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Thursday, February 27, 2014

Selling a product the public does not want

The American Academy of Pediatrics has come out with a position statement directing families away from the use of retail clinics ( "AAP statement). The policy statement was reported on widely in the lay press but the full report is published online in the Journal Pediatrics (which is behind a pay wall). In the official report, the authors highlight the points raised in the 2006 report where the AAP originally published a report in opposition to the use of retail clinics. They highlighted the following points to justify their opposition:
  • Fragmentation of care
  • Possible decreased quality of care
  • Provision of episodic care to children who have special needs and chronic diseases, who may not be readily identified
  • Lack of access to and maintenance of a complete, accessible, central health record that contains all pertinent patient information
  • Use of tests for the purpose of diagnosis without proper follow-up
  • Possible public health issues that could occur when patients who have infectious diseases are in a commercial, retail environment with little or no isolation (eg, fevers, rashes, mumps, measles,strep throat)
  • Seeing children who have “minor conditions,” as will often be the case in an RBC, is misleading and problematic. Many pediatricians use the opportunity of seeing the child for something minor to address other issues in the family, discuss any problems with obesity or mental health, catch up on immunizations, identify undetected illness, and continue strengthening the relationship with the child and family. Visits for acute illnesses are important and provide an opportunity to work with patients and families to deal with a variety of other issues.
Furthermore, additional criticism was leveled based upon the observation that retail clinics as presently deployed are not compatible with the medical home model of care delivery where the priorities are:

1. The patient should have an ongoing relationship with a personal physician trained to provide first contact,
continuous, and comprehensive care;
2. The personal physician should lead a team of professionals who collectively take responsibility for the ongoing care of the patient;
3. The personal physician should be responsible for all aspects of the patient’s care;
4. Care should be coordinated and integrated across all elements of the complex health care system; and
5. Care should be facilitated through registries, information technology, and health information exchange.

Contrast this with the list with the reasons for retail clinic use identified in a recent WSJ article shown below: 

"Retail clinics also are generally open seven days a week, don't require an appointment, accept more types of insurance than doctors do and charge 30% to 40% less for similar services, studies show. Costs vary widely by region and service offered, but getting a common ailment treated at a retail clinic, without insurance, typically runs between $50 and $75....
Studies show that people who use retail health clinics tend to be younger, healthier and more affluent than average. As many as 70% of parents who use them have a pediatrician but say they can't wait for an appointment or take time off work when the doctor's office is open, said Ateev Mehrotra, a policy analyst at RAND Corp., who has studied the clinics for years....
 "Some pediatric practices say they won't see you if you go to a retail clinic," he said. "And we've heard that some patents tell retail clinics, 'Please don't tell the pediatrician that I'm here.'  "

This is a typical example of the medical community having priorities which are different from the patient communities. The AAP espouses principles which their membership and leadership value. They just don't happen to be what their patients value quite as highly. The retail clinics offer what patients and their families value most; access, convenience, and value. Well over half of the reasons listed above relate to convenience. I also assume that the "Did not want to bother the pediatrician" means gong to the pediatric office is a hassle for all involved. We are well over 75% of the justifications are driven by convenience

The pediatric community has probably been better about dealing with access and convenience than most the medical community, but they still appear to place a higher value on a host of other priorities. Like the broader medical community, there is a drive to convince patients as to what they should want and some degree of indignance when patients come to different conclusions when they weigh their options. Where the pediatricians see they bring value to patients is quite different from where patients seem to see where they obtain value. 

The most recent report is not so unyielding in that it recognizes some potential role in partnering with retail clinics to provide urgent care when the pediatrician simply cannot accommodate. They still are highly protective of the role of pediatricians and how they add value to their patients: 

"In addition, there has been scope of care “creep” within the RBC setting, as these clinics now provide services such as childhood immunizations and “school and sports physicals.” These offerings impinge on core preventive care services of the pediatric medical home and are mis-perceived by patients and families as an appropriate substitute for regular preventive care within the medical home."

Patients and their families want what they want and when given the opportunity, they will almost always chose convenience and cost over almost everything else. I am not sure I can fault that decision. While this might not be the case for obvious serious illness requiring unique expertise and capabilities, for the most part patients will get the service they desire when they use a retail clinic. Scare tactics suggesting that there is a clinically significant risk of missing some hidden pathology are basically never accompanied by actual numbers demonstrating the significance of such a risk. The risk to the standard medical office business model is much more likely than the risk to patient health.

Better, faster, and cheaper will always prevail. Good enough, faster, cheaper will come out on top as well.

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