Retail Clinics, Health Care Costs, and Medical Ethics

The March issue of Health Affairs includes an report by Ateev Mehrotra and colleagues about the impact of retail clinics on health care utilization and cost. His team used insurance claims from Aetna to study the question of the degree to which retail clinic visits replace physician office and emergency room visits or represent additional utilization.

In-store clinics like the 1,100 CVS Minute Clinics offer prompt attention for minor ailments and preventive care. They're convenient and cost less than physician office visits and vastly less than an emergency room visit. Health policy gurus have hoped that they would improve access and reduce costs.

It looks as if the hopes are half fulfilled. The clinics do improve access for minor conditions and as such are a welcome service. According to the Convenient Care Association - the trade association for retail clinics - to date consumers have made 35 million visits to these entities. But Mehrotra and colleagues found that 58 percent of the visits appeared to represent new utilization, with the result that covering retail clinic visits cost Aetna $14 more per patient per year.

The medical group where I and my family have gotten our care for decades operates its own internal version of retail clinics. During daytime hours it's possible to be seen for same day appointments and advance practice nurses are available 24/7 by telephone. When I've used the service my primary care physician has received immediate feedback via the electronic medical record. In one instance I would have gone to an emergency room if urgent care had not been available. And my impression from what I've read from Kaiser Permanente is that in the setting of an integrated group practice, walk-in capacity is cost effective as well as popular with patients.

So what's the big lesson from the Health Affairs report?

For me the study implies that our recurrent hope for a magic bullet that will reduce cost without integrating the care system and creating a budget for it is a pipe dream. Retail clinics have a lot to offer, but they won't solve our cost problem. Telemedicine also has a lot to offer, but it won't do the cost containment job for us either.

Instead of imagining that a magic bullet will solve the cost trend without our making hard choices, we instead need to bite the bullet and create budgeted care systems like the much maligned not-for-profit HMOs from past years. 

Why the U.S. Isn't Ready for Single Payer Yet

Dr. Samuel Metz, an anesthesiologist in Oregon, has a letter in the August 27 New York Times arguing for a single payer system in the U.S. Several responses follow.

I wanted to write about the exchange especially for European friends I spoke with on a recent trip. They were universally puzzled - "how can it be that you in the States don't have health care for all?"

Dr. Metz is obviously correct. No sane society designing a system from scratch would create the cockeyed U.S. non-system. The hodge podge we have is a result of history (making health insurance an employment benefit during World War II) and theology (our faith in free markets even when experience tells us they don't work).

To help explain - to myself and others - why we in the U.S. are so resistant to doing the obvious right thing, here's one of the responses to Metz, with my comments interlaced in bold italics:

Dr. Metz’s call for single-payer national health care imposes costs on taxpayers rather than directly on those being served. Note the assumption that shared responsibility for health care is unjust. Would the writer do away with police, fire depart-ments and public education because they "impose costs on taxpayers" rather than "directly on those being served"? Patients are not charged more for services they value the most or are more costly to provide. If I want more costly clothes or a sports car, it's clear that I should be responsible for financing my own preferences. But if you get cancer, would it be right for me to say "the chemotherapy is costly, and you value it most, so you should pay for it yourself"? Extending the model of optional purchases to chemotherapy for cancer or appendectomy for appendicitis turns health care needs into consumer whims. But needs and whims are not the same! Tax bills simply rise in sync with something else like income, property or sales. Here the writer assumes the single payer is passive and helpless in relation to prices and service patterns. That's actually how our "free market" system behaves! Single payer systems, and other forms of universal coverage, are much more active in managing the cost trend than the invisible hand of the U.S. market is.

It takes no leap of faith to understand how this will affect demand for health care. Anyone who has dined at a fixed-cost food buffet knows the outcome of not directing price with food portions. Comparing medical care to "a fixed-cost food buffet" again shows the writer's underlying framework - health care is like hot dogs, a trivial matter of consumer whim. Patients who don't need chemotherapy or appendectomy don't ask for these services just because they're paid for, even if they do eat an extra hot dog at the buffet. And there's no reason that a single payer system couldn't apply value-based principles, with full coverage of needed services for which there are no alternatives, but partial or no coverage for low value services, or services that have less costly equivalents.

It is tempting to believe that government will fairly and efficiently make these choices for us, but experience suggests otherwise. The writer is flat-out wrong. Citizen satisfaction is significantly higher in countries with publicly financed universal coverage, and health outcomes are as good or better. He's revealing his theology - blind faith that governments are always bad/markets are always good. Dr. Metz appears to anticipate this problem given his suggestion that Congress’s power to tax is indisputable and so government will predictably raise taxes to pay for growing demand for health care.

MICHAEL L. MARLOW

San Luis Obispo, Calif., Aug. 25, 2011
The writer is a professor of economics at California Polytechnic State University, San Luis Obispo.

Professor Marlow is an accomplished scholar. The fact that such a well-informed person subscribes to the political and economic theology his letter evinces shows why the U.S., alas, is not yet ready to give serious consideration to publicly financed, not-for-profit health care. If Vermont's single payer program succeeds, that will chip away at our reflexive anti-government/anti-communitarian approach to the health system.

All kinds of economic interests - the "medical-industrial complex" - favor the status quo, but the faith-based beliefs Professor Marlow's letter exemplifies are the largest impediment to steering our system in the direction virtually every other developed country has taken.

In talking about U.S. health care theology with my European friends I quoted Schopenhauer: "As a serious conviction, it could be found only in a madhouse; as such it would then need not so much a refutation as a cure."