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The Boston Globe reports that some of Massachusetts largest insurers are beginning to cover medical visits made at retail clinics at CVS and Walgreens drug stores. Blue Cross/Blue Shield of Minnesota is waiving copays for visits to retail clinics. The American Association of Family Physicians (AAFP) is not happy about this.
Carpe Diem says the AAFP’s resistance to accept retail clinics can be understood follows: “The family doc cartel is worried about increased competition.”
Most people believe that vaccines are for kids. The CDC and public health departments have done a good job of keeping vaccination rates high for children. With the advent of new vaccines for adults, the key now is to increase vaccination rates for these older groups.
The Wall Street Journal (“Get your shots“) details a few of the vaccines that adults should receive.
| Vaccine | Cost | Age and dosage |
| Tetanus/diphtheria/whooping cough | $65 | 19-64 years old, one dose. |
| Tetanus booster | $45 | All adults over 19, every 10 years. |
| Measles/Mumps/rubella | $50-$65 | 19 to 49, one or two doses if not previously vaccinated or infected. |
| Shingles | $220 | Over 60, one dose. |
| Pneumonia | $45 | 19-64, one or two doses when risk of disease is present. One dose after age 65 |
| Influenza | $20-$30 | 19-49, one dose/yr for high risk group. Over 50, one dose/yr |
Not included in the list is the HPV vaccine against cervical cancer.
Another point of interest is that it is increasingly difficult for physicians to supply vaccines to patients. With so many vaccines, the logistics of ordering all these perishable vaccines is very difficult. Further, as vaccines costs have increased, physicians will have to invest more and more capital into vaccine inventory.
For this reason, alternative providers such as pharmacies may a solution. With a vast experience in storage of drugs and supply chain management, pharmacies can easily absorbed the increased adult vaccine demand.
In the Wall Street Journal article, we have the following story:
The doctor didn’t have the shingles vaccine in stock, and recommended they try a walk-in clinic at a nearby drugstore, where the nurse practitioner provided a two-page handout on the vaccine and answered some of their questions. Though the price was about $219 each, all but $40 was covered by their drug benefit plan.
The next time you get a shot, it may be at your local CVS or Walgreens and not at the doctor’s office.
Tags: Pharmacies, vaccines
David Williams of the Health Business Blog reviews an article from the Boston Globe (“Immigrants…“) stating that immigrants reduce the cost of health care. How can this be with so many immigrants relying on government programs and free clinics to receive their care?
While it is true that immigrants are consumers of medical care, they are also producers as well. A study of the health care workforce in Massachusetts finds that 40% of pharmacists, 28% of physician assistants, 22% of opticians, 21% of licensed practical and vocational nurses, 17% of dentists and 14% of paramedics are foreign born workers. Twenty-eight percent of physicians and surgeons are foreign born.
An increased supply of health care workers from foreign countries can help decrease labor costs for medical care.
Tags: Immigration, Physician Assistants
Looks like the convenience clinic trend is coming to my neck of the woods in Southern California. According to the San Diego Union-Tribune (“Are retail clinics a healthy choice?“) six Minute Clinics are opening in San Diego county with ten more on the way before year’s end.
These clinics likely will lower the cost of obtaining a flu shot. Not only will providing the flu shot be less expensive for the provider, the patient will have fewer time costs waiting for a doctor or driving to an inconvenient physician location. These clinics are likely just as safe as a physician’s office if the patient is healthy. However, if a patient has multiple diseases and needs a more in depth check-up, these convenience clinics will be poor substitutes in terms of quality. There is always a tradeoff.
Tags: Flu Shot, Minute Clinic, San Diego
Many health care policy researchers believe that non-physician clinicians, such as physician assistants, nurse practitioners and midwives can help to reduce cost while maintaining quality. Midwifery has gained in popularity over recent years. Groups such as the American Public Health Association, Public Citizen and the National Organization for Women all support increased access to midwifery care.
The question remains whether or not midwife care during pregnancy is inferior, equivalent, or superior to physician care. Amalia R. Miller attempts to answer this question in her 2006 B.E. Press paper.
Differences between midwives and physicians
Quality
One problem with measuring the quality of care received by those who use midwives is that of selection bias. For instance, healthy women may be more likely to use a midwife. Pregnant women with serious complications will be more likely to use physicians. Thus, a researcher may erroneously conclude that pregnant women treated by physicians are more likely to have cesareans, when a more appropriate conclusion would be that physicians treat a less healthy patient base and thus preform more cesareans.
The best study preformed to date is a Chambliss et al. (1992) paper. The authors conducted “[a] randomized blinded clinical trial was conducted in which 492 low-risk patients were assigned to either physician or midwifery management.” Unlike most non-randomized trials, the authors found a small positive relationship between midwifery and cesarean rates.
Methods
The Miller (2006) paper looks at how midwifery affects cesarean rates. They use 1989-1999 Natality Detail Files as well as the 1989-1999 March Current Population Surveys (CPS) as her data source. The author considers a simple OLS regression using cesarean rates as the dependent variable and the use of midwifery–along with other covariates–as the independent variables. The problem of selection bias remains.
Thus, the authors use the enactment of Any Willing Provider laws as a proxy for state-wide midwifery usage. These laws “prohibit discrimination against a class of providers.” While Any Willing Provider laws are not directly related to midwives, the authors also use specific state midwifery reimbursement laws to proxy for midwifery usage. The claim made by Ms. Miller is that these laws are exogenously enacted; this creates a natural experiment and allows a difference-in-difference regression.
Results
Ms. Miller finds that midwifery reimbursement laws, unsurprisingly, do increase midwifery usage by pregnant women but more general Any Willing Provider laws do not alter midwifery usage rates. The authors continues to state that “…The main finding of the Chambliss et al. (1992) study is confirmed: there is no evidence that the expansion of midwifery led to a reduction in cesarean section rates. Hence, the results from the small randomized trial appear to generalize to the population at large, while the non-random trials likely suffered from selection bias due to inadequate controls for patient health and preferences. ”
What has happened to physician assistant (PA) education in recent years? An article by P. Eugene Jones (Academic Medicine 2007) enlightens readers with the latest information.
The states with the most PA programs are: New York (19), Pennsylvania (15) California (10), Texas (8) and Florida (6). Alaska, Delaware, Hawaii, Mississippi, Vermont and Wyoming all have zero PA programs. Unsurprisingly, PA concentrations are highest in the states with the highest population.
For the 2002-2003 academic year, one year of PA education costs $36,000 for residents and $44,000 for non-residents. These figures include tuition costs and student fees plus expenses for books and equipment.
The most surprising finding of the article is that there is a trend for PAs to choose jobs outside the primary care fields. I once thought that PAs could be a replacement for primary care doctors when: 1) a patient was healthy or had a disease which was relatively simple to diagnose and treat, and/or 2) when patients wished to spend more time with their medical provider. In fact, Dr. Jones cites an article which claims that PA productivity is 84% of that of a FTE family medicine physician.
Nevertheless, Dr. Jones finds “…the distribution of PAs in the primary care settings of family medicine, general internal medicine, and general pediatrics was 50.8% in 1996. By 2006, only 36.1% were reportedly practicing in theses settings.”
Much has been written on this site about the growth of convenience clinics (see posts on July 25, April 26, and April 17). The Economist’s Free exchange blog adds to the discussion (“A spoonful of monopoly…“). It warns how the AMAs monopoly powers may be a threat to convenience clinics such as Medical Marts.
“The fact that there is a shortage of family physicians in many areas did not stop the AMA from trying to stem the growth of these clinics by passing a resolution in June that asked government authorities to investigate the possibility of a conflict of interest in clinic-housing drug store chains that, in effect, both write and fill prescriptions.”
Free exchange agrees with the opinions stated previously on Healthcare Economist. Convenience clinics should expand choice, offer a low cost alternative, reduce waiting times, make available expanded hours of operation, and should maintain high quality standards for basic ailments. The Free exchange blog concludes:
“However, it seems the AMA would like to make sure its members profit no matter what choice you make. As it happens, nurse practitioners are required by law to practise under the supervision of a physician in 28 states — including in Illinois. I’ll swallow a stethoscope if the AMA didn’t have more than a little to do with the existence of those laws. “
Earlier this month, VentureBeat reported that QuickHealth, a Burlingame, Calf. company that operates walk-in medical clinics, said it has raised an $8.5 million in a second round of financing. The company’s report states the following:
Take Care Health Systems LLC, an operator of retail clinics predominantly in the Midwest, completed its sale to Walgreen Co. in May for undisclosed termsâ¦CVS Corp. completed the acquisition of MinuteClinic in September 2006 for undisclosed termsâ¦.America Online Inc. founder Steve Case, through Revolution Health, has backed InterFit Health Inc.âs RediClinics chain. Wal-Mart Stores Inc. formed an agreement with SmartCare Family Medical Centers in 2006 to include its retail clinics in stores in Colorado, Nevada and Arizona. SmartCare is backed by the Colorado Fund I and individual investors.
It looks like investors see lots of potential for these convenience clinics.
As my colleague Mike Ewens wrote to me: “Monopolists hate competitors and have to use the government to keep them away.”
An example that takes center stage can be found in a recent Chicago Tribune article (“AMA takes on Retail Clinics“) . Some doctors have asked the AMA to ban on in-store clinics currently being opened by companies such as Wal-Mart and Walgreens.
Why would doctors want to do this? Likely this is to protect their ability to charge high prices to their patients. How can they justify their demands to the public? They claim in-store clinics put patient’s health at risk.
The article concludes:
“We would be disappointed if the AMA adopted a policy that is counter to what patients are demanding, which is more accessible and affordable health care that reduces overall costs,” Walgreens spokesman Michael Polzin said in a statement. “It would be hard to argue against those principles. The bottom line is, retail clinics are improving health-care access and health outcomes while keeping the patient’s doctor informed as the patient desires.”
I see no reason to outlaw in-store clinics. Giving consumers more choice is always a good thing.
âCan you imagine if a Wal-Mart store operated like Americaâs health care system? You would walk into the store and there would be a huge array of merchandise. But you would not be able to tell the products apart. You would not know how much they cost. And in the end, you would not know the total bill — just a predetermined fraction of itâ?
This quotation is from a speech by Wal-Mart CEO Lee Scott at the World Health Care Congress (full text available here). In the speech Mr. Scott gave his vision of how to improve health care going forward.
$4 Generics
Wal-Mart offers many generic drugs for $4. Mr. Scott has claimed that this pricing strategy has saved Wal-Mart customers millions of dollars. I myself was wondering how Wal-Mart could offer the pharmaceuticals at such low prices. Here’s how:
Wal-Clinics
According to the speech and a Reuters article, Wal-Mart will open 400 in-store clinics in the next 2-3 years. This news gives more evidence that the trend towards convenience clinics–which I documented earlier in the month–is here to stay. Mr. Scott gives some more details regarding the Wal-Mart in-store clinic model:
“The providers running the clinics will determine what services to offer, which will generally include preventive and routine care for conditions such as allergies and sinus infections, as well as basic services such as cholesterol screenings and school physicals at affordable prices. They will be staffed by either certified nurse practitioners or physicians.”
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