Physicians lay out their vision of retail clinics’ role
For the most part, primary care physicians have accepted that retail clinics are a fact of life. The American College of Physicians recently published a set of recommendations laying out how the two might co-exist peacefully and to their mutual patients’ benefit.
Bottom line: Retail clinics have a role providing a well-defined and narrow scope of clinical service, says ACP in its policy position paper, published in the Annals of Internal Medicine, published online Oct. 15. But they should supplement – not replace – a person’s longitudinal relationship with his or her primary care doctor.
“The expansion of both the number and scope of retail health clinics raises many questions about the role of retail clinics long term and how they may complement or augment good medical care and routine preventive health services,” said ACP President Wayne J. Riley, MD, MPH, MBA, MACP, when the College published its recommendations in October. “A balance must be struck between the convenience and easy access retail clinics provide, with the importance of establishing relationships between patients and physicians, particularly for patients who have complex medical histories and/or multiple medical problems.”
Research shows that for selected low-acuity conditions treated at retail health clinics, the quality of care is similar to the care a patient would receive in a traditional office setting, and patients have reported high levels of satisfaction with retail clinic care and convenience, report the paper’s authors. “However, short-term satisfaction has given way to long-term concerns about how the proliferation of retail clinics and the expanded scope of practice into management of chronic conditions may affect primary care and the function of a patient’s medical home, as well as concerns about the potential for overprescription of antibiotics and lost opportunities in identifying other medical issues that may be present.”
ACP’s six recommendations
- Retail health clinics should serve as an episodic alternative to care to an established primary care practice for relatively healthy patients without complex medical histories. Ideally, all patients should establish a longitudinal care relationship with a physician. Physicians should discuss circumstances in which the use of a retail health clinic might be appropriate. All care settings should develop strategies to provide patients with improved access via flexible scheduling and after-hours business care.
- Retail health clinics should have a well-defined and limited scope of clinical services that are consistent with state scope-of-practice laws and with the more limited physical space and infrastructure that such settings permit. These well-defined and limited services should be clearly disclosed to the patient prior to or at the visit.
- Retail clinics should use standardized medical protocols based on evidence-based practice guidelines. “These protocols help to ensure that safe and high-quality care is being provided to patients, and decrease the potential for liability for the person providing care,” according to ACP. Because standardized protocols fail to account for the potential for human errors or unexpected events that may affect outcomes, “[d]iscussions about the place of retail clinics in the health care system should therefore include some degree of quality-reporting metrics in line with the requirements of other health care professionals.”
- Retail health clinics should have a structured referral system to primary care settings and encourage patients they see to establish a longitudinal relationship with a primary care physician if the patient does not have such an existing relationship. ACP believes that it is not appropriate for retail clinics to refer patients directly to subspecialists without consultation by a primary care clinician in order to ensure continuity of care. Retail clinics should offer information about ways patients can connect with physicians in their area, and provide contact information for community health centers, area physicians’ offices, patient-centered medical homes or other local healthcare information resources, says ACP. Retail clinics should keep up-to-date information about these types of resources that are available within a 10-mile radius of the clinic, as well as the best available information on primary care resources that accept the major insurance providers in the area.
- The retail health clinic should promptly communicate information about a retail health clinic visit to a patient’s primary care physician, including but not limited to the administration of any vaccination, prescriptions, tests, or postcare instructions. “Communication between a retail health clinic and a patient’s physician or medical home is fundamental to reducing the potential for disruption of continuity of care,” according to ACP. “An unreported visit to a retail clinic for an ear infection creates a small gap in the patient’s medical record; additional unreported visits that build up over time may lead to large holes that impact the effectiveness of care coordination.”
Physicians should be encouraged to engage patients in a discussion on how to appropriately follow up with the physician or patient-centered medical home after a retail health clinic visit. Meanwhile, patients should be encouraged to engage the retail health clinic about when and what information will be sent to their primary care physician and discuss their retail health clinic visit with their physician.
- ACP believes insufficient data exist concerning the provision of chronic disease management in the retail health clinic setting and recommends against chronic and complex disease management in these settings. ACP recommends controlled research into the safety, efficacy, and cost-effectiveness of chronic disease management in the retail health clinic setting.
“In addition to the pragmatic concerns about management of chronic conditions in the retail clinic setting, the relative novelty of such clinics and the limited number offering these types of comprehensive services means that little research has been done on the safety, efficacy, or cost-effectiveness of management of chronic conditions in this setting,” writes ACP. “Although research supports the cost-effectiveness and safety of management of some low-acuity health conditions in the retail setting, these results cannot be extrapolated to chronic disease management.”
‘Whole person’ care
Consumers have more options than ever before, and retail health clinics are part of a movement away from traditional primary care delivery models to patient-driven, convenient ambulatory care models, according to ACP. “Telemedicine and physician contracting practices, which provide health care services with an eye toward patient convenience, also offer alternatives to the traditional primary care model.
“The patient-centered medical home (PCMH) may provide patients with increased access to care with the benefit of an ongoing relationship between a patient and their physician. The ACP strongly advocates for the PCMH model as a method of providing continuous, ‘whole-person’ care through all stages of a patient’s life; improving access to health care services for patients; and increasing physician and patient satisfaction. The PCMH model aims to centralize care across the health system for all of a patient’s health care needs, including preventive, acute, and chronic care services. One of the pillars of PCMHs is ‘access to care that matches a patient’s needs and presences,’ and PCMHs strive to deliver accessible, integrated, and coordinated care for patients.”
ACP members include 143,000 internal medicine physicians, related subspecialists, and medical students.