Word last week that CVS will cut some of its in-store MinuteClinics, opening some of them only in flu season got me thinking about the pros and cons of these types of clinics. In addition to CVS, Walmart and Walgreens also have clinics in their stores for a total of about 1,100 locations nation-wide.
These clinics are good for a spur of the moment need but do they really help address the need of the uninsured and those who are really diagnosed with something long term? The answer is more no than yes.
First, the advantages.
In-store clinics offer the basics such as basic physicals, checks for diabetes, cholesterol, and high blood pressure. Some offer help you to quit smoking (you’ll be buying your anti-craving pills and nicotine gum in their pharmacy, of course). They also provide shots for flu and pneumonia prevention and the basic childhood vaccinations. Their web sites provide the full lists of services offered.
Additionally, the clinics probably help keep people who have simple problems such as strep throat, ear aches, bladder infections, rashes, ear wax, the flu, a cold, pink eye, sprains and other acute minor problems from clogging up busy emergency rooms. Think you may be pregnant? Come on in for a test.
They are relatively affordable. The average charges are around $60 - $80 for the common conditions listed above or for a check up such as a school physical, sports physical or health screening. Additional charges may apply. For example, the price of shots is added on to your visit charge in some cases and if you need a prescription filled, you still have to buy it (at the in-sore pharmacy, of course, and pick up some shampoo, deodorant and toothpaste while you’re at it).
Convenience is probably the major advantage, with hours 7 days a week and no appointment necessary. Evening hours are available which is good for working families and kids who are in school.
The clinics are staffed by advanced practice nurses (nurse practitioners) and physicians assistants. Both classes of these professionals are uniquely qualified to provide the services the clinics offer.
This is all good. It’s hard to argue against making acute care, screening and prevention more conveniently available.
However, the clinics do fall short, especially in the area of comprehensiveness, the ability to diagnose and treat complicated chronic illness and the promotion of continuity of care rather than episodic care. Patients registering at an in-store clinic should lower expectations. (Read more.....)
These are basically “above the waist” clinics, unless you have athlete’s foot. They do treat that. Below the waist? Find another option.
In-store clinics are set up to skim off the easy diagnoses and treat them, leaving the complex medical issues to other health care providers. For example, babies younger than 18 months, women and men with possible or overtsexually transmitted diseases, HIV testing, women needing pap tests for cervical cancer breast exams with a connection to a mammogram are not served. If you have a gynecologic problem you may be out of luck. Colon cancer screening with a take home test? Not on the list. Family planning? Not advertised on the list. And if you actually have diabetes, high blood pressure, heart disease, asthma, arthritis, a pinched nerve, or any chronic condition, you will be referred to your primary care provider – if you have one. If you don’t and you have no insurance, to where will you be referred?
Although there are 1,100 in-store clinic locations around the country, a quick survey of the ones located in the Chicago area show that they generally avoid areas with the highest concentrations of poverty and the uninsured. By contrast, community health centers have over 7,000 locations nation-wide, located in the most highly impacted communities, and provide services regardless of ability to pay. Unfortunately, many community health centers struggle with rapid access as they are overwhelmed with uninsured and low-income patients trying to get in, and few probably offer Sunday hours, although most offer evening and Saturday hours and 24-hour answering services for telephone advice.
The fee at in-store clinics seems reasonable, but can be a barrier. At our health center, many low-income, uninsured patients struggle to pay their flat $30 fee per visit and, as a result, we collect an average of $21 per visit. We never decline services based on the ability to pay. In-store clinics will not slide your fee down based on your income and will not accept a payment less than the full charge.
I am a big fan of the talents and skills of advanced practice nurses and physicians assistants. In Illinois, these professionals may practice without a physician on-site. Our health center uses this model in some of our school-based health centers. Advanced practice nurses and physician’s assistants in Illinois must have a collaborating physician. At in-store clinics, the collaborating physician will never be on site and available to lay eyes and hands on, an advantage we have at our health center’s comprehensive care locations. It is more difficult to collaborate with a physician when the physician is off site.
Overall, I’m glad the in-store clinics are out there. They fill a specific niche. But a smart health care consumer should realize their limitations. Policy makers should pay attention to the growing need to manage chronic care and to provide quick access to complex medical problem solving for safety-net populations. Big box clinics are an “above the waist” entrepreneurial approach but not a solution to the care of the uninsured.
What do you think?
END OF POSTING – THANK YOU FOR READING
Showing posts with label health care. Show all posts
Showing posts with label health care. Show all posts
Sunday, March 15, 2009
Sunday, March 8, 2009
Federal Stimulus Dollars Flow to Community Health Centers
Federal stimulus dollars have been directed by Congress to community health centers. Health Centers are economic engines that provide hundreds of thousands of health care jobs nation wide as well as stimulus to the economy through purchasing of supplies and equipment.
The American Investment and Recovery Act of 2009 includes (read more):
$2 billion for community health centers. There are over 1,000 community health centers nation wide with over 7,000 service sites. For example, Erie Family Health Center is 1 community health center with 8 service locations.
Included in the $2 billion mentioned above:
$340 million has just been announced for health centers to immediately increase the number of uninsured patients served by hiring more health care workers, increasing hours of operation, and increasing existing health center services. Applications are due on March 16th to compete for these funds.
$155 million has been already awarded to community health centers who applied to launch new sites last year and were not funded. In Illinois, the following community health centers just received $1.3 million each to add a new service site: Lawndale Christian Health Center (Chicago), Lake County Health Department/Community Health Center, Community Health and Emergency Services (Carbondale), and Friend Family Health Center (Chicago, and affiliate of the University of Chicago).
$1.5 billion for construction, renovation, equipment and health information technology systems at the community health center level. We do not yet know how community health centers will be able to compete for these funds. Buildings such as Erie Family Health Center's, Humboldt Park location (Chicago, pictured above) are in need of state of the art upgrades.
Community health centers are cost effective providers of primary health care. Health centers provide primary care for 17 million individuals in the US, over 1 million in Illinois and over 500,000 in the Chicago metro area. Currently at least 45.7 million Americans are uninsured. This does not count the underinsured and those who are not residents of the US but who are workers and their family members who need health care.
Sunday, November 11, 2007
Who should run health care in Cook County?
Who should govern the Cook County Bureau of Health Services?
The current rubric gives the Cook County Board responsibility for oversight of public health and health care. We need experts who know how to run hopsitals and clinics. Most experts agree that the Cook County Board must relinquish oversight to an independent health commission. This is not new news. Earlier this year health experts, under the umbrella of Northwestern University's Feinberg School of Medicine came together and recommended this.
You can read the whole report from Northwestern University’s Feinberg School of Medicine about important priorities and directions that can be taken by Cook County Bureau of Health. The authors of this report should know. They are all veterans of the Cook County Bureau of Health Care system. They have worked there. They know the inside information. There are successful models from around the country that they draw upon in the recommendations section.
Not to be left out, Cook County Board President Stroger appointed his own Blue Ribbon Commission. Read the Blue Ribbon Commission Report to get a sense that we run health care in our County as if it was some feifdom from the middle ages. Time to turn it over to the experts in hospital management, public health systems and financial outcomes. We'll see if President Stroger has the political courage to follow these recommendations.
The current rubric gives the Cook County Board responsibility for oversight of public health and health care. We need experts who know how to run hopsitals and clinics. Most experts agree that the Cook County Board must relinquish oversight to an independent health commission. This is not new news. Earlier this year health experts, under the umbrella of Northwestern University's Feinberg School of Medicine came together and recommended this.
You can read the whole report from Northwestern University’s Feinberg School of Medicine about important priorities and directions that can be taken by Cook County Bureau of Health. The authors of this report should know. They are all veterans of the Cook County Bureau of Health Care system. They have worked there. They know the inside information. There are successful models from around the country that they draw upon in the recommendations section.
Not to be left out, Cook County Board President Stroger appointed his own Blue Ribbon Commission. Read the Blue Ribbon Commission Report to get a sense that we run health care in our County as if it was some feifdom from the middle ages. Time to turn it over to the experts in hospital management, public health systems and financial outcomes. We'll see if President Stroger has the political courage to follow these recommendations.
Saturday, November 3, 2007
Death and Health Insurance
This column by Bob Herbert column by Bob Herbert in the NY Times got me thinking about the relationship between health insurance and what physicians write on death certificates. Does lack of health insurance increase the risk of death?
This letter was not published, but 2 by others took a different approach.
November 3, 2007
To the Editor:
Re “Worsening the Odds” (Op-Ed, Nov 3): Bob Herbert describes the unfortunate case of a 45 year old medically uninsured craftsman with progressive headaches who died of metastatic cancer to the brain. He suggests that lack of health insurance contributed to the cause of death.
At our inner-city community health center, 70% of the adults we serve lack health insurance. We commonly see preventable complications of disease.
In Illinois, physicians must enter the official cause of death on the death certificate. On the following two lines physicians may choose to add that the death was “Due to or as a consequence of …” Perhaps we should routinely write “lack of health insurance” or “inability to obtain preventive care” on these lines. By doing so, the role played by this important factor will become an official part of the public record.
This letter was not published, but 2 by others took a different approach.
November 3, 2007
To the Editor:
Re “Worsening the Odds” (Op-Ed, Nov 3): Bob Herbert describes the unfortunate case of a 45 year old medically uninsured craftsman with progressive headaches who died of metastatic cancer to the brain. He suggests that lack of health insurance contributed to the cause of death.
At our inner-city community health center, 70% of the adults we serve lack health insurance. We commonly see preventable complications of disease.
In Illinois, physicians must enter the official cause of death on the death certificate. On the following two lines physicians may choose to add that the death was “Due to or as a consequence of …” Perhaps we should routinely write “lack of health insurance” or “inability to obtain preventive care” on these lines. By doing so, the role played by this important factor will become an official part of the public record.
Sunday, May 27, 2007
Cook County Bureau of Health Cuts Now to Spend More Later
The Cook County Bureau of Health is trying to close a budget deficit. Currently the round peg of $835M in health system expenditures has to fit into the square hole of a $730M target. An historic closing of County-run community clinics combined with one of the largest layoffs of doctors and nurse practitioners has created repercussions across the region. The problem? No strategic plan, no governance by health care experts.
Meanwhile, the response by Cook County managers is to strangle prevention efforts and to cut resources that allow people to get health care close to home, at a neighborhood clinic. Let's keep the emergency department free to see true emergencies instead of clogging it up with folks who just need a refill on their diabeted medication.
Paradoxically, cutting back on neighborhood-based care will put more stress on the system by forcing patient to stand in line for routine services at Stroger Hospital. Or worse, wait until they are too sick and end up with costly hospitalization.
Can someone do the math?
Meanwhile, the response by Cook County managers is to strangle prevention efforts and to cut resources that allow people to get health care close to home, at a neighborhood clinic. Let's keep the emergency department free to see true emergencies instead of clogging it up with folks who just need a refill on their diabeted medication.
Paradoxically, cutting back on neighborhood-based care will put more stress on the system by forcing patient to stand in line for routine services at Stroger Hospital. Or worse, wait until they are too sick and end up with costly hospitalization.
Can someone do the math?
Cutting off a system for community to hospital referrals saves money and time. So why cut it?
Testimony of
Lee Francis, MD, MPH
Interim CEO, Erie Family Health Center
May 23, 2007
Erie Family Health Center is a federally qualified health center celebrating its 50th year. With 8 service locations ranging from North Lawndale, West Town, Humboldt Park, and Logan Square all the way to Albany Park, we provide over 120,000 patient visits annually to over 30,000 patients. On a budget of $20M we employ 260 health care workers. Although we are located in Chicago, approximately 10% of our patients come from Suburban Cook County, the rest from the City.
On March 27, 2007 Dr. Robert Simon, Interim Chief, Cook County Bureau of Health Services, notified community health centers participating in the cooperative computerized specialty referral system called IRIS that our patients would no longer be able to access services for specialty consultations and testing effective April 16, 2007. He stated that a task force had been formed to evaluate the issue and would report back to him in 1-1.5 months. After over a month of requests through various high level channels, Dr. Simon finally met with us last week and some sort of work group with our input was formed. The first meeting will be in early June. Meanwhile patients go without services. We are asked to refer them to the ER for simple and complex problems alike that are best sorted out directly between primary care doctor and specialist.
Shortly after IRIS was cut off, I saw Sra. C. in my clinic. She has terrible diabetes and sees the diabetes and kidney specialists at Fantus Clinic. Her colon cancer was diagnosed and cured by the skilled surgeons at the hospital. She attends the eye clinic because she has diabetic eye disease and the ear nose and throat clinic because she has lost much of her hearing. She complained of chest pain and I felt that she needed a stress test. Stroger Hospital is her health care provider of choice. She chooses. Yet, for the first time in over 10 years, since the Stroger ER first referred her to me, I could not link her with an appointment for a stress test. Here’s the kicker – she has both Medicare and Medicaid, and she is choosing the County for her health care. Should I send her to the ASC so another doctor, who doesn’t know her, can decide if she needs a stress test or not? Or to another hospital who is more eager to bill for the service?
This decision has left thousands of Cook County residents out in the cold – residents who have a right to Bureau services.
IRIS is part of the Neighborhood Referral Program, a system with almost 20 years history. It creates a successful exchange relationship between tertiary care hospital and its specialty clinics and neighborhood health centers such as ours which specialize in primary care.
In 2006, Erie made 2,907 referrals for services on the Stroger Hospital campus, 84% of which were scheduled for service. Seven percent of patients referred actually had good solid health insurance. In exchange, Erie has accepted over 400 new patients per year from Stroger ER and the ASC walk in clinic – taken them under our wing and provided them affordable, high quality comprehensive primary care services – regardless of their ability to pay. We have been doing this for over 10 years; we have accepted over 4,000 into our system. Multiply these numbers by 10 or 20 to get an idea of the number of patients unloaded from the Stroger campus and able to receive care in their communities. We are talking 40,000 – 80,000 people who are being helped right in their own neighborhoods.
When we accept patients through NRP, we accept the financial burden. Each visit costs us $153. Our Federal grant accounts for only 23% of our income. Medicaid and Medicare pay about $120 per visit, only 60% of what the County receives per Medicaid visit. We fundraise the rest. If the patient is uninsured, we ask for a reasonable fee of $30 per visit. The average patient currently pays about $18, or 60% of our self-pay fee. We ask a small fee of $4 for medications we supply. We know how to compassionately collect self-pay fees, we know how to bill Medicaid and Medicare and other payers. We even accept Visa and Master Card!
Dr. Simon has stated that community health center use of the IRIS system costs the County $20M per year. No one has any idea where this number comes from. Community clinics account for only 16% of IRIS referrals. If this 16% costs $20M then, the other 84% of usage from Bureau clinics must cost $105M for a total cost of the IRIS system of $125M. Please ask Dr. Simon to show on paper how the IRIS system, for all users, costs a total of $125M per year out of a total expense line of approximately $853M (total per Dr. Simon).
More important: What is the “cost of waste” of not having such a system? What is the additional cost of thousands of new emergency room and ASC visits at over $200 per visit. What about preventable heart attacks, cancers, strokes at tens of thousands of dollars each? From the standpoint of the public good, this question deserves an answer from the financial experts at the Bureau.
We requested that the IRIS system be turned back on while we work together as partners to evaluate the system and increase efficiencies. So far the answer has been “no”. We all agree that we can and must improve efficiencies in the system. At least turn on the most vital parts of the system and restore access to the most needed services.
Lee Francis, MD, MPH
Interim CEO, Erie Family Health Center
May 23, 2007
Erie Family Health Center is a federally qualified health center celebrating its 50th year. With 8 service locations ranging from North Lawndale, West Town, Humboldt Park, and Logan Square all the way to Albany Park, we provide over 120,000 patient visits annually to over 30,000 patients. On a budget of $20M we employ 260 health care workers. Although we are located in Chicago, approximately 10% of our patients come from Suburban Cook County, the rest from the City.
On March 27, 2007 Dr. Robert Simon, Interim Chief, Cook County Bureau of Health Services, notified community health centers participating in the cooperative computerized specialty referral system called IRIS that our patients would no longer be able to access services for specialty consultations and testing effective April 16, 2007. He stated that a task force had been formed to evaluate the issue and would report back to him in 1-1.5 months. After over a month of requests through various high level channels, Dr. Simon finally met with us last week and some sort of work group with our input was formed. The first meeting will be in early June. Meanwhile patients go without services. We are asked to refer them to the ER for simple and complex problems alike that are best sorted out directly between primary care doctor and specialist.
Shortly after IRIS was cut off, I saw Sra. C. in my clinic. She has terrible diabetes and sees the diabetes and kidney specialists at Fantus Clinic. Her colon cancer was diagnosed and cured by the skilled surgeons at the hospital. She attends the eye clinic because she has diabetic eye disease and the ear nose and throat clinic because she has lost much of her hearing. She complained of chest pain and I felt that she needed a stress test. Stroger Hospital is her health care provider of choice. She chooses. Yet, for the first time in over 10 years, since the Stroger ER first referred her to me, I could not link her with an appointment for a stress test. Here’s the kicker – she has both Medicare and Medicaid, and she is choosing the County for her health care. Should I send her to the ASC so another doctor, who doesn’t know her, can decide if she needs a stress test or not? Or to another hospital who is more eager to bill for the service?
This decision has left thousands of Cook County residents out in the cold – residents who have a right to Bureau services.
IRIS is part of the Neighborhood Referral Program, a system with almost 20 years history. It creates a successful exchange relationship between tertiary care hospital and its specialty clinics and neighborhood health centers such as ours which specialize in primary care.
In 2006, Erie made 2,907 referrals for services on the Stroger Hospital campus, 84% of which were scheduled for service. Seven percent of patients referred actually had good solid health insurance. In exchange, Erie has accepted over 400 new patients per year from Stroger ER and the ASC walk in clinic – taken them under our wing and provided them affordable, high quality comprehensive primary care services – regardless of their ability to pay. We have been doing this for over 10 years; we have accepted over 4,000 into our system. Multiply these numbers by 10 or 20 to get an idea of the number of patients unloaded from the Stroger campus and able to receive care in their communities. We are talking 40,000 – 80,000 people who are being helped right in their own neighborhoods.
When we accept patients through NRP, we accept the financial burden. Each visit costs us $153. Our Federal grant accounts for only 23% of our income. Medicaid and Medicare pay about $120 per visit, only 60% of what the County receives per Medicaid visit. We fundraise the rest. If the patient is uninsured, we ask for a reasonable fee of $30 per visit. The average patient currently pays about $18, or 60% of our self-pay fee. We ask a small fee of $4 for medications we supply. We know how to compassionately collect self-pay fees, we know how to bill Medicaid and Medicare and other payers. We even accept Visa and Master Card!
Dr. Simon has stated that community health center use of the IRIS system costs the County $20M per year. No one has any idea where this number comes from. Community clinics account for only 16% of IRIS referrals. If this 16% costs $20M then, the other 84% of usage from Bureau clinics must cost $105M for a total cost of the IRIS system of $125M. Please ask Dr. Simon to show on paper how the IRIS system, for all users, costs a total of $125M per year out of a total expense line of approximately $853M (total per Dr. Simon).
More important: What is the “cost of waste” of not having such a system? What is the additional cost of thousands of new emergency room and ASC visits at over $200 per visit. What about preventable heart attacks, cancers, strokes at tens of thousands of dollars each? From the standpoint of the public good, this question deserves an answer from the financial experts at the Bureau.
We requested that the IRIS system be turned back on while we work together as partners to evaluate the system and increase efficiencies. So far the answer has been “no”. We all agree that we can and must improve efficiencies in the system. At least turn on the most vital parts of the system and restore access to the most needed services.
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