Rise of retail clinics giving doctors a chill

AMA to make push for more scrutiny of sites staffed by nurse practitioners

By Bruce Japsen
Tribune staff reporter

June 12, 2006

Feeling threatened by the proliferation of retail health clinics staffed by nurse practitioners, the nation's largest doctors group is pushing this week for increased scrutiny of the clinics and the nurse practitioners who staff them.

Basically, the American Medical Association has a problem with caregivers like Laura Maxwell.

Maxwell, a 25-year-old licensed nurse practitioner with a master's degree, checks coughs, gives vaccinations and dispenses other routine medical care at The Little Clinic in a Kroger grocery store in Louisville.

"We see lots of minor illnesses like colds, sore throats, and write a lot of prescriptions, typically for viruses," said Maxwell, who views her clinic as a complement to a physician's care. "It's a place they can go when the doctor's office is closed."

The Little Clinic, which operates eight facilities in three states, opened sites in Mt. Vernon and Carbondale, Ill., within the last year.

As at most other retail clinics, the operators say their offices are open seven days a week, with evening hours, and no appointment is necessary. A doctor comes by to review charts and other decisions made by the nurse practitioners but typically does not see patients.

Such clinics advertise that they will treat patients with routine maladies in 15 minutes or less, the amount of time you might spend in a waiting room at a doctor's office as physicians pack more patients into a day.

Clinics are hiring nurses with advanced degrees to fuel their aggressive expansion, and that is making some physicians nervous about their practices and pocketbooks. They also say it could affect the care people receive.

Some AMA members say the clinics should not be a substitute for the doctor-patient relationship and need more uniform state rules requiring closer physician involvement.

The public should greet this new medical-care model with a healthy dose of skepticism, AMA officials say.

"The AMA is concerned about patients who would seek care in a free-standing clinic and have a more serious disease that would not be initially diagnosed or diagnosed quickly [in the retail clinic]," said Dr. Rebecca Patchin, an AMA board member and pain-management specialist who is a former nurse.

Although nurse practitioners have advanced degrees that can require six years or more of medical education, Patchin said physicians can have twice the education and training.

"When I was a nurse before I went to medical school, I did not always know what I didn't know," she said.

The AMA's annual meeting of its policymaking House of Delegates runs through Wednesday at the Chicago Hilton. A report and recommendations regarding retail clinics are among the dozens of topics the group will consider as it decides where to focus its lobbying clout.

Number mushroomed

The AMA's worries come as the number of retail health clinics has mushroomed from less than a half dozen five years ago to several hundred projected by the end of this year. The clinics are well funded, with some of the nation's biggest retailers and groceries opening kiosklike clinics, usually near their pharmacy counters.

Last month, for example, Deerfield-based pharmacy giant Walgreen Co. jumped into the business, announcing plans to develop more than 20 clinics in its Kansas City area and St. Louis stores in a major expansion.

More than a dozen AMA delegates testified before a committee Sunday, raising numerous concerns, including whether retailers were cherry-picking patients in suburban areas.

"I don't think you will find any of these clinics in the inner city," Dr. Arthur Snow, an AMA delegate and family physician from Shawnee Mission, Kan., not far from Walgreens' targeted expansion in the Kansas City area. "I'm concerned about the care."

Retail-clinic developers and the nurse practitioners on staff defend the model as an important and convenient way for consumers to access the health-care system, particularly for the 45 million uninsured Americans who cannot afford traditional doctors.

Walgreens said fees at its retail clinics will range from $48 to $68 but cost less for consumers with health-care coverage, depending on the person's plan. Most health plans provide some coverage for clinic visits, which cost less than the $100 or more for a typical doctor's office visit, industry analysts say.

"Access to care is very important," said Jan Towers, director of health policy for the American Academy of Nurse Practitioners. "Even with episodic conditions, people end up in an emergency room because they cannot get into a doctor's office, and that costs the health-care system."

Retail-clinic developers say they are not trying to take the place of traditional doctors and want to work with them, as is required by state regulations.

Telephone consultations

Yet AMA members say a physician's affiliation with a retail clinic and the nurse practitioner on site varies widely among states. In some states, AMA members say, a doctor is available only for telephone consultation.

In Illinois, rules are considered stricter than other states because a nurse practitioner must have a collaborative agreement with a physician, who must be on site at least once a month to provide medical direction and consultation. That is not always true in other states, the AMA says.

Among the AMA's recommendations expected to be presented to delegates this week is a requirement that doctors be involved in the protocols of the clinics, and that nurse practitioners establish a referral system with physician practices.

"Definitely, you need a closer relationship with a doctor," said Dr. Peter Eupierre, an internal medicine physician and president of the Illinois State Medical Society.

"It would be very difficult for a nurse practitioner to work totally independent," Eupierre said. "How can you describe a rash over the phone? Describing a rash is not the same as seeing it yourself."

Yet supporters of retail clinics say the relationship between doctors and the retail clinics and their practitioners is fine. They say the AMA is overreacting to something that is filling unmet medical needs.

"It's a new concept, and there is a lot of preoccupation on the part of the AMA to maintain oversight for health-care activities," Towers, of the nurse practitioners group, said, adding doctors shouldn't worry about losing business.

"If a patient has to wait weeks to be seen for something that is acute, they are not going to be in the doctor's office anyway."