Recently, Kathleen Cowling, DO, an assistant clinical professor at the College of Human Medicine, Michigan State University, was at a cell phone counter pondering her mobile options when the clerk asked her what she did.
Upon learning that she was an emergency physician, he held up his hand with two bent fingers. Everything is still attached, he said. I had a grinding wheel accident a year ago.
Four doctors had taken care of him, and a specialist and plastic surgeon reattached his fingers. It wasn't perfect, but he was thrilled. It's a classic example of how the emergency department is the last place people want to go, but how it's the answer to their problems, said Dr. Cowling.
But as small clinics seeking lucrative and easy parts of the emergency care market begin to dot the landscape æ located anywhere from near a hospital's emergency department to a corner of Wal-Mart æ many are beginning to question whether they could threaten the existence of emergency departments by siphoning off patients who are easy and cheap to treat and leaving the hospitals with the more difficult and expensive injuries and illnesses.
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On one hand, those who operate such clinics say they are helping patients who would wait hours in a crowded emergency department. On the other, emergency medicine organizations point out that these clinics will not solve ED crowding. These patients do not crowd emergency departments; that job is done by seriously injured or ill patients who are boarded in the department while awaiting a bed in the hospital.
Dr. Cowling said she worries about patients who seek care in the tiny clinics in drugstores and retailers. These clinics don't necessarily have the answers, and don't have those specialists to call, she said. I think it's sad. People will think it's the answer. Everything from specialty hospitals on down siphon off the cream, and make it harder [for us] to provide the services everyone needs.
The MinuteClinic Model
Jim Woody Woodburn, MD, the chief medical officer of MinuteClinic, Inc., sees the other side of the coin. This is a different kind of model, he said. We have a 75-square-foot facility in CVS Pharmacies. The company currently operates 81 clinics in major cities in the South and Midwest, and plans to open at least 150 more in 2006.
We are not a doc-in-a-box, he said. The clinics are staffed by nurse practitioners and physician assistants. We've taken a narrow slice of clinical care. We are not urgent care. We call it a MinuteClinic because it's quick, focused, and convenient, said Dr. Woodburn, who trained in emergency medicine.
The clinics are set up to treat only a few conditions, such as strep throat, ear infections, conjunctivitis, sinusitis, mild bronchitis, and uncomplicated female urinary tract infections. If you have had any of those conditions, you know what you have, he said. You need someone to confirm it, and write a prescription.
Most insurance plans reimburse for care provided at the clinics, he said, so patients pay their insurance co-pay or from $49 to $59 in cash or by credit card.
MinuteClinic staff relies on an electronic medical record system that includes clinical practice guidelines for treating those conditions. While the clinic personnel have had to call 9-1-1 for someone having chest pains on occasion, that's very rare, he said.
His clinics have treated more than 420,000 patients in the past six years. While the clinics are now in limited locations, Dr. Woodburn plans expansion. It just takes us time to get out there. We'll be everywhere, he said, noting that he does not subscribe to the notion that his clinics are the answer to the emergency department crowding.
Most of our patients wouldn't have gone to an emergency department, he said. Most would have gone to emergency care clinics. This provides a third tier of care, a new layer for when you can't get in to see your own doctor, and you don't want to hang around the urgent care clinic. We are very convenient but very high quality.
He said staff training is important, as is the desire to provide an adjunct to busy urgent care centers. Dr. Woodburn noted that the clinics could be considered as after-hours access for people who use family practice clinics, adding that MinuteClinics are open Saturday and Sunday.
Dr. Woodburn said others running similar clinics must understand what they can do well and stick with that, with an emphasis on quality and training. This is not a cash cow, he said. We hope our competitors provide good quality because they could damage all of us if they don't pay attention to the details.
Decompressing Crowding
Stephen Dresnick, MD, the president and CEO of Sterling Healthcare, said he has seen the emergence of urgent care centers in a variety of settings. If you put in physicians or practitioners who are qualified to take care of the limited scope of things they should be doing, you are OK. If they are seeing anything that comes in, including potential heart attacks, and they don't have the skills to make that diagnosis, it could be problematic. The quality of physicians is paramount.
Such clinics could offer older emergency physicians the opportunity to practice in a less stressful environment, he said. I do think there will be an opportunity for emergency physicians to participate, but it's too early to tell, Dr. Dresnick said.
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I don't think you see Wal-Mart turning people away at the door saying, 'We are overcrowded.' I'm not sure why we whine about it. - Dr. Stephen Dresnick
For one thing, hospitals are not as eager to re-enter the urgent care business they pioneered 20 years ago, but he said he doubts that such clinics will reduce demand on the nation's overloaded emergency departments. Nor does he think it will hurt their bottom line. If you look at what [the clinics] are good for, they're the things that aren't good in the emergency department, the colds, the sore throats, the earaches.
I think it's part of the other trend in medicine. As we move toward consumer-based health care programs, like health savings accounts, the consumer who has a stake in how his dollars are spent will pay attention to things like cost.
I think the reason you see [companies] like CVS wanting these centers in their stores is to capture the pharmacy, Dr. Dresnick said. They are looking for traffic. If you are going to go to the Super Wal-Mart, you want to take care of all your needs. While you are waiting to be seen by the doctor, you can spend a couple of hundred dollars shopping. I'm not sure the stores' reasons for doing it are altruistic.
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We are not a doc-in-a-box. - Dr. Jim Woody Woodburn
Crowded emergency departments are a symptom of poor management, he said. I don't think you see Wal-Mart turning people away at the door saying, 'We are overcrowded.' I'm not sure why we whine about it. People come to emergency departments because they know it's where they get good care, Dr. Dresnick said. Management in hospitals and emergency departments need to figure out a way to decompress the situation.
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© 2006 Lippincott Williams & Wilkins, Inc.