The Rhode Island Department of Health's recent decision to grant approval, with 22 conditions, to CVS to open seven retail health clinics in pharmacies throughout Rhode Island came down in the form of a 43-page document. In my humble opinion, it's a well-written, even eloquent ode to the importance of primary care and the challenges of regulating health care in a state where for-profit health care is no longer around the corner but setting up shop on it. (I recommend reading the decision, available here.) Here's my close reading of the decision and how it could impact you.
CVS has opened MinuteClinics in 28 states. And according to its application to the health department, it's already the nation's largest retail health clinic chain, seeing patients at more than 800 locations. The value proposition for consumers seems to be this: the clinic is open outside traditional doctor's office hours, seven days a week; it can take care of basic health screenings and minor illnesses; and it's probably conveniently located. MinuteClinics aren't promising comprehensive primary care, but a reliable stand-in: kids need a camp physical, and camp starts tomorrow? Got a sore throat but can't get in to see your doctor until morning? Need your Epi-pen refilled? Also, CVS may feel like a "known" quantity, or trusted name, compared to the seemingly wide range of quality and convenience you might find in the region's assortment of unaffiliated urgent care clinics.
A list of concerns
But not everyone in Rhode Island seems to have been jumping up and down about the prospect of seven new retail clinics. Doctors' groups went on the record saying they worried the clinics would eat into their own primary care practices and threaten an already tough business model, for instance. The health department also articulated four major concerns it had to consider before approving or denying CVS' application:
- The ethics of health care providers and prescribers working for a pharmacy. Would patients feel obligated to buy their prescriptions from CVS? The department felt that even though CVS MinuteClinics had taken steps to minimize this apparent conflict of interest, it still looked like a conflict of interest. How could you trust that your nurse practitioner wasn't just writing you a prescription to boost the pharmacy's bottom line?
- The risk of "fragmenting" health care even further. Any time a patient gets seen for something at a MinuteClinic, doctors argued, that's another opportunity lost to provide a certain continuity of care, to develop relationships, to have those conversations about prevention and wellness that primary care doctors are known for.
- The pitfalls of caring for kids at a walk-in, retail clinic. Pediatricians like to track a child's development over time, ensure the child is seen at specific intervals, and monitor any developmental or genetic problems. Doctors argued that MinuteClinics weren't the right setting for this kind of continuous care.
- The need to increase access to primary care services for underserved areas. Would MinuteClinics help fill any gaps in access, geographically speaking? And would they keep the state's commitment to providing care to people who can't afford it?
Public meetings were held. Comments were submitted. The application was studied. Regulations were considered.
In the end, the health department couldn't find convincing evidence that MinuteClinics eroded primary care practices or patient relationships. That doesn't mean, Dr. Michael Fine told me recently, that it couldn't happen. But the evidence isn't there now. Also, CVS satisfied the regulators that it had taken steps to avoid the appearance of a conflict of interest between providing health care and selling prescriptions.
What's more, the health department has asked MinuteClinics to agree to 22 conditions before it will officially approve the application to open seven clinics. The conditions are supposed to address those four issues, above. For instance, the state is requiring MinuteClinics to tell patients clearly, and post signs saying that they don't have to buy their prescriptions at that CVS pharmacy or any CVS pharmacy. To reduce "fragmentation," MinuteClinics will have to provide a referral to a primary care physician to any patient who doesn't have one. They'll also have to use the state's electronic medical records and enroll in KidsNet, the system that tracks a child's vaccinations.
The concern about "fragmenting" the primary care system makes sense if everyone has a primary care physician and no one uses electronic medical records. But the fact is that not every Rhode Islander has a regular primary care provider.
The concern doctors expressed about MinuteClinics eating into their primary care practice business is also understandable. Primary care practices are operating under some tough conditions right now. But perhaps it's helpful to remember that MinuteClinics don't seem to want to replace your primary care physician; they're not offering the kind of comprehensive primary care a PCP can.
So what does the future of primary care look like in Rhode Island, given this new entrant on the scene? The infrastructure looks more robust. We've got a pretty high ratio of primary care providers to residents, compared to other states. We've made investments in primary care, boosting the number of patient-centered medical homes, for example. But are we healthier? Are patients empowered to use their health care? Do they know how? That remains to be seen. It's clear, however, that primary care is evolving to offer patients more convenience, more coordination or care, and more of a focus on their needs.