08:09

    NNAMDIAnd joining us from studios at Harvard Medical School is Dr. Ateev Mehrotra. He is a professor of public health policy at Harvard Medical School and a researcher at the RAND Corporation. Ateev Mehrotra, thank you for joining us.

  • 13:08:24

    DR. ATEEV MEHROTRAThanks for having me on, Kojo.

  • 13:08:26

    NNAMDIYou too can join the conversation. Give us a call, 800-433-8850 if you have comments or questions. Have you ever gone to a CVS MinuteClinic or a Walgreens health care clinic? Where do you go to get a strep throat test or a flu shot, 800-433-8850? Or you can send email to kojo@wamu.org or send us a Tweet @kojoshow. Nancy Gagliano, for listeners who have never been to a clinic at a pharmacy or at a big box chain store, tell us who staffs your MinuteClinics and what range of services people can get there.

  • 13:08:59

    GAGLIANOWell, thank you. So MinuteClinic has over 800 MinuteClinics across the country currently. They are staffed predominantly by nurse practitioners. And in some states we have physician assistants providing the care. These providers are trained and certified in family medicine, which means they can take care of a wide range of services from -- for children through adults.

  • 13:09:27

    GAGLIANOThe spectrum of services we take care of are pretty common and pretty straightforward. So we do everything from things like sore throats, earaches coughs, colds, scrapes, bumps, bruises, vaccinations. We'll check your blood pressure, check your cholesterol. All of these things are to provide convenience right out in the community, as you were suggesting in your opening. But we really do want to make sure that our patients also have a primary care provider that they then can follow up with and be connected with for the long term.

  • 13:10:03

    NNAMDIAteev Mehrotra, the academy -- the American Academy of Pediatrics said it doesn't believe retail clinics should handle children's primary health care because they don't offer the continuity of care that a pediatrician does. What does your research show about the quality of care that retail clinics provide?

  • 13:10:23

    MEHROTRAYeah, I think a number of physicians have raised concern that the providers at these clinics, nurse practitioners and physician assistants may not provide -- might provide inferior quality of care. Our research, as well as the research of others, has been actually very reassuring in that the quality of care as measured by how often people are getting antibiotics or whether their appropriate tests are being ordered has, again, all shown that it's very similar to the quality of care that you would get at a physician's office.

  • 13:10:52

    NNAMDIErnest Carter, retail clinics got started about a decade ago. In the early days of the industry you worked with Wal-Mart to set up clinics in several southern states. But their growth hit a plateau in recent years before starting to expand again. What effect is the Affordable Care Act having on the market for retail clinics?

  • 13:11:11

    CARTERWell, I think that ultimately the Affordable Care Act will expand retail clinics significantly. I think that what has to happen in the interim is that the model for health care, the systems of health care will have to transform. And because people are starting to take more of a population health approach and look at different models like the model of using an integrated practice unit like -- that comes out of the Harvard Business School, Michael Porter's work, and to start to look at how funding and costs can be shared across a system of care. I think that's when health -- when retail clinics will expand. At the fee-for-service level it's difficult, especially in underserved areas.

  • 13:11:58

    NNAMDINancy Gagliano, same question to you. What effect the Affordable Care Act is having on the market for retail clinics.

  • 13:12:04

    GAGLIANOSo I would completely agree as people become more and more insured, their expectations for access will only become greater. And we currently have what's estimated to be a 40,000 physician shortage in primary care. So we need more access to primary care. And the concept that there's opportunities in this country for population health management is really extraordinary.

  • 13:12:34

    GAGLIANOOne of the things we do at MinuteClinic is we affiliate with local health systems and then integrate our electronic medical records so that we can be that extension. So if it's appropriate for a patient to get their blood pressure checked and they need to get it checked on a weekend, they can come in and see us and then get that result right back to the doctor's office.

  • 13:12:57

    NNAMDIIndeed that has to do with the next question I'm raising, the question of convenience. Nancy Gagliano, retail clinics are responding in part to a demand for accessible after-hours care and the ability to be seen quickly without an appointment. Half of the visits to your clinics are reportedly on nights and on weekends. How does convenience figure into your business model?

  • 13:13:19

    GAGLIANOSo I think you highlighted something that's really important. Half of the patients we see we're seeing in the evenings and on the weekends. So, you know, people have very busy lives, and unfortunately so do physicians. Physician's offices are packed. It's hard to squeeze in another patient and therefore the demand for access is definitely outstripping the capacity.

  • 13:13:45

    GAGLIANOThe other thing that's worth noting is 50 percent of the patients who come to a MinuteClinic report that they don't have a PCP. So we're providing access as well as that. And many patients say that they would have gone to an emergency room, which we all believe, you know, we don't want to bog down our emergency rooms with strep throats and coughs and colds. So convenience and access is really important today.

  • 13:14:14

    NNAMDIAteev Mehrotra, what do your studies show about the role of convenience in all of this?

  • 13:14:19

    MEHROTRAYou know, we've done both interviews with patients at these clinics and also done some analyses of who visits these clinics in general. To echo what Nancy said, you know, many of the patients who visit these clinics, they tend to be mostly young adults, people who don't typically go to a primary care physician as much as someone who's older. As Nancy said, many of the patients don't have a primary care physician.

  • 13:14:44

    MEHROTRAIn talking to patients, often what we heard was, you know, I'm busy. Both of us work. We -- it's hard for us to miss work and get into our doctor's office. This is a convenient option. I can drop in, not miss work and get care in and out and get back home. And that's something that's really valued by people across the country.

  • 13:15:06

    NNAMDIErnest Carter, convenience?

  • 13:15:08

    CARTERYes. I think convenience is one of the primary drivers. And so what we have to be acutely aware of is that when we start to design health care systems that reach a whole population and we have to factor in the fact that convenience is one of the drivers. And so that we know that these touch points like a retail clinic should be used for convenience in that they can be integrated into a doctor's practice for instance.

  • 13:15:37

    CARTERAnd that's what doctors have sort of recalcitrant about that because they're concerned that they're going to fragment their care. I think the attitude has to change and has to say, we need to integrate.

  • 13:15:48

    NNAMDIHere is Ashley in Washington, D.C. Ashley, you are on the air. Go ahead, please.

  • 13:15:54

    ASHLEYThank you for the opportunity to join in. My name is Ashley Jeffers and I am an advanced practice registered nurse student with Georgetown University here in Washington, D.C. I've been practicing as an emergency room and trauma nurse for about 11 years. And over the past two years I've sought to advance my role and I am going to graduate from Georgetown in less than a year as a primary care nurse practitioner.

  • 13:16:20

    ASHLEYI work here in Georgetown's emergency room and I can personally attest to the fact that a large percentage of our patients, especially during the nights and weekends, could be safely, effectively and at a lower cost be treated by these MinuteClinics. And advanced practice registered nurses are largely in support of these clinics. And I would just like to echo that we are not trying to replace the physician's role -- to integrate and supplement their care. Because the Affordable Care Act is providing millions more Americans with the ability to access health care equally.

  • 13:17:00

    ASHLEYAnd we're just trying to improve the health of our overall community. And we focus on prevention and early detection of disease. So I want to thank you for the opportunity to join in and just voice, you know, a nurse practitioner's perspective.

  • 13:17:18

    NNAMDIWell said, Ashley, and good luck to you. Thank you very much for your call.

  • 13:17:21

    ASHLEYThank you, Kojo.

  • 13:17:22

    NNAMDIAteev Mehrotra, retail clinics only provide a small percentage of the overall health care in the U.S. but their popularity is growing. What are the numbers?

  • 13:17:34

    MEHROTRAYeah, what we've seen is a rapid growth in the number of both clinics in the United States -- and there's been a recent upsurge in particular from MinuteClinic opening a number more clinics. And in the terms of the number of patients who are visiting a clinic, we see about 6 million was our latest estimate in terms of number of retail clinic visits in a single year. And in some other work we've done, about 5 percent of the population had visited a retail clinic in certain urban communities on a yearly basis.

  • 13:18:03

    NNAMDI800 -- 800-433-8850. Where do you go for health care after hours or on weekends? You can send us an email to kojo@wamu.org. Ateev, can you talk about pricing? Retail clinics often post their prices online so people know up front what they'll pay. And I've read that those prices are typically 30 to 40 percent lower than you'd pay for the same service at the doctor's office. Is that true?

  • 13:18:30

    MEHROTRAYeah, and I think one thing that we don't often talk about retail clinics but I think is one of the most important aspects of them is that price transparency. When a patient visits me in clinic or in the hospital, they don't know how much it's going to cost. And often I don't know how much it's going to cost. And I think that's the experience of most Americans when they seek care.

  • 13:18:46

    MEHROTRAAnd I think one of the places -- one of the things that I think is particularly notable about retail clinics is that you go to the website, you go and they have a menu -- or in front of the clinic and they have a menu and it lists the prices. And those prices -- and in our interviews with patients, in particular those who are uninsured, that was one of the key attractions. They would describe experiences going to the emergency department, getting care, getting an exorbitant bill in the mail, bill collectors.

  • 13:19:12

    MEHROTRAAnd even though a retail clinic visit is not cheap, it's still a substantial amount of money, they like the fact that they knew how much it was going to cost up front. And I think that's something that I hope our larger health care system moves toward soon.

  • 13:19:26

    NNAMDINancy, what kinds of insurance do you accept at MinuteClinics and how does it affect -- how does that affect who shows up for care?

  • 13:19:34

    GAGLIANOSo that's a great question, Kojo. MinuteClinic prized a contract with all insurance companies possible across the country. And we have well over 300 contracts. We've been a little bit challenged in the past with obtaining contracts with Medicaid and Medicaid Managed Care contracts. But in the last three years we've made really tremendous strides. And that has therefore allowed us to be much more of a viable option for the less fortunate of us. And therefore we're finding that our mix of patients is definitely changing over the last couple of years.

  • 13:20:16

    GAGLIANOAbout 85 percent of the patients who come to MinuteClinic now do use their insurance. And this is different than a number of years ago where it was closer to 20 to 30 percent of patients were using -- were not using insurance.

  • 13:20:31

    NNAMDIHere's John in Westminster, Md. John, you're on the air. Go ahead, please.

  • 13:20:36

    JOHNThanks, Kojo. I'm a dean of a family nurse practitioner program and I just have two comments about retail clinics. And first of all, they serve a wonderful job for us in terms of having our nurse practitioner students go there as they -- and be their preceptor. So they help train our nurse practitioners. And second of all, being a nurse practitioner for 25 years I've -- they've really helped keep people from becoming sicker because they just had -- patients have had troubles with access to care. And now some of these things that they can help prevent by being seen sooner where in the past they had to wait days or weeks for an appointment.

  • 13:21:18

    NNAMDIOkay. Thank you very much for your call. Care to comment, Ernest Carter?

  • 13:21:22

    CARTERNo, I think that's absolutely true. And I think that the nurse practitioners are going to play a tremendous role in -- not only in the treatment but also in the prevention. And I think that's going to be the largest part of how the Affordable Care Act is going to influence retail clinics. Because they are going to allow the cost of the whole total health care system to lower because they are going -- because they concentrate on preventative measurements. And then they can be integrated with the practice of medicine, as I believe they will be. I think that'll be a tremendous cost savings. And nurse practitioners are ideal for that.

  • 13:22:00

    NNAMDIGot to take a short break. Thank you very much for your call, John, but you too can call us at 800-433-8850. What role can retail clinics play in communities with a shortage of doctors? That's one of the things we'll be talking about when we come back. You can also send us an email to kojo@wamu.org, a Tweet @kojoshow or go to our website kojoshow.org and ask a question or make a comment there. I'm Kojo Nnamdi.

  • 13:24:01

    NNAMDIWelcome back to our conversation on MinuteClinic and retail-based health care. We're talking with Dr. Nancy Gagliano, chief medical officer of CVS MinuteClinic. She joins us by phone from Rhode Island. Dr. Ateev Mehrotra. He is a professor of public health policy at Harvard Medical School and a researcher at the RAND Corporation. He joins us from studios at Harvard Medical School. And Dr. Ernest Carter is a physician and deputy health officer of Prince George's County. He joins us in our Washington studio.

  • 13:24:30

    NNAMDIErnest Carter, some communities including parts of Prince George's County do not have enough doctors to serve their population. You got a Health Enterprise Zone grant from the State of Maryland to try to address the problem. What's the magnitude of the physician shortage and what role can retail clinics play in addressing it?

  • 13:24:49

    CARTERWell, we have a significant problem with having primary care physicians in Prince George's County but it's in an unequal distribution throughout the county. There are some areas that have adequate and more than adequate physicians and other areas that don't. And so the extent of the problem is large from a public health standpoint.

  • 13:25:15

    CARTERAnd when we looked at -- when we had a study done -- impact study done, we came to the conclusion that there's about 60 physicians -- primary care physicians slash primary care providers that we need in our county to get up to adequate numbers. So with the Health Enterprise Zone that was a grant that we got from the state to help address this problem. And not only that but also to transform our system of care in those areas where there's a significant shortage.

  • 13:25:43

    CARTERSo the enterprise zone actually focuses in on area (sic) code 20743, which is Capitol Heights. And in there that was a significant shortage of physicians. We needed almost 20 to be able to actually to serve that one zip code. And we didn't have nearly those many. So we have put in place incentives which this particular grant gave us to attract doctors into the area.

  • 13:26:10

    CARTERNow, to be relevant to our conversation today, I'm very much interested and have been very interested in how we increase access, our footprint. Even when we have -- for every one physician, retail clinics expand our footprint significantly in terms of access to care. And how we actually work with those retail clinics is one of the challenges that we have. But we believe that we can do that and make it significant to our population.

  • 13:26:42

    NNAMDIHere's why you got to get up to speed in Capitol Heights. That's where my son and his family live. So you got to get on the case in Capitol Heights.

  • 13:26:49

    CARTERNo problem, Kojo. I got it covered.

  • 13:26:53

    NNAMDINancy Gagliano when you're looking for new locations for MinuteClinics, is there a certain profile of a community that works well for you? Do you look for areas that are underserved by doctors?

  • 13:27:06

    GAGLIANOSo we look at a variety of factors. One of the most important factors actually, believe it or not, is the store size. Since all of our MinuteClinics are within a CVS, the store has to be big enough to have the space to accommodate a MinuteClinic. So that's almost the first layer. And then the other thing we do is look at how close other clinics are. And as you can imagine, putting a clinic that is not near any other clinic is hard to staff and hard to support from a management perspective as well as a marketing perspective.

  • 13:27:41

    GAGLIANOSo we like to start in a market by having a handful of clinics to kind of get the team up and running. And then after that, based on how busy certain areas are, then we expand and expand further and further. So for example, we have -- I know we have three clinics in the Prince George's County. Maryland in general is -- for example, we have 12 clinics overall.

  • 13:28:08

    GAGLIANOMinuteClinic is in an expansion mode, meaning that we're adding 100 to 150 new clinics a year. So I would certainly anticipate us continuing to grow and expand in Maryland. And would -- you know, I'm not from the area so I apologize but would certainly be very interested in following up with Ernest about the Capitol Heights area and see if that's something that we might have some opportunity to work together on.

  • 13:28:37

    NNAMDIAteev Mehrotra, your research shows that most retail clinics are not, in fact, located in underserved communities. So how much are they helping to meet this need?

  • 13:28:47

    MEHROTRAYeah -- no, I think, Kojo, you captured it that I think there's a lot of potential. And at least many have hoped that retail clinics could be a mechanism to expand access to care in underserved communities, including those areas of Prince George's County. Our research hasn't found that -- you know, there are about 10 percent of -- a little bit more than 10 percent of the clinics in our last work were located in underserved communities. So there are some in underserved communities but they're not preferentially located there.

  • 13:29:15

    MEHROTRAThey're preferentially located, it appears currently at least, in wealthier communities, suburban communities. That might be driven by what Nancy described in terms of the stores that could be located. But unfortunately right now they are -- at least in our work, have been located exactly where the doctors are in those communities.

  • 13:29:34

    NNAMDIOn to the telephones. Here is Sarah in Twin Brook, Md. Sarah, you're on the air. Go ahead, please.

  • 13:29:41

    SARAHLet me pull over. Hang on.

  • 13:29:43

    NNAMDISarah is pulling over and we are hanging on while Sarah is...

  • 13:29:47

    SARAHOkay, I'm getting there. I'm a retired health care professional. And my husband works in an emergency room. And there's a positive and then there's negatives. The positives about these urgent health care clinics and MinuteClinics is that it takes the minor cases that really can be taken care of in that type of setting out of the emergency room so that, as I've heard the complaints, he has time to take care of the people that really need medical care, you know, the car accidents and the heart attacks and strokes and the major emergencies that need to be seen in an emergency room.

  • 13:30:29

    SARAHTheir emergency room does have a quick visit area which they do staff with physician assistants but they also have a -- have to have a physician there as backup. And so there's -- that's the positive side is that they are -- at least for him, they're giving him opportunity to spend more time taking care of the patients that really need to be seen in an emergency basis versus as the urgent care or the simple medical clinic...

  • 13:30:59

    NNAMDIWell, you said positive side and I infer from that that there's also a negative side.

  • 13:31:05

    SARAHWell, the negative side is that sometimes patients will go to an urgent clinic or urgent care when the really do need to be in the emergency room. And then...

  • 13:31:17

    NNAMDIBut...

  • 13:31:18

    SARAH...most of those urgent clinics will refer the patient to the emergency room if they need it. But I've heard of occasional cases where he said, well, you know, they should've really come to the emergency room first or the clinic shouldn't have tried to deal with it. They should've sent them first. But I don't hear that very often. My personal question would be, what kind of oversight -- I guess the menu that you're talking about would be good if a patient shows up and says, well, we only do these few things. And if you have something more -- something that's not on the treatment...

  • 13:31:50

    NNAMDIAll right. Allow me to have Nancy Gagliano respond to that. Nancy Gagliano.

  • 13:31:55

    GAGLIANOHi there. So a couple of issues were brought up. First of all, yes, unfortunately very rarely, which is much less than 1 percent of the time do we have to send somebody to emergency room. But unfortunately sometimes people think they have something minor when they have something more severe. And our providers are very well trained to identify those problems.

  • 13:32:19

    GAGLIANOIn addition, all of the services we provide, we have guidelines on the appropriateness of the condition and on what types of conditions and what types of parameters the patient should be transferred onto additional care. So if their temperature is very high or their blood oxygen level is low or their lung exam is abnormal, that might be a reason to refer them on for additional care.

  • 13:32:46

    GAGLIANOThe other thing that was mentioned was the question about oversight. So every single nurse practitioner and physician's assistant has a collaborating physician who they are always available for backup and as well as provide chart review and collaborative phone calls and education with their providers. So whenever a practitioner might be in doubt as to what is the best course of action, they always have their collaborating physician to chat with.

  • 13:33:19

    NNAMDIAteev Mehrotra, what are the most popular services people get at retail clinics? You reported that several years ago flu shots topped the list of vaccines administered by clinics and accounted for roughly 40 percent of the visits. Is that still the case?

  • 13:33:34

    MEHROTRAIn the work that we did, one of the things that's really striking about retail clinics is that there is this menu. It's a relatively limited scope of issues. And a small number of problems really, you know, make up the majority of those visits. So as you already mentioned, Kojo, flu shots -- well, vaccinations in general but flu shots predominantly. But other common problems, upper respiratory illnesses, bronchitis. You're worried that you have strep throat. You're worried you have an ear infection, some allergies.

  • 13:34:03

    MEHROTRAJust that small set of problems really made up more than 90 percent of all the visits to retail clinics. So it's -- as a physician it's very striking to see such a narrow scope of care. Though again, there's maybe about 100 million visits for that type of care across the country to doctor's offices. So it's one of the most -- these kinds of problems are the most common reasons people see a provider on a yearly basis.

  • 13:34:25

    NNAMDIWe got a Tweet from Mike who writes, "How do retail clinics share patient information with primary care physicians to ensure continuity of care?" Ernest Carter, some doctors complain that retail clinics fragment health care for patients and do not, in fact, provide continuity of care. What's the relationship between clinics and primary care doctors? Is it supportive? Is it competitive? Both and I'll start with you Ernest Carter but then I'll also ask the other two panelists to answer the same question.

  • 13:34:54

    CARTERWell, I think it's dependent on the retail clinic. I will give kudos to CVS in the fact that they work very hard to communicate with the primary care physician. Their health information technology systems, the EMR, they work very hard to communicate in terms of getting to the physicians.

  • 13:35:13

    CARTERThere are other retail clinics that don't do quite the same job. And one of the things that I am a real advocate of is to come up with the types of systems that will link retail clinics to patients and their primary care physicians. That is where the rubber really meets the road, especially when we're driving physicians into patient-centered medical homes. And this should be a part of their overall actually service offering (sp?) .

  • 13:35:45

    CARTERAnd when you look at the formation of ACOs, retail clinics actually should be a part of that and should share in the cost. Also, they should have performance measures like -- and be held to standards. And I think that that would improve how the communications occur between the primary care physicians and the retail clinics.

  • 13:36:09

    NNAMDINancy Gagliano.

  • 13:36:11

    GAGLIANOWell, thank you for the kudos, Ernest. And yes, it is -- communicating with physicians is something that we take very, very seriously. I'm a primary care provider by training. I spent 21 years as a PCP before joining MinuteClinic. And I view retail health as you do, as the extension of primary care and primary care support right in the community. But we can really only be successful if we are acting like a partner and acting in extension.

  • 13:36:48

    GAGLIANOSo we have a couple of processes that are automated that really are dear to enhance that communication. So for example, if a patient comes to MinuteClinic, they are always asked if they have a primary care provider. If they do and they give us permission, the computer system automatically that evening sends a copy of the patient's summary to the primary care physician typically by fax. Sometimes by mail if they don't have fax. T he patient always receives a copy of their visit summary as well and are told to bring that to their PCP.

  • 13:37:28

    GAGLIANOIf a patient comes to us and they don't have a primary care provider, we automatically print out a list of local primary care providers in their community who are accepting patients and encourage them to develop that relationship.

  • 13:37:41

    GAGLIANOAnd then finally, as I mentioned in the very beginning, we have 32 health system affiliations across the country. And with those affiliations -- and you're right, a lot of them are working to become ACOs, accountable care organizations, we're integrating our electronic medical records so that our providers can see the patient summary, their allergies, their problems and whatnot. And our record, our visit summary can go right into the electronic medical record.

  • 13:38:13

    GAGLIANOAnd I think that is the ultimate ideal situation where we are indeed an extension of the PCP so that they're comfortable sending their patients to us in the evenings and weekends, knowing that they're going to get the patient summary, as well as knowing that we're going to know what medications and allergies the patient has.

  • 13:38:33

    NNAMDIAteev Mehrotra, another area of concern among doctors is whether people who go to a clinic once are they inclined to go back again, essentially cutting the doctor out of the equation for low level care. Do you see that happening?

  • 13:38:48

    MEHROTRAYeah, it's a concern. There's the communication aspect but there's also the aspect of disrupting primary care relationships. As Ernest and Nancy have both talked about, we're moving towards a health care system which is focused on the patient-centered medical home. And one of the common concerns I hear from primary care physicians is that when a patient goes to a retail clinic, it's one less visit to me. And that that potentially could disrupt what we believe is an important thing, which is that relationship between the primary care physician and the patient.

  • 13:39:17

    MEHROTRAI guess we've done some work to try to assess that. The first is just to state something we said earlier. For the majority of patients who go to a retail clinic, they don't have a primary care physician. So there is often no relationship to disrupt. But another aspect of this is for those who do have a primary care physician, maybe not surprisingly we do see that when patients go to a retail clinic they're more -- they are often likely to go back. And so there is a decrease in continuity and number of visits to a primary care physician.

  • 13:39:46

    MEHROTRAI might add just one other point, which is another concern that's often raised, is that well, if patients go to a retail clinic, they're less likely to get preventive care or their diabetes or other chronic illness managed. And in that aspect we didn't find, in our research, any negative impact of going to retail clinics.

  • 13:40:04

    NNAMDIOn to the telephones again. Here is Ross in Reston, Va. Ross, you're on the air. Go ahead, please.

  • 13:40:11

    ROSSHi, there. Just had a very positive story about the costs. Somebody had mentioned something about the costs being 30 to 40 percent lower. And I had a common experience last summer of the tick bite and the associated bulls eye. And I wanted to get this taken care of within the recommended two-day timeframe or whatever. So I did go to a local 24-hour type trauma center that's associated with our local hospital, and went through the sign-up procedure. And I just paused to ask the staff person, before I went in to see the doctor, roughly what sort of costs we were looking at.

  • 13:40:53

    ROSSAnd she quoted me that it would be somewhere in the neighborhood, just north of $1,000. And even though this was a case where the cliché of, don't worry, insurance will cover this, I just couldn't bring myself to keep going. The following day I went to one of these types of MinuteClinics, I believe it was in Herndon, Va. And the staff person was professional and courteous and knowledgeable. And I walked out with a prescription. And I think the cost was somewhere around $40. And I just walked out thinking, Okay, this is sort of the way it should be. That was my need and this particular clinic filled it perfectly.

  • 13:41:44

    NNAMDIYou saved in the vicinity of $960 either for -- out of your pocket or your insurance carrier's pocket. That worked for you.

  • 13:41:55

    ROSSWell, correct. And I don't see the point in passing along this type of incredible cost, in my opinion, to the black hole of insurance, even though, again, my portion was just going to be a small part of that...

  • 13:42:11

    NNAMDISure.

  • 13:42:12

    ROSS...it just did not seem to be a match of costs and services.

  • 13:42:17

    NNAMDIThere you go. Thank you very much for that. We're going to have to take a short break, unless there's someone who wants to comment on that. Dr. Carter, you want to comment on that?

  • 13:42:24

    CARTERNo. I think that's a great example of why having access to care at a convenient time really helps save costs. And I think that'll lead to further discussions I think after the break.

  • 13:42:37

    NNAMDIWhen we come back after the break, we'll be looking at the intersection of medical care and public health and taking your calls. 800-433-8850. Or send email to kojo@wamu.org. You can also send us a tweet @kojoshow. I'm Kojo Nnamdi.

  • 13:44:32

    NNAMDIWe're talking about retail-based health care with Dr. Ernest Carter. He's a physician and deputy health officer of Prince George's County. Dr. Nancy Gagliano is chief medical officer of the CVS MinuteClinic. And Dr. Ateev Mehrotra is a professor of public health policy at Harvard Medical School and a researcher at the RAND Corporation. Ernest Carter, as I said, let's look at the intersection of medical care and public health. How do retail clinics bridge the two?

  • 13:45:01

    CARTERWell, that's a very good question and I'm glad you asked me, Kojo, because I've felt that the -- there is an intersection between how do we improve health outcomes and leverage our retail establishment to do that -- our grocery stores, pharmacies? Because that's where people's health behavior actually is engendered. And so I've felt very excited about and I know the APHA, the Association of Public Health Association -- American Public Health Association was very excited about the fact that CVS and Wegmans and Target stopped selling cigarettes, because that's where people buy them.

  • 13:45:45

    CARTERAnd that's -- it should be a message that says, you know, this particular poison should not be distributed in our communities. But, moreover, in terms of the retail clinics, it's a beautiful integration between retail and health. And I think that retail clinics are going to play a really important role in how we change health behavior. And as I mentioned before, not only in prevention, but they're also going to play a role in care coordination between the time -- between your doctor visits. That's when your care actually gets coordinated. And I think that the retail clinics will play a large role in that.

  • 13:46:22

    CARTERAnd in transition care, when you're coming out of the hospital and going home, there's a gap. And in that gap, that's where the retail clinics, I think, actually have a role to play. And I know that there are a lot of -- a lot of different organizations that do care coordination. But I think that will be. And lastly, in public health, you know, we have to get our message across. We have to target the population about, how do you change your behavior? How do you eat better? How do you -- how's the best way to lose weight, et cetera.

  • 13:46:53

    CARTERAnd going through the retail vehicle is, I think, very significant. The only other last think I will say, Kojo, is that when we did some work at Howard University looking at how do we educate diabetics. And we put -- we targeted various places. We found that it was in, actually, the pharmacy and grocery stores where we had a big success.

  • 13:47:17

    NNAMDINancy, as Ernest Carter mentioned, CVS recently decided to stop selling cigarettes and to position itself as a provider and promoter of health care and related products. Are the MinuteClinics moneymakers for CVS? What factors are influencing your decision to double the number of clinics in the next few years?

  • 13:47:36

    GAGLIANOWell, first of all, thank you for highlighting the fact that we're eliminating cigarettes at CVS. I'm very proud of the company. And I absolutely agree that we, as an organization, have a responsibility to help support the community and community health. You know, I think MinuteClinic is profitable on an enterprise basis across the country. But I don't think that's really the reason why CVS and MinuteClinic are together. CVS is definitely looking at itself as an organization that is a health care organization.

  • 13:48:20

    GAGLIANOAnd, as Ernest was saying, that the community has to really take responsibility on helping with population health, although I am a firm believer in the primary care medical home model. I also know that as a society, we need to take this responsibility among all of us to improve general health care. So for an example, a typical patient who has diabetes sees their provider about once every three to four months. But if they use CVS, they're in CVS about six times in that month.

  • 13:48:54

    GAGLIANOSo if we start looking at the community and its responsibility, you can see MinuteClinic as having an active role as well, where MinuteClinic can do a diabetes check in between their provider visit. Or MinuteClinic has a service for smoking cessation. And, you know, not only are we stopping cigarettes, but we -- selling cigarettes, we want to help people who smoke cigarettes to stop. So MinuteClinic has a weight-loss program that is based on the DASH diet, a very healthy diet, and a smoking-cessation program, so that we can really be part of the prevention and the population health answer.

  • 13:49:38

    NNAMDIAteev Mehrotra, what do patient satisfaction surveys say about the convenience, the quality of health care at retail clinics? And what are the lessons in those number for primary care doctors and the medical establishment?

  • 13:49:52

    MEHROTRAYou know, I think, Kojo, in general, patients are very happy when they go to one of these clinics and actually often are happier than they get if they would go to a primary care physician. I think that probably stems from two issues. The first is that often it's about getting patients in and out quickly in a convenient place, a store that they're familiar with. And I think that's appreciated. And I also think, and as a physician I'll say our -- we are not -- we don't take often enough time with patients. And I think that the nurse practitioners have done a better job at retail clinics and elsewhere about spending more time with a patient.

  • 13:50:32

    MEHROTRAAnd I think patients appreciate that. And therefore, they're far more satisfied. You know, and it'll be interesting to see how this evolves over the coming decades as we evolve in there. I generally feel that the health care system has to focus more on serving patients in a more convenient way that's more patient centric. And whether that's being care that's provided in sites like clinics, the retail stores that are familiar to them, providing care at home, at the worksite, and trying to really focus on it from a patient-centric way as opposed to often what I think has been the sort of norm is that we do things from a provider-centric way, what's most convenient for us.

  • 13:51:11

    NNAMDIOn to Melissa in Washington D.C. Melissa, thank you for waiting. You're on the air. Go ahead, please.

  • 13:51:17

    MELISSAHi, Kojo. Thanks for taking my call. I just wanted to -- I've been to four or five different MinuteClinics in multiple states all over the place. I've had an amazing experience each time. The first time I was a little nervous, saw the nurse practitioner. But remembered that most of my doctors' offices, I'd also seen nurse practitioners, so I wasn't that worried. She spent lots and lots of time with me asking questions. And then, you know, on one occasion, I just needed over-the-counter cold medicine. Another time I had a rash. She gave me -- went out and found the correct topical ointment.

  • 13:51:50

    MELISSABut most importantly, most recently, I was -- left for a family vacation, got on the airplane, started feeling sick, landed on the other side of the country for a vacation, and was feeling absolutely terrible. Decided to go to a MinuteClinic, because I obviously didn't have a doctor nearby. And sure enough, I had strep throat. And they gave me medicine, the antibiotics. And I was in and out in a quick amount of time. And I was feeling better the next day because I was treated quickly, even though I was very far from home.

  • 13:52:20

    MELISSASo I can't say enough about them. And I think from a public policy perspective, the best thing we can do to lower health care costs across the country and to help everybody, is to provide more individual, personalized experiences like this that are in and out, and address small issues with the appropriate level of interaction and professionalism as well.

  • 13:52:44

    NNAMDIMelissa, thank you very much for your call. We got an email from Catherine in Springfield who said "The arguments against retail clinics staffed by nurse practitioners are invalid. Much of day-to-day care is nursing care. Nurse practitioners are highly educated. This is a welcome return to something approximating the great Visiting Nurse and Settlement House Programs of the late 19th and early 20th century. It was those nurses and their teaching based care who brought down child and maternal mortality and helped to bring tuberculosis under control.

  • 13:53:14

    NNAMDI"With transport to hospitals easily accessible, there really is no excuse for insisting that the only point of care is the physician. The Visiting Nurse Programs died in the late 1920s, with the influence of the physicians." Care to comment on that, Ernest Carter?

  • 13:53:28

    CARTERWell...

  • 13:53:29

    NNAMDIA little bit of history.

  • 13:53:30

    CARTERNo and I really have a great appreciation for that. I often tell the people who I work with at Prince George's in the health department that, when you look at a patient when they're in the hospital and you notice they come in sick and they get better, the reason they get better is because there's intensive nursing care while you're in the hospital, with a minimal interaction from the doctor. The doctor does some few things. But it's the nursing care and the coordinated services that you get while you're in a hospital, you get better.

  • 13:54:00

    CARTERThen you leave, and all of sudden you no longer have a nurse. You no longer have the coordinated care. And you're going to see the doctor in x-number of days, and maybe at another time interval. So there are these large time intervals between the time you actually see your primary care and your nurse, and you fall off the wagon a little bit. You get sick again. And next thing you know, you're in. So that's why I really do believe that retail clinics, with their nurse practitioners there and with the -- with what Nancy said, they have like six visits in between your primary care -- will address this care coordination issue because the nursing is very, very important in health care.

  • 13:54:38

    CARTERAnd I think that we need to get back to it just like the -- that particular person said, to having -- injecting nursing into our health care coordination.

  • 13:54:49

    NNAMDIWe got a tweet, Nancy, from someone who says, "Is CVS considering adding limited dental services to its clinics? Dental care is something too many people lack."

  • 13:55:01

    GAGLIANOYou know that's a great question and we're always looking for opportunities to safely expand our services. We have heard from a number of our patients that access to dentists is challenging, and particularly if they have an abscess over the weekend and can't get in to see their dentist. So it is something we are exploring as well as, like we coordinate and collaborate with physicians, is finding dental and dentist collaboration across the country so that we can make sure our patients get the follow-up care that they need in that health care realm as well.

  • 13:55:41

    NNAMDIAnd this email we got from Maria. "What is the referral process in the retail clinics for families who come in hungry, homeless, with evidence of domestic violence, child abuse, et cetera?" Again, Nancy?

  • 13:55:55

    GAGLIANOSo that is a very complicated issue. And I think one of the things that is still fundamental to our model is that we really believe in the primary care home. And that all patients, no matter what socioeconomic group, whether they have mental illness, whether they have other challenges, that they are a part of a medical neighborhood. So in that type of a situation, we would help facilitate an appointment with a primary care caregiver. We have local -- we have listings of local free clinics and local community-based health centers, so that we're often trying to help navigate for a patient to get them into a situation that will get them the care that they need.

  • 13:56:49

    NNAMDIYou wanted to say, Ernest Carter?

  • 13:56:51

    CARTERYeah, and that's one of the -- one of our primary focuses in Prince George's County now with our public health. We're very focused on integrating our public health system into primary care. And our public health system actually brings a lot of services to bear, social services, services for the homeless, et cetera. So we're trying to integrate our services with primary care.

  • 13:57:15

    CARTERAnd so when a retail clinic services should come into, for instance, into our area, we would integrate those services so that we would have a smooth workflow between -- and put in the processes and protocols that would allow a retail clinic or a primary care provider to be able to do those types of referrals and get that patient into -- or that person, patient into the necessary services that they need.

  • 13:57:42

    NNAMDIDr. Ernest Carter is a physician. He's the deputy health officer in Prince George's County. Dr. Nancy Gagliano is chief medical officer with CVS MinuteClinic. And Dr. Ateev Mehrotra is a professor of public health policy at Harvard Medical School and researcher at the RAND Corporation. Thank you all for joining us.

  • 13:58:00

    NNAMDI"The Kojo Nnamdi Show" is produced by Michael Martinez, Ingalisa Schrobsdorff, Tayla Burney, Kathy Goldgeier, Elizabeth Weinstein, and Stephanie Stokes. Brendan Sweeney is the managing producer. Our engineer is Tobey Schreiner. Natalie Yuravlivker is on the phones. Thank you all for listening. I'm Kojo Nnamdi.

  • 13:58:23

    NNAMDIComing up tomorrow on "The Politics Hour," Maryland's gubernatorial candidates lock horns in a televised debate, Virginia's governor seeks an end run around the legislature to expand Medicaid. Plus, bringing scandal to D.C. One lawmaker hopes to convince a popular television show to film in the nation's capital. "The Politics Hour," tomorrow at Noon on WAMU 88.5 and streaming at kojoshow.org. And for listeners in Ocean City, Md., it's "Coastal Connection," with Bryan Russo.

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