Health Care in a Big Box

Last Editorial Review: 3/7/2005

Medical clinics are opening in stores like Target all over the country. Are these one-stop shops a boon or bane to the health care industry?

By Martin Downs
WebMD Feature

Reviewed By Brunilda Nazario

Discount superstores, or big-box stores as many like to call them, epitomize the wants of time- and budget-strapped American consumers: everything, cheap, in one place. For shoppers in greater Minneapolis and Baltimore, that includes not only housewares, groceries, and photo processing, but also health care.

At Target stores in these cities you can get medical tests, vaccinations, and treatment for minor ailments at a MinuteClinic, located near the store pharmacy. A menu posted outside the clinic lists the services available and conditions treated, with a price for each. Sinus infection, $44. Mono, $51. Cholesterol test, $37.

Patients need no appointment, and a visit is supposed to take about 15 minutes.

"If there are two or three people ahead of them they can take a beeper and do some shopping, and we can beep them, or they can leave their cell phone number," says Cathy Wisner, PhD, a nurse practitioner who works at a Minneapolis MinuteClinic and is also a company vice president.

You won't see a doctor at a MinuteClinic. There are none. Nurse practitioners, qualified and licensed to provide the kind of care MinuteClinic offers, do the job, aided by a computer program that guides them through the process. If a patient comes in with what he thinks is strep throat, for example, and the strep test comes back positive, the program will let the practitioner print out a prescription for antibiotics. If it's not strep, then the software won't allow antibiotics to be prescribed.

Patients whose problems turn out to be more serious are referred to their primary care doctor or an emergency room, in which case there's no charge for the visit. MinuteClinic CEO Linda Hall Whitman likens the MinuteClinic model to self-serve banking. "You wouldn't go to MinuteClinic for appendicitis or chest pain, and you wouldn't go to an ATM to take out a mortgage," she says.

If nothing else, MinuteClinic shows that people don't mind getting medical attention at the same place where they buy their laundry detergent. Since the first one opened in 2000 (under the name QuickMedx) at a Minneapolis Cub Foods supermarket, MinuteClinics have treated more than 130,000 people.

"I think there is a need in many areas of our country for that kind of care," says Judy Hendricks, a nurse practitioner in Delaware and board president of the American College of Nurse Practitioners. "If there's adequate screening and referral processes, then it's a service to the community."

The location of MinuteClinics in big-box stores highlights how central those stores are to life in many parts of America, but it doesn't appear to be a move by retailers to capture a bigger share of the health care market. MinuteClinic's business relationship with stores in which it operates may be symbiotic, but it's limited to leased space.

In addition to its Target and Cub Food locations, there are MinuteClinics on the University of Minnesota campus and at the Best Buy and Guidant corporate headquarters.

Saving Time and Money?

"It's all about time," Whitman says. "People are just out of time."

Considering that a MinuteClinic visit could be accomplished during a lunch break, whereas a trip to the doctor could take most of the afternoon, the appeal is obvious. Relatively low cost is a draw, too.

According to the Minnesota Council of Health Plans, an industry association, the average charge for seeing a doctor about a sore throat, including a strep test, is $109. A visit to a hospital emergency room for the same thing averages $328. MinuteClinic charges $48.

Most insurance plans in the areas MinuteClinic serves cover the visits, and patients are charged the same co-payment as for a traditional doctor's office visit. Some companies that provide their own health insurance, typically larger corporations, encourage workers to use MinuteClinics. "We have great support by self-insured employers," Whitman says. "In Minnesota, 23 employers have chosen to eliminate or discount the co-pay."

But not everyone sees the MinuteClinic model as an ideal fix for an overburdened health care system.

"It definitely disrupts the doctor-patient relationship," says Mary Frank, MD, president of the American Academy of Family Physicians. "It isolates problems that sometimes can be openings to other health care issues, or preventive-care discussions."

Whitman, however, argues that MinuteClinic keeps primary care providers in the loop. The software that practitioners use automatically faxes a copy of a patient's diagnostic record to the primary care doctor.

Depending on the diagnosis, the program also prints out a patient-education handout, which the practitioner then goes over with the patient. "Health education is a big part of what we do," Wisner says.

Will MinuteClinic Model Ease The Load on ERs?

After three years of working in a MinuteClinic, Wisner sees a lot of familiar faces. A family of four might be in several times a year, she says, as mom, dad, and the kids all suffer from seasonal woes, from bronchitis to allergies. "We tend to see some of the same folks, which is nice," she says.

Hendricks notes that in the medical center where she works, she is in fact a primary care provider to many people. "I have patients that see me and haven't seen the physician that I work with for years," she says.

Nevertheless, she stresses the value of working with doctors. "The ideal situation is one where nurse practitioners can function independently but have ready access to a variety of other health care professionals to consult and refer to." MinuteClinics don't have that access.

Frank agrees. "We encourage our members to practice in teams," she says. "The MinuteClinic should not be a turf issue between physicians and mid-level providers."

A doctor's office can save patients time by having nurse practitioners on staff for handling minor and routine problems, freeing up the doctor to deal with more complicated cases. And if what you assume to be bronchitis, for example, is actually something graver, the doctor may be just down the hall. One potential drawback of MinuteClinics is that if your self-diagnosis is wrong, you'll have to make the doctor's appointment you tried to avoid by going to a MinuteClinic.

Some might argue that treating something simple like strep throat isn't the best use of a high-tech trauma/emergency center and that perhaps the MinuteClinic model could help relieve some of the load on ERs.

Emergency doctor Michael Bishop, MD, says he doesn't think so. If clinics like MinuteClinic do become widespread, "It's going to have no impact," says Bishop, president of the Unity Physician Group in Bloomington, Ind. Emergency departments, he says, "provide access for those people who cannot get access, for whatever reason."

For patients with health insurance, the reason may be that a family doctor isn't available when needed. But there are also millions of uninsured and poor, who emergency departments are required by law to treat regardless of their ability to pay. "The charges may be high, but that doesn't necessarily mean the payments are going to be high," Bishop says.

Are Wait Times Improving in Doctors' Offices?

Recognizing that patients are fed up with gathering cobwebs while they sit in doctors' waiting rooms, the American Academy of Family Physicians has urged its members to reorganize their practices.

Weston Welker, MD, a family doctor in Huntsville, Ala. made some of the recommended changes over a year ago. He says that the way he used to operate, he was usually double booked during peak seasons. If you had woken up with a sore throat and called him, "It may have been that I had 30 patients booked that morning already," he says. "It was just a madhouse."

Now, he leaves one-quarter of his available appointments open every day. "Anyone who calls in has free access to those. That's worked out very well," he says.

Patients may not be able to come in at the exact time of their choosing, but they can be reasonably assured they'll be seen that day, and with appointments not double booked, they're more likely to get in and out the door on time.

"We're trying to make things as easy and patient-centered as we possibly can," Frank says. "We're on the move with that."

MinuteClinic is on the move, too, perhaps to a store near you. Opening clinics at eight Baltimore-area Target stores in August 2004 was the first step in the company's plan to expand nationwide. They're keeping their next grand opening under wraps.

Whether the MinuteClinic model will become to health care what big-box stores are to retail, time will tell. But if convenience and low prices don't win you over, then maybe the small personal touches will. Just as Wal-Mart's greeters meet customers at the door, MinuteClinic practitioners wish patients a speedy recovery. "We always send a get-well card," Wisner says.

Published March 7, 2005.

SOURCES: Cathy Wisner, PhD, vice president of operations, MinuteClinic, Inc. Linda Hall Whitman, CEO, MinuteClinic, Inc. Mary Frank, MD, president, American Academy of Family Physicians. Weston Welker, MD, family physician, Huntsville, Alabama. Minnesota Council of Health Plans. Family Practice Management, April 2004. Judy Hendricks, nurse practitioner; board president, American College of Nurse Practitioners. Michael Bishop, MD, president, Unity Physician Group, Bloomington, Ind.

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