The most tangible outcomes of a volatile three-year medical-political struggle in Massachusetts appear to be that you can now get your rash examined in a CVS pharmacy, but you cant buy cigarettes while youre thereat least not at a Boston CVS.
MinuteClinic faced a tough fight in opening outlets in Mass., and it’s still not welcome in Boston
When MinuteClinic, a CVS subsidiary, announced its plans to open facilities in Massachusetts and seek waivers from regulations that traditional healthcare institutions must follow, the controversy erupted immediately as organized medicine came at them with its guns blazing.
On March 30, 2008, the state Public Health Department put new guidelines in place for limited-service clinics and MinuteClinic would eventually receive 21 licenses for such facilities with the first opening in the town of Medway on Sept. 17, 2008.
In all, there are some 500 MinuteClinics in 25 states, with 17 open in Massachusetts. The company plans to open at least 18 more in the near future, but none so far are planned for Boston where Mayor Thomas Menino and others have virulently opposed them arguing that they would have a negative impact on the citys network of community health centers.
The problem with the market-based system for healthcare is that you cant keep dividing off the parts that can make you money and leave the rest of it, says Bill Walczak, CEO of the Codman Square Health Center in Bostons Dorchester neighborhood. You can create the usual incentives and disincentives but, clearly, what we dont have is a system designed to keep people healthy. And, obviously, a pharmacy operating as a clinic that diagnoses only eight different sicknesses is extremely fragmenting and damaging to the safety net.
On the other hand, as the state serves as the nations laboratory for universal health insurance coverage, Massachusetts has learned that coverage doesnt necessarily equate to access. This point was recently hammered home by a survey conducted by the Merritt Hawkins & Associates healthcare search and consulting firm, which found that Boston had some of the longest wait times to see a physician.
In a telephone survey of 1,162 medical offices conducted between September 2008 and March 2009 covering five specialtiescardiology, dermatology, family practice, OB/GYN and orthopedic surgeryin 15 metro areas, Merritt Hawkins found the average wait time in Boston to be 49.6 days. The next-highest area was Philadelphia, where the average wait was 27 days.
To see a family practice physician, a patient in Boston needed to be patient. The wait is 63 days. The next-longest wait is the 59 days it takes to see a family doctor in Los Angeles. According to Merritt Hawkins, you only have to wait a week to see a family practice physician in Miami.
There was a need for and a demand for these types of services and this type of care, says Chip Phillips, president of MinuteClinic. Generally, I would say the clinics in Massachusetts have performed well and the traffic ramped up quickly.
When MinuteClinic first sought to open in Massachusetts, it requested waivers for state regulations that require an area for soiled linen storage, separate entrances for patients, minimum exam-room space, patient bathrooms with handwashing stations, and a separate reception desk.
When the Massachusetts Medical Society got wind of this one might say the soiled linen hit the fan.
They did not feel like they had to comply with the regulations that have been in place forever because it wouldnt fit into their business model, says Bruce Auerbach, the immediate past president of the Massachusetts Medical Society and vice president and chief for emergency services at 128-bed Sturdy Memorial Hospital in Attleboro. The position of the medical community was that it was not appropriate to waive the rules that had been put in place to ensure handicapped access, infection control and patient privacy to conform to the business model of a profit-making enterprise. We made the case that the existing regulations should not be waived, andif they wanted to exist as a licensed clinic in Massachusettsthey had to follow what all the entities need to follow.
Public hearings demanded
On June 14, 2007, Auerbach teamed up with the presidents of the Massachusetts Hospital Association and Massachusetts League of Community Health Centers and the state chapters of the American Academy of Pediatrics and American Academy of Family Physicians to demand that the state Public Health Departmentwhich received MinuteClinics license applicationhold public hearings on issues concerning retail clinics.
Hearings were held in the fall in Boston and Worcester, and one of the people who testified was Leonard Morse, Worcester commissioner of public health and the former chairman of the American Medical Associations Council on Ethical and Judicial Affairs.
I realize their purpose, and I realize that there are long delays and there are people with nonurgent conditions filling the emergency rooms resulting in crowding and more delays, Morse says. These are all reasons for having MinuteClinics.
Morse says his complaints include a lack of patient privacy (for example, he thinks retail clinics should have floor-to-ceiling partitions for better soundproofing), as well as ethical concerns over having prescriptions filled under the same roof theyre written, having cigarettes sold in the same facility healthcare is delivered, and the erosion of the doctor-patient relationship.
They are not staffed by physicians; they are staffed by nurse practitioners, so its for people who have nonurgent conditionsbut how do they know they have nonurgent conditions? Morse asks. Its like the definition of minor surgery is surgery done on someone else. Its hard for me to categorize patients going to a MinuteClinic as having nonurgent conditions because no patient should be considered casually. They have to be considered for all possibilities.
While many of us utilize and have great respect for advanced-practice clinicians, we recognize they are not physicians and do not have the same training and background as an M.D. or D.O., he says, referring to nurse practitioners and physician assistants. A nuance or subtlety in the way the patient presents could be missed.
Phillips says that there have been a wide variety of reactions to the arrival of MinuteClinics in various markets and the Massachusetts reaction fell within the spectrum.
He adds that MinuteClinic realized that one of two things had to happen for the company to operate in Massachusetts: They either had to get a waiver from having to conform to the same regulations as a traditional clinic, or the Public Health Department had to craft specific regulations for retail clinics. After the hearings, the department chose the latter and coined a new term to go along with retail or convenient-care clinic: limited-service clinic.
Along with rules on infection control and handicapped access, limited-service clinics had to post the services they provide and the regulations dont allow them to be licensed to do anything else. They also had to post that patients were not required to fill prescriptions at the host facility. If cigarettes were sold at the host facility, the clinic is required to post information determined by the Public Health Departments tobacco control program.
Each clinic is also required to keep a roster of primary-care practitioners and have procedures for notifying them when a patient needs treatment beyond the clinics scope.
The regulations recognize that they are in a physical space that is much more restrictive than a usual clinic, says Paul Dreyer, director of the Public Health Departments Bureau of Healthcare Safety and Quality.
A separate license application is needed for each individual facility, meaning a company cannot get global approval and develop multiple sites off a single license, so each site must be inspected.
We look to see if the physical plant is as described in the plans and make sure the handicapped regs are complied with, Dreyer says.
Dreyer says MinuteClinic was issued 21 licenses, but four facilities have not yet opened. He adds that no one has applied to open a limited-service clinic within the Boston city limits and no one else in the state has opened a facility except for MinuteClinic, although he wouldnt be surprised if Take Care Health Systems, which is owned by Walgreen Co., does so.
Walgreens has expressed interest, Dreyer says. Im not sure if we have any license applications from Walgreens, but they certainly have expressed interest.
When asked its intentions for Massachusetts, Take Care responded with an e-mail.
We continue to have interest in opening in Bostonan area where there is a true need for more access points to care, the e-mail states. Timing of our launch is undetermined. Take Care Health Systems is committed to expanding access to high-quality, affordable and convenient healthcare to as many markets as possible.
One early study shows limited success for MinuteClinic in Massachusetts, but its data may be too early to accurately gauge the situation.
The Deloitte Center for Health Solutions surveyed 4,000 adults back in October and the Boston metropolitan area lagged behind others in retail clinic usebut that was less than a month after the first Massachusetts MinuteClinic opened.
Nationwide, 13% of those surveyed said they had visited a retail clinic, but only 5% of Boston-area respondents had. Also, nationally, 28% said that they would rather visit a retail clinic than wait a week for a doctors visit, but only 18% in Boston said so.
Were still a young industry, says Tine Hansen-Turton executive director of the Convenient Care Association, a trade group representing retail clinics. Were ready, willing and able to be a partner in providing access to affordable, quality care, which I know we can provide.
John Cicero, director at Chadds Ford, Pa.-based IMA Consulting, says there is a distinct advantage to being first. Right now, its just about trying to capture market share, and the first in the market is typically the most successful, Cicero says. I think initially, youll see a significant population of clinics and then theyll pull back.
Meanwhile, the Massachusetts Medical Society hasnt let up its attack.
At its interim meeting in November, it passed a resolution recommending stricter oversight of limited-care clinics, and warned that insurance plans that provide incentives for patients to receive care at retail clinics may interfere with continuity and quality of care. In February, it threw its support behind bills to ban the sale of tobacco wherever healthcare professionals are employed. And, at its May 7-8 annual meeting, the society passed a resolution calling for insurance copayments for treatment received at retail clinics to be equal to or higher than those for care received during a physician office visit.
The city of Boston also has kept active and, on Feb. 9, by order of the city Public Health Commission, all tobacco products were removed from its drugstores. On the first day, every single pharmacy in the city of Boston was in compliance, says Barbara Ferrer, executive director of the Boston Public Health Commission, adding that the measure wasnt taken to obstruct retail clinics from opening in drugstores. Nobody raised that issue, she says. We had very little opposition. Im sure there was some, but we heard very little.
While noting that she has the utmost respect for CVS and Walgreen, Ferrer says that as good as it might work elsewhere, the convenient-care model is not a good fit for Boston with its network of 26 community health centers and its 12 teaching hospitals that provide primary-care service.
There was a proposal to open a MinuteClinic in a location that was within a half-mile of three community health centers; what would be the point of opening a facility where there is such an availability of primary care? Ferrer asks. Im not sure why we would be pushing that model. When you look at all the incidents of chronic conditions, you want to be encouraging long-term relationships with providers and medical homes.
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