From The Floor
Retail Health Clinics: A Boon to Nurse Practitioners?
An opportunity for entrepreneurial nurse practitioners
I attended a meeting several weeks ago in Downtown Los Angeles where the topic of discussion mirrored very closely what was to be the topic of this month’s column: retail health clinics. The panelists appeared well informed about the subject at hand, including the physician-member, whose bias couldn’t be missed each time he spoke. He continually expressed his trepidation of continuity of care, how the clinic costs would meet the needs of a more affluent crowd, and how patients might choose to substitute care at their doctor’s office for the care offered at the retail health clinic. His competence in his area of expertise could not be doubted, but his condescension concerned me because the retail health clinic in our current health care environment plays a critical role.
What Are Retail Clinics?
I’d like to start with a broad definition of what a retail health clinic is, and its scope of practice. A quick search of the American College of Nurse Practitioners website provides the following information:
“A recent and emerging issue in NP practice has been the growth of retail health care clinics located in major retail chains such as Target, Wal-Mart and drugstore chains such as CVS and Walgreens. Most of these retail health clinics (also called the “convenient care industry”) are being staffed by nurse practitioners and provide patients with fast, affordable treatment for routine medical conditions as well as preventive care. NPs are using their skills to assess, treat and prescribe medications, in addition to providing health screenings, medical tests, vaccinations/immunizations and physicals in some locations.”
California nurse practitioners, unlike physician assistants, are given quite a bit of autonomy in making clinical decisions, thus freeing them from a great deal of direct supervision by a physician. I think it’s this autonomy that the physician panel member feared more than anything else since he continued to express his desire that every person have a family physician to oversee and coordinate his or her care. However, this is not very practical in today’s health care environment.
For one thing, there are very few physicians today who are going into family practice due to poor reimbursement. For another, it’s not very realistic that every person will have a family physician if Congress succeeds in passing the health care insurance reform package currently being argued in the hallowed halls of our nation’s capital. Why? Our country, like so many others, has both a nurse and a physician shortage. The current physician shortage can hardly accommodate the current insured patient load, and most assuredly cannot accommodate tripling the number of patients should the health care reform package pass. This doesn’t mean that I oppose the reform; I, like so many of my fellow nurses, have made it clear: Business as usual cannot continue. We need to address how our citizens and non-citizens access and receive care, which is why I see retail health clinics playing a vital role in our continuum of care.
An Ethical Dilemma
The primary focus of these clinics is episodic care, making them a very good alternative to the local emergency department for the person suffering from a seasonal cold or general ear infection, or in need of a flu shot or other similar immunization. These clinics are generally housed in a local drug store such as Sav-On, CVS, Walgreens and Wal-Mart, which provides a somewhat symbiotic relationship since without the drug store there could be no clinic.
This was one of the sticking points for the physician on the panel, as he was concerned that this relationship had, at the very least, an appearance of a conflict of interest. He queried whether patients receiving care from the retail clinic might feel as though they need to purchase prescriptions and other necessary health and medical supplies from the drug store in which the clinic was housed. Or perhaps the nurse practitioner might feel compelled to promote the store’s agenda, thus skewing his or her practice to meet whatever demands the store might make of the clinic.
Though this is a possibility, I think it is a highly improbable scenario because his argument could be applied to any of the clinics and hospitals where patients seek treatment. For example, patients receiving care from their local hospital might choose to have their prescriptions filled at the in-house pharmacy rather then make an additional trip to the local drug store for that same service. Or what about hospitals that have small in-house drug stores that provide a selection of health care items?
Waiting Isn’t a Game
Retail health care clinics also provide two very important aspects that are lacking in our current system: convenience and a patient-oriented model of delivery. Those of us who have primary care physicians know all too well that no matter how kind, compassionate and excellent our physician might be, his or her model is not patient-oriented in the same way a retail clinic is designed to be.
We’re all aware at this point that we don’t see our physician at our actual appointment time. More often than not we are expected to wait anywhere from 20 minutes up to an hour longer than what was scheduled. Urgent care and emergency department visits are often longer, with some hospitals wait times exceeding 10 hours. So it’s not surprising then that some people will find the retail health clinic an acceptable or better solution than scheduling an appointment to see their regular physician, especially in cases where the care needed is not serious.
When I made an unexpected stop at my local retail health care clinic there was only one patient waiting to see the nurse practitioner, and it was solely because he had arrived during the advertised lunch break. Several signs were posted at the clinic’s entrance that provided a wealth of information to visitors and potential patients about hours of operation, services offered and associated fees, which goes a long way in educating the patient about the costs associated with providing health care.
Cost of Care
Not that long ago my daughter was treated at an urgent care clinic for an unexpected asthma attack. The cost of care was around $200, but she had to fight to get a detailed bill (she was a cash-pay client). The following day, one of our cats needed to see the vet for an abscess that had burst. The cost of treatment was just a little over $200, but we received a bill so detailed it included the cost of an Elizabethan collar and nail clipping. All of this made me wonder: How come vets seem to have a better idea of the costs associated with their services, but physicians and other health care providers seem clueless?
The retail health care clinics seem to have a more realistic grasp on this, which of course generated much discussion among the panelists. How might retail clinic costs be yet another barrier to the under- and uninsured? Would they be able to afford the care?
The panelist representing the retail clinics brought forward a very interesting point of view. She said that many people choose these clinics because the cost of waiting is even higher than the cost of care, especially to the working poor. For them, waiting three, six or more hours can end up costing them more than a $60 dollar clinic visit.
I found this example very thought provoking because I’ve rarely heard health care professionals take into account the wait time and its associated cost when addressing how health care is accessed by the under- or uninsured.
Continuum of Care
I had the pleasure of interviewing our area’s equivalent of the director of nursing for MinuteClinic. Anisha Dua, RN, NP, was very energetic and knowledgeable about her role, and the role of the clinics she oversees. After our interview, I came away with a strong feeling that the organization’s mission was not to supersede the role of the patient’s primary health care provider, but to help ensure that patients receive a continuum of care.
Dua described how each patient is given a copy of the nurse’s notes or the option to have the information faxed or emailed to their current health care provider. Patients without a provider are counseled on the benefits of having one, and if the patient requests such a referral the nurse practitioner can give them a list of places taking new patients that are located within a five-mile radius of that specific clinic. The nurse practitioners that run these clinics have a very defined scope of practice and work diligently to provide care to their patients, thus leading me to believe that physicians have little to fear.
I asked Dua what characteristics are important for a nurse practitioner who isthinking of making his or her area of practice a retail health care clinic, and she offered the following: being open to listening to the patient, open to learning, being comfortable with autonomy of “practice,” and having an adventurous spirit. She went on to share that they make an effort to have the same practitioner assigned to the same clinic so they would be able to develop a relationship with the patients.
Dua confirmed that she felt some resistance from the local physician community in the beginning, but as they’ve become more aware of the scope of practice and the skill of the nurse practitioners, their attitude has shifted more toward acceptance, which she attributes to the practitioners’ efforts to provide patients who have physicians in the area with copies of the patient’s medical record and to encourage those patients without primary physicians to seek one out for follow-up care.
I don’t think retail clinics will somehow bring an end to the doctor visit, but I do think their focus on a specific set of services, illness and injuries is a very valuable resource to the patient market. It does, I think, address the age-old frustration that so many patients — both with and without insurance — are faced with when they feel that the evaluation of a health care professional might be needed for something that may or may not be minor, such as a cold, fever, possible sprain and so forth. Their physician might not be able to see them for several days, or they might only be able to receive care by making a trip to the ED. But a quick visit to the local retail health care clinic solves this conundrum. The nurse practitioner can treat the patient if it’s in his or her scope of work, or refer them to their primary physician if the condition requires it, or even call 911 if the patient is in need of emergency care but wasn’t aware of it.
I think, like the ED or ICU, retail clinic work is not for the meek and requires, as Dua described, someone with an adventurous spirit. Practitioners who already enjoy the autonomy provided by the NP care model, but also have a bit of the entrepreneurial spirit, would find this work most rewarding.
I can also see the retail clinics playing a role in helping patients manage chronic disease, such as asthma, diabetes, high blood pressure and so forth. There is substantial research that shows the benefit of nurse practitioners in cases such as these, and there might also be a role in providing care for geriatric patients. Many of them use the same pharmacy, and a retail clinic in that pharmacy could provide a much-needed follow up, which in turn might allow the nurse practitioner to notify the patient’s primary care physician of any notable changes.
These clinics truly are a niche for patients who seek care and treatment and for the nurse practitioners that choose to staff them. It’s also yet another reason why I think nursing is one of our greatest professions. Where else can you find such a wide variety of existing and rewarding work experiences?
American College of Nurse Practitioners
Take Care Health Systems
Quick Quality Care
The Little Clinic
Geneviève M. Clavreul RN, Ph.D., is a healthcare management consultant who has experience as a director of nursing and as a lecturer of hospital and nursing management.
This article is from workingnurse.com.