By Reed Abelson and Julie Creswell
April
7, 2018
Is the doctor in?
In this new medical age of urgent care centers and retail
clinics, that’s not a simple question. Nor does it have a simple answer, as
primary care doctors become increasingly scarce.
“You call the doctor’s office to book an appointment,” said Matt
Feit, a 45-year-old screenwriter in Los Angeles who visited an urgent care
center eight times last year. “They’re only open Monday through Friday from
these hours to those hours, and, generally, they’re not the hours I’m free or I
have to take time off from my job.
“I can go just about anytime to urgent care,” he continued, “and
my co-pay is exactly the same as if I went to my primary doctor.”
That’s one reason big players like CVS
Health, the drugstore chain, and most
recently Walmart, the giant retailer, are eyeing deals with Aetna
and Humana, respectively, to use their stores to deliver medical care.
People are flocking to retail clinics and urgent care centers in
strip malls or shopping centers, where simple health needs can usually be
tended to by health professionals like nurse practitioners or physician
assistants much more cheaply than in a doctor’s office. Some 12,000 are already
scattered across the country, according to Merchant Medicine, a consulting
firm.
On the other side, office visits to primary care doctors
declined 18 percent from 2012 to 2016, even as visits to specialists
increased, insurance
data analyzed by the Health Care Cost Institute shows.
There’s little doubt that the front line of medicine — the
traditional family or primary care doctor — has been under siege for years.
Long hours and low pay have transformed pediatric or family practices into
unattractive options for many aspiring physicians.
And the relationship between patients and doctors has radically
changed. Apart from true emergency situations, patients’ expectations now
reflect the larger 24/7 insta-culture of wanting everything now. When Dr. Carl
Olden began watching patients turn to urgent care centers opening around him in
Yakima, Wash., he and his partners decided to fight back.
They set up similar clinics three years ago, including one right
across the street from their main office in a shopping center.
The practice not only was able to retain its patients, but then
could access electronic health records for those off-site visits, avoiding a
bad drug interaction or other problems, said Dr. Olden, who has been a doctor
for 34 years.
“And we’ve had some folks come into the clinics who don’t have
their own primary care physicians,” he said. “So we’ve been able to move them
into our practice.”
Merger Maneuvers
The new deals involving major corporations loom over doctors’
livelihoods, intensifying pressure on small practices and pushing them closer
to extinction.
The latest involves Walmart and Humana, a large insurer with a
sizable business offering private Medicare plans. While their talks are in the
early stages, one potential partnership being discussed would center on using
the retailer’s stores and expanding its existing 19 clinics for one-stop
medical care. Walmart stores already offer pharmacy services and attract older
people.
In addition, the proposed $69 billion merger between CVS Health,
which operates 1,100 MinuteClinics, and Aetna, the giant insurer, would expand
the customer bases of both. The deal is viewed as a direct response to moves by
a rival insurer, UnitedHealth
Group, which employs more than 30,000 physicians and operates
one of the country’s largest urgent-care groups, MedExpress, as well as a big
chain of free-standing surgery centers.
While both CVS and UnitedHealth have large pharmacy benefits
businesses that would reap considerable rewards from the stream of
prescriptions generated by the doctors at these facilities, the companies are
also intent on managing what type of care patients get and where they go for
it. And the wealth of data mined from consolidation would provide the companies
with a map for steering people one way or another.
On top of these corporate partnerships, Amazon, JP Morgan and
Berkshire Hathaway decided to join forces to develop some sort of health care
strategy for their employees, expressing frustration with the current state of
medical care. Their announcement, and Amazon’s recent forays into these fields,
are rattling everyone from major hospital networks to pharmacists.
Doctors, too, are watching the evolution warily.
“With all of these deals, there is so much we don’t know,” said
Dr. Michael Munger, president of the American Academy of Family Physicians.
“Are Aetna patients going to be mandated to go to a CVS MinuteClinic?”
Constant Changes in Care
Dr. Susan Kressly, a pediatrician in Warrington, Pa., has
watched patients leave. Parents who once brought their children to her to treat
an ear infection or check for strep, services whose profits helped offset some
of the treatments she offered, are now visiting the retail clinics or urgent
care centers.
What is worse, some patients haven’t been getting the right
care. “Some of the patients with coughs were being treated with codeine-based
medicines, which is not appropriate at all for this age group,” Dr. Kressly
said.
Even doctors unfazed by patients going elsewhere at night or on
weekends are nervous about the entry of the corporate behemoths.
“I can’t advertise on NBC,” said Dr. Shawn Purifoy, who
practices family medicine in Malvern, Ark. “CVS can.”
Nurse practitioners allow Dr. Purifoy to offer more same-day
appointments; he and two other practices in town take turns covering emergency
phone calls at night.
And doctors keep facing new waves of competition. In California,
Apple recently decided to open up its own clinics to treat employees. Other
companies are offering their workers the option of seeking medical care via
their cellphones. Investors are also pouring money into businesses aiming to
create new ways of providing primary care by relying more heavily on
technology.
An Absence of Proof
Dr. Mark J. Werner, a consultant for the Chartis Group, which
advises medical practices, emphasized that convenience of care didn’t equal
quality or, for that matter, less expensive care.
“None of the research has shown any of these approaches to
delivering care has meaningfully addressed cost,” Dr. Werner said.
Critics of retail clinics argue that patients are given short
shrift by health professionals unfamiliar with their history, and may be given
unnecessary prescriptions. But researchers say neither has been proved in
studies.
“The quality of care that you see at a retail clinic is equal or
superior to what we see in a doctor’s office or emergency department,” said Dr.
Ateev Mehrotra, an associate professor of health care policy and medicine at
Harvard Medical School, who has researched the retail clinics. “And while there
is a worry that they will prescribe antibiotics to everybody, we see equal
rates occurring between the clinics and doctor’s offices.”
Still, while the retail clinics over all charge less,
particularly compared with emergency rooms, they may increase overall health
care spending. Consumers who not long ago would have taken a cough drop or
gargled with saltwater to soothe a sore throat now pop into their nearby retail
clinic for a strep test.
Frustration with the nation’s health care system has fueled a
lot of the recent partnerships. Giant companies are already signaling a desire
to tackle complex care for people with a chronic health condition like diabetes
or asthma.
“We’re evolving the retail clinic concept,” said Dr. Troyen A.
Brennan, the chief medical officer for CVS. The company hopes its proposed
merger with Aetna will allow it to transform its current clinics, where a nurse
practitioner might offer a flu shot, into a place where patients can have their
conditions monitored. “It requires new and different work by the nurse
practitioners,” he said.
Dr. Brennan said CVS was not looking to replace patients’
primary care doctors. “We’re not trying to buy up an entire layer of primary
care,” he said.
But people will have the option of using the retail clinic to
make sure their hypertension or diabetes is well controlled, with tests and
counseling provided as well as medications. The goal is to reduce the cost of
care for what would otherwise be very expensive conditions, Dr. Brennan said.
If the company’s merger with Aetna goes through, CVS will
initially expand in locations where Aetna has a significant number of customers
who could readily go to CVS, Dr. Brennan said.
UnitedHealth has also been aggressively making inroads, adding a
large medical practice in December and roughly doubling the number of areas
where its OptumCare doctors will be to 75 markets in the United States. It is
also experimenting with putting its MedExpress urgent care clinics into
Walgreens stores.
Big hospital groups are also eroding primary care practices:
They employed 43 percent of the nation’s primary care doctors in 2016, up from
23 percent in 2010. They are also aggressively opening up their own urgent care
centers, in part to try to ensure a steady flow of patients to their
facilities.
HCA Healthcare, the for-profit hospital chain, doubled its
number of urgent care centers last year to about 100, according to Merchant
Medicine. GoHealth Urgent Care has teamed up with major health systems like
Northwell Health in New York and Dignity Health in San Francisco, to open up
about 80 centers.
“There is huge consolidation in the market right now,” said Dr.
Jeffrey Le Benger, the chief executive of Summit Medical Group, a large
independent physician group in New Jersey. “Everyone is fighting for the
primary care patient.” He, too, has opened up urgent care centers, which he
describes as a “loss leader,” unprofitable but critical to managing patients.
Eva Palmer, 22, of Washington, D.C., sought out One Medical, a
venture-backed practice that is one of the nation’s largest independent groups,
when she couldn’t get in to see a primary care doctor, even when she became
ill. After paying the annual fee of about $200, she was able to make an
appointment to get treatment for strep throat and pneumonia.
“In 15 minutes, I was able to get the prescriptions I needed —
it was awesome,” Ms. Palmer said.
Patients also have the option of getting a virtual consultation
at any time.
By using sophisticated computer systems, One Medical, which
employs 400 doctors and health staff members in eight major cities, allows its
physicians to spend a half-hour with every patient.
Dr. Navya Mysore joined One Medical after working for a large
New York health system, where “there was a lot of bureaucracy,” she said. She
now has more freedom to practice medicine the way she wants and focus more on
preventive health, she said.
By being so readily available, One Medical can reduce visits to
an emergency room or an urgent care center, said Dr. Jeff Dobro, the company’s
chief medical officer.
As primary care doctors become an “increasingly endangered
species, it is very hard to practice like this,” he said.
Long-Term Lifelines
But more traditional doctors like Dr. Purifoy stress the
importance of continuity of care. “It takes a long time to gain the trust of
the patient,” he said. He is working with Aledade, another company focused on
reinventing primary care, to make his practice more competitive.
One longtime patient, Billy Ray Smith, 70, learned that he
needed cardiac bypass surgery even though he had no symptoms. He credits Dr.
Purifoy with urging him to get a stress test.
“If he hadn’t insisted,” Mr. Smith said, “it would have been all
over for me.” Dr. Purifoy’s nurse routinely checks on him, and if he needs an
appointment, he can usually see the doctor that day or the next.
“I trust him 100 percent on what he says and what he does,” Mr.
Smith said.
Those relationships take time and follow-up. “It’s not something
I can do in a minute,” Dr. Purifoy said. “You’re never going to get that at a
MedExpress.”
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