Bread, milk -- and a diagnosis

Times Staff Writer

WHAT a Monday morning this was shaping up to be. Carrie Clemens’ head pounded, breathing through her stuffy nose was difficult and her symptoms were worse despite a weekend of bed rest. But work beckoned -- and she had no time to visit the doctor.

And so, before checking in at her job, Clemens stopped by a small walk-in clinic at a Costa Mesa Rite Aid. There, she received a sinusitis diagnosis from a nurse practitioner, filled a prescription for an antibiotic to treat it and was out in 15 minutes.

“I can pop in here and get on with my day,” says Clemens, 32, of Huntington Beach. “And I won’t have to wait for hours in my doctor’s office with a bunch of other sick people.”

As the nation’s healthcare system struggles to provide affordable care to all who need it, store-based health clinics are springing up around the country. By using mostly nurse practitioners instead of doctors, and operating in a corner of an existing business, the clinics are able to provide some basic health services for around $40 to $70 per visit -- in less time than it takes to eat lunch. Most are even open evenings and weekends, when the lights are out in private doctors’ offices.


Some doctors and health experts worry that the clinics may not always provide quality medical care -- and that they could prevent a patient from forming a relationship with a primary-care doctor. But clinic operators say their services are an innovation whose time has come. The emphasis on convenience and low cost fills an unmet need in today’s healthcare system, they say.

“Consumers are increasingly finding that access to their primary-care doctor is problematic,” says Mary Kate Scott, a Los Angeles-based healthcare consultant who wrote a report on the trend last year for the California HealthCare Foundation. “Either you don’t have a primary-care doctor or it takes a very long time to get an appointment.”

With deductibles and co-pays ever increasing for doctors’ visits, many consumers find the flat fees charged by retail clinics a bargain, says Scott. When not covered by insurance, the cost for a doctor’s visit can cost $70 and up. Even with insurance, co-pays of $35 are commonplace. Add that to additional premiums charged if the yearly deductible hasn’t been met and walk-in clinics’ fees become comparable.

For uninsured Americans or those without primary-care physicians, such clinics can help avoid crowded hospital emergency rooms and the resulting long waits.


“A large number of uninsured people are hourly workers,” says Michael Howe, chief executive of the Minneapolis-based chain MinuteClinic. “If these people have to go to an emergency room for care, it’s not just the cost they are bearing, it’s the lost wages as well.”

Walk-in clinics, which are usually set up in drugstores, groceries or big-box stores such as Wal-Mart, are expected to grow from more than 200 in 2006 to as many as 2,000 by the end of this year, according to a report by the California HealthCare Foundation, an independent philanthropic organization based in Oakland that focuses on improvements in healthcare delivery.

No more doc-in-a-box

The premise behind quick, after-hours medical care is not new. Two decades ago, walk-in clinics -- often referred to as doc-in-a-box -- were opening in almost every city and suburb.


Almost as quickly, it seems, the clinics were shuttered -- victims of low profits despite their popularity with consumers.

Today’s walk-in clinics are different, clinic operators say, and thus stand a better chance of surviving. Doc-in-a-box clinics were typically free-standing centers, staffed by both doctors and nurses who provided a broad range of primary-care services, even X-rays and lab tests. Such clinics accepted insurance and charged fees similar to those of primary-care doctors.

But the centers -- with all the expenses of a regular doctor’s office but no regular patient base -- simply weren’t cost-effective.

“What they found was that if you’re trying to provide vast needs in primary care, this was not the best way to do it,” says Dave Mandelkern, founder and president of QuickHealth, a chain of walk-in clinics based in Burlingame, Calif.


In contrast, the retail-based clinics opening today are usually staffed by nurse practitioners or physician assistants, both of which can prescribe a wide range of medications within their specialty area (such as pediatrics or primary care). The clinics are tiny -- usually 500 square feet or less. Nurse practitioners or physician assistants are authorized by the clinic operator to treat and prescribe medications for 25 to 40 simple conditions, including colds and flu, pinkeye, minor skin burns, bug bites, poison ivy and urinary tract infections. The clinics also offer a limited range of inexpensive, on-the-spot diagnostic tests such as pregnancy, mononucleosis and strep testing. Most provide flu shots and other basic immunizations.

The staff follows guidelines set by the clinics’ operator or physician supervisor on what types of conditions they are allowed to treat and what medications they may prescribe. Patients with symptoms or conditions that are beyond this limited range are referred to a doctor or hospital. Many clinics employ doctors who can be reached by phone if questions arise.

Because the clinics encourage walk-ins, a receptionist is not needed to book appointments. An estimated 60% of walk-in clinics don’t take insurance, which eliminates billing costs, although patients can ask their insurer for reimbursement. Patients who belong to preferred provider organizations are most likely to receive reimbursement; HMO patients are unlikely to do so.

“These centers work because they are limited,” says Tine Hansen-Turton, executive director of the Convenient Care Assn., an association trade group that formed late last year. “The overhead is lower. The practitioner is seeing the patient for 15 minutes max. From a business perspective, it makes more sense.”


At the Lindora Health Clinic, nurse practitioner Janet Schmitt, who treated Clemens, did not ask for a health history other than to inquire about allergies to medications. “We only ask questions relevant to what is going on,” says Schmitt. She also phoned the adjacent pharmacy with Clemens’ medication need so that time wasn’t wasted writing out a prescription.

“Every other consumer retail service has figured out that you have to be more customer friendly,” Mandelkern says. “You need to treat the customer as king rather than treat the provider as king.”

Doctors have doubts

But many doctors aren’t so sure the customer is being treated well -- even if he or she feels like royalty.


Last year, several national medical organizations -- including the American Medical Assn. and the American Academy of Family Physicians -- issued recommendations that they said would help ensure patients are well cared for at such clinics. The recommendations include using treatments proven to be the best approach for a particular condition, having a system to refer sicker patients to doctors, specialists or hospitals and informing patients of the providers’ qualifications so that patients wouldn’t mistakenly believe they were seeing a doctor.

Although the American Medical Assn. and the American Academy of Family Physicians appear mildly supportive of walk-in clinics for minor acute care, both groups say consumers should also have a primary-care doctor.

“The key thing from the standpoint of the AMA is that patients receive good, quality care,” says Dr. William Hazel, a trustee of the American Medical Assn. “Good, quality care traditionally has been in a situation where there is some continuity of care; where you establish some relationship with the physician.”

But the appeal of such clinics is not lost on the traditional medical establishment, Hazel notes.


Walk-in clinic operators “perceive there is a gap they can fill in terms of offering convenience,” he says. “If these clinics prove to be safe and effective, and there is data to substantiate that, then there’s a possibility they’ll help. We just don’t know yet.”

The American Academy of Pediatrics issued a statement in December, however, strongly opposing retail-based health clinics for the care of children and adolescents. The group said such clinics undermine the concept of having a “medical home” where one practitioner oversees all healthcare needs. Walk-in clinics may also lead to fragmentation of care, may not keep good records or encourage follow-up, the group charged, and could enable the spread of communicable disease because of the lack of an isolation area.

Further, the group said, pediatricians often use minor acute care visits -- such as treating a sore throat -- to check the child’s overall health, provide immunizations or to advise parents on other health issues.

Howe dismisses such fears. Most walk-in clinics do not treat babies, he says, adding that the concerns about quality and disruption of a medical home are overblown. MinuteClinic, he says, has 145 centers in 18 states and has not had a malpractice lawsuit in more than 700,000 patient visits. The clinics, he say, err on the side of caution, referring elsewhere those patients who do not clearly have a minor illness.


“You hear concerns about quality of care,” says Howe. “The facts don’t support the histrionics. The practitioners are perfectly trained for these conditions.”

Clinics meet a need

Executives and consultants working in the healthcare field agree that such clinics have the potential to relieve some pressure on overburdened primary-care doctors and prevent the unnecessary use of hospital emergency rooms. According to a recent report from the American Academy of Family Physicians, 39% more primary-care doctors will be needed in the coming decade. Between 1997 and 2005, however, the number of medical school graduates who entered primary care decreased by more than half.

Moreover, a poll of emergency room users published in October by the California HealthCare Foundation found that 46% admitted their problems could have been handled by a primary-care doctor. Two-thirds of those patients said they would have gone to such a doctor instead of the hospital if an appointment had been available. Almost half said they couldn’t get a same-day appointment.


The report also found that uninsured people often chronically use the emergency room even for minor acute-care problems. One convenient care chain has focused its services on the uninsured.

Uninsured workers, says Mandelkern, of QuickHealth, “have incomes and money to spend, they just don’t have health insurance. They can’t afford the $90 a primary-care doctor would cost and they sure can’t afford the $400 an emergency room would cost.”

Emergency rooms are required to treat everyone, regardless of their ability to pay. States end up paying for the care of those who cannot pay.

QuickHealth has six clinics located in the Bay Area and Fresno and hopes to expand this year with another two dozen clinics throughout the state. The clinics, which are staffed by doctors, charge $39 for a standard visit; lab tests and immunizations start at $19. Services, along with the price for each, are posted on a large menu board at the clinic entrance. Doctors are instructed to discuss costs with patients.


“Customers love the fact that pricing is transparent,” Mandelkern says. “The one thing people hate about the current medical experience is when they ask how much something is going to cost, they can’t get a straight answer.”

Many clinic operators have also partnered with their host drugstore to offer patients a limited number of generic drugs for $4 to $10 per prescription.

All walk-in clinics offer to fax or e-mail patient records to a primary-care doctor, says Hansen-Turton of the Convenient Care Assn. They will also help customers find a regular doctor.

“These clinics can refer patients who don’t have a medical home,” she says. “They are very interested in being a connector to primary care.”


At least one healthcare group, Sutter Health, looks at walk-in clinics as a natural partner to traditional healthcare. The group, a nonprofit organization made up of hospitals and physician groups in Northern California, opened its first walk-in clinic last month and plans to expand to six clinics in the Sacramento area this year. Both Sutter patients and those who see non-Sutter doctors can be treated at the clinics, says Dr. Thom Atkins, medical director of Sutter Express Care.

“I think the demand for services shows a demonstrated need for this,” says Atkins. “I hope doctors see we’re not trying to build something that competes with them.”

Lindora Inc., long known for its medically supervised weight loss programs, also recently decided to enter the convenient-care field. Primary-care providers aren’t well equipped to quickly or conveniently handle minor illness and lifestyle problems such as obesity, says Cynthia Stamper Graff, president and chief executive of Lindora Inc. The company will soon have Lindora Health Clinics in three Orange County Rite Aid stores.

“We know our patients want convenience,” says Stamper Graff. “The nurse practitioner is right there in the [drugstore] aisles.”


Clinic operators dismiss fears that consumers will bypass necessary medical care. Consumers intuitively understand when quick, walk-in care is sufficient and when they should make an appointment to see their doctor, they say. Clinic operators say that 5% to 10% of their customers are referred to a doctor or hospital for specialized care.

The advent of health savings accounts, in which consumers manage their own healthcare dollars before their insurance kicks in, encourages people to be savvy shoppers, says Scott, the L.A. consultant. Health savings accounts are tax-sheltered funds consumers can set aside to pay for healthcare. The accounts are usually linked to high-deductible insurance plans.

Because they are spending their own money, consumers want to make sure they are getting the most for their dollar, says Scott. “Consumers today are so much more involved and engaged in their healthcare and are able to make smarter choices for themselves.”

For Clemens, that meant returning to work -- a Monday morning disaster averted.




When to walk in


About 5% to 10% of people who use walk-in medical clinics are referred elsewhere for more sophisticated care. How do you know if a walk-in clinic will suffice or if you need to call your primary care doctor or seek emergency care?

One rule of thumb for using a walk-in clinic is believing that the illness is minor and that you already suspect what it is, says Michael Howe, chief executive of MinuteClinic, the nation’s largest chain of walk-in clinics.

“Retail clinics are more about confirmation of the diagnosis,” he says.

Also, remember that most clinics treat illnesses in four categories: urinary tract infections, problems with the eyes and ears (pinkeye, swimmer’s ear), upper respiratory infections and skin conditions.


Other tips:

Don’t take babies younger than 18 months to walk-in clinics. Most clinics won’t take babies and some won’t take children younger than 5.

Don’t go if you’re highly contagious or think you may be contagious (such as with chicken pox).

If it’s going to require disrobing, forget it. Clinics don’t have gowns or facilities for disrobing.


Don’t go if you may need X-rays. These clinics don’t have the equipment.

Go elsewhere if you are having mysterious or severe pain, particularly chest pain. If there’s a chance you’re having a heart attack or stroke, call 911 or go to an emergency room.

Walk-in clinics aren’t for disease management. You need to see a primary care doctor on a regular basis, for example, to determine whether your diabetes or cholesterol medication is working or your asthma is under control. Walk-in clinics can be used for initial screenings, however, to see if you have high blood pressure or high cholesterol.

Some clinics offer sports, back-to-school or employment physicals as well as basic immunizations.


Source: Convenient Care Assn., MinuteClinic