Sunday, April 06, 2014

Walk-in Health Care: Growing Popularity (and Concerns)

From The Washington Post, April 6, 2014
Not a lot of time for a long blog post today, but I came across this article in this morning's Post and have been thinking about its implications for health care ever since.

The basic arguments in the article are as follows:

1. Between the growth of eligible patients (something that will continue to grow with expanded coverage facilitated by the Affordable Care Act) and the continued decline of doctors graduating from medical schools with specialities in primary care or family practice, gaining access to primary care has become increasingly difficult.

2. Consequently, retail chains, such as CVS's Minute Clinic, have expanded pharmacy offerings in their stores to include basic care for things like infections, vaccinations, and sports physicals. Some offer testing for basic preventative measures, like blood sugar testing, according to the article.

3. The services provided by these retail chains are more convenient, faster, and cheaper than other available options.

In a sense, the clinics solve a few problems. In an environment where people lack easy, quick access to medical services that physicians offices are too pressed to provide, the clinics can dispense antibiotics before infections (and discomfort) become severe, offer timely vaccinations (a critical need during flu season at the very least), and alleviate some of the burdens placed on the existing primary care system.

But, there are problems with this, too, some of which the article addresses but doesn't really offer a clear solution for:

1. The impact this might have on the care of children, in particular, is unknown and troubling. As the article quotes from an American Academy of Pediatrics (AAP) representative: "There is no such thing as a ‘minor illness’ when it comes to children. Pediatricians use these ‘minor illness’ visits to identify other, potentially more serious issues." What seems like a series of acute illnesses may be masking a chronic condition that goes unnoticed because there isn't a consistent physician caring for a child. Pediatricians and primary care doctors also watch for other issues children may be experiencing, such as nutrition issues, developmental problems, or even signs of abuse. All of these may be missed under such a disjointed system of care.

2. A lot hinges on preventative care, from our own long-term health to many health policies (not least of which, the Affordable Care Act). Increasingly, disease is not conceptualized as a single, isolated incident, but as a stress point that occurs at the end of a steady progression of illness, which has been exacerbated by individual circumstances and lifestyle choices. Properly caring for the little things that happen to us over time may be more essential to our long-term health than we realize, and reliance on acute or emergency care may exacerbate the negative affects of short-term thinking.

The problem of the dwindling primary care provider is a really serious issue. It strikes me that, on one end of the spectrum, the issue is addressed by concierge medicine--a specialized, expensive system where access to a physician is restricted by how much one is willing to pay. In this case, a select few can get same-day appointments, a doctor's email address, and, if needed, a quick diagnosis and prescription to treat an ear infection or an in-hospital consultation and coordination of care after a heart attack.

On the other, we have the CVS Minute Clinic. Here, you may not have a doctor's email address (or even see an actual doctor), but the service performs the same functions, providing quick, convenient access to medical information within the time constraints of otherwise busy people. Here, access is almost universal, but it's not as complete or complex and lacks the relationship-building and health maintenance objectives of the concierge option. While this system may solve acute problems, again, we're addressing acute measures to the possible detriment of chronic conditions that go unnoticed.

All of this might not be a problem. But we at least need to acknowledge how it is at complete odds with our larger objectives of preventative medicine that shape expectations for medical care and outcomes today and ask what the impact will be if this is the system that is takes up residence where the doctor's office once stood.

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