Thursday, February 21, 2008

Retail Health Care: Part of the Problem or Part of the Solution?

Becky, that Girl in Short Shorts, has a thoughtful post on the emerging retail health care industry, those limited-service clinics inside Wal-Mart or your local shopping mall:
An estimated 18,000 Amerians die every year because they can't afford or can't qualify for health insurance. That's five times the number killed in 9-11. Not to mention all the people who are stuck in sucky jobs because they don't dare lose their current insurance.

But you know what we can start doing ? Pay doctors with cash. There will be some people that can not afford it, and the government will have to help. But a lot less than nowadays, because it will be a heck of a lot cheaper.

This is how people got health care thirty years ago, before America became infatuated with monthly premiums and co-pays.

And there are some doctors who are already starting to reject insurance and accept only cash. They are able to charge less and spend more time with each patient because they do not have to hire four assistants whose sole duty is to process insurance claims.

Dr. Vern Cherewatenko ,a Seattle physician, went to cash only services six years ago when his practice was going broke. He and his partners were spending hundreds of thousands of dollars a year just to process claims. Before, he charged $79 for an office visit and got $43 from an insurance company months later, minus the $20 in staff time it took to collect the payment. Now he charges $50.

I know this sounds radical and I am likely to be burned at the stake with a stethoscope up my ass. But if people pay for their own medical care, doctors have to charge less and do better work. Because, when we pay for stuff, we shop around.

But really, this is just traditional medicine.

The American Medical Association--in the part of its incarnation that is a special interest group for physicians--is really leery of retail clinics:

AMA members testified that the clinics should not be a substitute for traditional doctor-patient care and that they need more uniform state rules mandating closer relationships with physicians. They also expressed concern about the educational levels of nurse practitioners and the suburban locations of the clinics, questioning whether the facilities are "cherry-picking" higher-income patients. AMA is expected this week to recommend a requirement that doctors be involved in the protocols of the clinics and that nurse practitioners establish a referral system with physician practices, among other proposals, the Tribune reports. Rebecca Patchin, an AMA board member who is a former nurse, said, "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 retail clinics.

But what's really at issue here is that retail clinics often depend primarily on nurse practitioners, not doctors, which threatens to cut into the traditional business of family physicians, as MSNBC notes:

Increasingly, American consumers are shopping for health care the way they buy a hamburger or milk shake at a fast-food chain: By standing in line at a local store under a menu.

Store-based health clinics — which are staffed mostly by nurse practitioners and offer quick services for routine conditions from colds and bladder infections to sunburn — aren't just a health care fad anymore, but fast becoming a serious industry.

So is this the future of health care in America?

Possibly. Let's make two assumptions for the sake of argument: (a) that no matter who's elected president, we're not going to get single-payer or other truly government-run universal health care, and (b) there continues to be widespread dissatisfaction and lack of coverage for millions in the current system, forcing some significant reforms over the next two years.

Allowing those, I expect two primary dynamics to drive the process: public health and routine preventative care.

Public health: inoculations, vaccinations, and regular testing of workers in farm, food and service industries are relatively inexpensive investments in large-scale prophylaxis, and are thus a legitimate interest for the government.

Routine preventative care: keeping that bronchitis from becoming pneumonia, doing that strep throat test, wrapping that sprained ankle. These services sound sort of trivial, but taken in total and expanded to cover the millions of people who head every day to emergency rooms for this kind of treatment, and you have a major capital liability and drain on the system.

What would happen if 90% of that kind of business could be siphoned off to retail health clinics? The resource drain from our hospitals would be dramatically curtailed, the waiting times for true emergencies would decrease, and costs would begin to fall....

But how do you answer the question of who would be visiting those clinics? Right now, the Wal-Mart clinics--like the walk-in clinics that take insurance--cater more to middle-class patients than the working poor.

Yet suppose, along with the Earned Income Tax Credit, every poor family in America received a $1,000/person routine health care voucher, redeemable at any of these clinics? With average current costs of such visits at $40-70, this would give each person the resources to make at least 18-20 clinic visits per year. At the end of the year, any unused funds on each voucher could be banked in an interest-bearing Health Savings Account.

The advantages of such a modest proposal should be self-evident.

Would it address cancer care or trauma care? Not directly, but despite the pseudo-fears of the AMA, poor people seeing nurse practitioners or physician assistants on a regular basis dramatically raises the chances of early detection of major medical conditions. And regardless of what health care system is in place, early detection is critical not only to a good prognosis, but lower costs of care.

My point is this: Reforming health care is NOT an all-or-nothing proposition. In Delaware, of the 105,000 people without health insurance, nearly 27,000 are actually eligible for existing coverage, but for some reason have not come forth to claim it. We need to start with the small steps that are practical in the immediate short run, steps that will not break us financially, and steps that do not demand a leap into the unknown as the most populous nation on earth ever to contemplate government-mandated, taxpayer funded, statist universal health care.

So in that sense, yes, I think retail health care is part of the solution.


tom said...

> keeping that bronchitis from becoming pneumonia

Steve has said this a number of times in the past days/weeks, and while I am by no means suggesting that people who are actually at risk for pneumonia shouldn't seek treatment, I think he is dramatically overstating the frequency of this occurrance.

For most people what keeps bronchitis from becoming pneumonia is called an immune system and you don't need to buy it at the clinic or have health insurance to have one.

If it were normal, or even common, for bronchitis to become pneumonia the subset of the human race susceptible to bronchitis and pneumonia would have disappeared from the gene pool long before we got around to inventing a treatment for it.

Steve Newton said...

Good point; I keep choosing that example because it has happened several times to me.

We all tend to generalize ourselves are representative.

tom said...

> Good point; I keep choosing that example because it has happened several times to me.

you should definitely be careful then, we don't want to lose you.

> We all tend to generalize ourselves are representative.

actually, I do the opposite. for reasons anyone who knows me well will understand, I tend to think of myself, or even the majority of my acquaintances as anything but a representative sample. it sort of goes with being a libertarian...