Location. Location. Location. 13% of Much Heralded Retail Health Clinics are in Medically Underserved Neighborhoods

standebuch, arzt, doktor, medizin arznei, 1568, photo via fotothek

Retail health clinics have sprouted up across America as of late. They can be found in grocery stores and pharmacies, are open nights and weekends, often (wisely) utilize the services of nurse practitioners for minor ailments and feature a clearly listed schedule of fees. According to the Washington Times, “visits typically cost $40 to $75,” and “people pay cash or use insurance.”

CVS Caremark Corp. and Walgreens Co. are the leading purveyors of retail clinics. At present, there are said to be more than 1200 of these clinics spread out across the nation; at issue here is how they are spread.

A new study authored by Dr. Craig Pollack of the University of Pennsylvania which was published in the Archives of Internal Medicine shows that a little more than 13% (123) of the 930 retail clinics operating last year were found to be “in areas defined by the federal government as medically underserved.”

The Washington Times states:

The researchers mapped 930 retail clinics operating last year, then used U.S. census data to describe the income and racial makeup of the neighborhoods. In counties with at least one retail clinic, the researchers compared census tracts with and without retail clinics.

Only 123 clinics were in areas defined by the federal government as medically underserved. Tracts with clinics had lower percentages of black and Hispanic residents, lower rates of poverty, higher rates of homeownership and higher median incomes.

The Washington Times reported that Dr. Pollack said that “The study’s results suggest financial incentives may be needed to lure the clinics to low-income neighborhoods.”

There are, I think, a few points to be derived form this article. First things first: the Washington Times article headline to the Associated Press story, “Few retail clinics found serving poor,” is an inference not necessarily substantiated by the underlying research. The research goes to the location of the clinics, not the economic status of the clientele. Importantly, other news outlets which ran the story, such as the Seattle Times, the Times Leader, and the A.P itself,  were careful to run the story under the title of “Study: Few retail clinics in poor neighborhoods.” It may well be that poor people do not frequent the retail clinics outside the neighborhoods in which they live, but the study does not purport to answer that question. It merely tells us where the centers are. The article states:

The poor and uninsured do make their way to retail clinics, said Margaret Laws, director of the California Healthcare Foundation’s Innovations for the Underserved program.

“People go out of their neighborhoods to work and shop,” she said. “I don’t think we should make the assumption that they won’t go out of neighborhoods to seek health care if it offers customer service, better hours and transparent prices.”

Ms. Laws makes a point worth noting, and although the Washington Times included this point in the article, it is unfortunate from a journalistic standpoint that the article’s title failed to reflect it.

In addition, it should be noted that another impetus for travel outside of one’s neighborhood is free health care. Which is exactly what Walgreens has offered to many this year. As we posted last month

Walgreens is offering free health care at its in-store Take Care clinics to patients (and their uninsured children and spouses) who have lost their jobs.  This program, called the Take Care Clinic Take Care Recovery Plan, is designed to assist current and future patients who lose their jobs and health coverage on or after March 31, 2009.

Limited as the program self-admittedly is, it is free. It is also worth mentioning that as a for profit enterprise, Walgreens is under no obligation besides their sense of good will to offer it. But as a for profit enterprise, they (and other retail clinics) can hardly be faulted for placing the majority of their clinics in areas they deem will be profitable. At the risk of beating a dead horse (primarily because I am met constantly by those who insist the horse is not dead and that we will soon be riding it to health reform and universal coverage ) a reliance upon for profit corporate America to undertake the unprofitable without government regulation and/or sponsorship is a misguided one. The primary duty of a corporation is to its shareholders; the primary duty of the government is to its people.

“Many people have promoted retail clinics as a cure for access to care for the underserved,” said Dr. Ateev Mehrotra of the University of Pittsburgh, who studies retail clinics but wasn’t involved in the new research. “These findings show that’s unlikely to happen.”

Dr. Pollock and his co-author, Dr. Katrina Armstrong, suggest that to further expand the reach of retail clinics “municipalities should consider offering incentives to store operators to open clinics in underserved areas where they already operate retail outlets. Currently, nearly a third of all chain stores are located in medically underserved areas.”

“There may be a real opportunity to put up clinics in underserved areas where there’s already supermarkets and drug stores” Armstrong says.

Las Vegas Health Care Practices Prompt State and Federal Concerns

Photo by BaLLYoOo via Flickr

This week MSNBC covered special hearings held by the health committees of both the Nevada Senate and Assembly.  The hearings aimed to reform certain state laws as a response to last year’s hepatitis C outbreak in Las Vegas, NV.  The outbreak required over 60,000 Las Vegas surgical center patients to be notified of possible infection– the largest patient-related notification effort in U.S. history– after improper injection of anesthesia resulted in several cases of hepatitis C.

According to MSNBC, proposed reforms in state law would offer stronger whistle blower protection for nurses, more frequent inspections of health facilities, and a streamlining of the reporting and investigation of future major patient problems.

In addition, Las Vegas is among a handful of regions at the center of federal concern over Medicare spending.   Yesterday, the Las Vegas Sun reported that a new study by the Dartmouth Atlas Project finds Las Vegas hospitals to be among the top ten percent most expensive in the country for Medicare spending costs.  Dr. David Goodman, co-principal investigator of the report, tells the Las Vegas Sun that these costs do not necessarily reflect a high level of care, but may actually be a product of “greedy” Las Vegas doctors billing for services beyond what they provide.  In the same interview, Goodman expressed fear that such practices may lead to the bankruptcy of Medicare– a program that some argue will be deficient by over 660 billion by 2023.

Such practices have not gone unnoticed in Washington.  House Representative Henry Waxman (D-Ca), Chair of the Energy and Commerce Committee, sees the recent Stimulus as an opportunity to establish needed oversight, according to CQPolitics.  In addition to monitoring state spending of Stimulus funds designated for health care, Waxman’s committee has crafted an oversight plan that looks out for “Medicare waste and fraud” in general.

Clinic Expansion Under Bush Thought Likely to Continue Under Obama

The NY Times reports that “President Bush leaves office with a health care legacy in bricks and mortar: he has doubled federal financing for community health centers, enabling the creation or expansion of 1,297 clinics in medically underserved areas.”
The article notes that:

“As a crucial component of the health safety net, they [community health centers] are lauded as a cost-effective alternative to hospital emergency rooms, where the uninsured and underinsured often seek care,”

and that

“Studies have generally shown that the health centers — which must be governed by patient-dominated boards — are effective at reducing racial and ethnic disparities in medical treatment and save substantial sums by keeping patients out of hospitals. Their trade association estimates that they save the health care system $17.6 billion a year, and that an equivalent amount could be saved if avoidable emergency room visits were diverted to clinics.”

As an example, the Times article cited Nashville’s United Neighborhood Health Services, a recipient of increased funding which has expanded more than two-fold in the last 8 years. The Times notes that “One of the group’s recent grants helped open the Southside Family Clinic, which moved last year from a pair of public housing apartments to a gleaming new building on a once derelict corner.” A 68 year old patient of that clinic who had just received breathing treatments, “said she would have sought care for her bronchitis in a hospital emergency room were it not for the new clinic. Instead, she took a short drive, waited 15 minutes without an appointment and left without paying a dime; the clinic would bill her later for her Medicare co-payment of $18.88.”

The article also states that “Despite the clinics’ unprecedented growth, wide swaths of the country remain without access to affordable primary care. The recession has only magnified the need as hundreds of thousands of Americans have lost their employer-sponsored health insurance along with their jobs.”

Widespread Support for Community Health Centers
The Times notes that “In response, Democrats on Capitol Hill are proposing even more significant increases, making the centers a likely feature of any health care deal struck by Congress and the Obama administration.”

In August, President-elect Obama sponsored a bill in the Senate “that would quadruple federal spending on the program - to $8 billion from $2.1 billion — and increase incentives for medical students to choose primary care. His wife, Michelle, worked closely with health centers in Chicago as vice president for community and external relations at the University of Chicago Medical Center.”

In his recent book on health care reform, HHS secretary Tom Daschle referred to the health centers as “godsends.” The Times article also notes that the federal program “was first championed by Senator Edward M. Kennedy” and “has earned considerable bipartisan support.”

Physician Compensation, Subsidies and Service Requirements
The article notes that with United Neighborhood Health Services starting pay for doctors is $120,000. “Because of a nationwide shortage of primary care physicians, the clinics rely on federal programs like the National Health Service Corps that entice medical students with grants and loan write-offs in exchange for agreements to practice as generalists in underserved areas. Of the 16 doctors working for United Neighborhood, seven are current or former participants.”

Follow-up Care Lacking
Although widely lauded as a viable solution to Primary Care medical delivery, the article notes that follow-up for more serious conditions can be problematic.

“A deeper frustration for health centers concerns their difficulty in securing follow-up appointments with specialists for patients who are uninsured or have Medicaid. All too often, said Ms. Bufwack [Chief Executive, United Neighborhood Health Services], medical care ends at the clinic door, reinforcing the need to expand both primary care and health insurance coverage. ‘That’s when our doctors feel they’re practicing third world medicine,’ she said. ‘You will die if you have cancer or a heart condition or bad asthma or horrible diabetes. If you need a specialist and specialty tests and specialty meds and specialty surgery, those things are totally out of your reach.’”
Read full NYT article here. Read WSJ Health Blog report here.