Friday, July 18, 2014

Innovation in American Medicine: the Case of RBCs

I was asked to do a review of this paper: Parents’ Experiences With Pediatric Care at Retail Clinics: Garbutt JM, Mandrell KM, Allen M, Sterkel R, Epstein J, Kreusser K, O'Neil J, Sayre B, Sitrin H, Stahl K, Strunk RC. JAMA Pediatr. 2013 Sep;167(9):845-50.
Retail Based Clinics (RBCs) are a great example of innovation in our system, and thus worth examining not only in themselves, but for what they illustrate.  Here's what I came up with.

American health care is clearly in a state of profound organizational transition. In contrast to countries with socialized medicine, organizational innovation in our private system should in theory be more dynamic, with many innovators trying many new things (some of which fail,) and more attuned to the wishes of the public. On the other hand, individual initiatives and the profit motive can lead to innovations that do not necessarily integrate with other parts of the system, and which may not improve quality in those aspects of care that cannot be evaluated by the patient. In addition, since the American system has very large vested interests in the hospital, insurance, and pharmacy sectors, it is possible that profit-seeking oligopolistic behaviors will predominate. It is obvious that many current innovations are both vertical and horizontal conglomerations. In a quest to improve true value, it is not clear whether the American or the more socialized systems will prove superior.

Retail Based Clinics (RBCs) are one of the most recent American organizational innovations. Ready access to acute care, especially during evenings and weekends, has long been neglected by our health care system. Large pharmacy companies have taken advantage of their access to capital and their high visibility in communities to establish RBCs on their premises to fill that access gap. While they appear to have become financially successful, serious questions surround RBCs. Do they further fragment an already fragmented system? Do they provide high-quality care? Do they succumb to the temptation to drive further profits by prescribing too many medicines to be bought at the parent company's store where they are located?

This simple but wonderfully direct study looks at some of these questions in the St. Louis area by simply asking patients who they find in the waiting rooms of 19 private practices about their RBC visits. They find that an amazing percentage of patients have been seen in RBCs – 25%. They find that they use them because of “convenience,” although almost half the visits were at times the private offices were open. There were virtually no efforts made to integrate with the medical home, by either the RBCs or the patients. And perhaps most strikingly, there is prima facie evidence that the quality of care appears to be quite poor, although presumably profitable to the sponsoring company.

The high utilization of the RBCs should be a wake up call for pediatricians in practice. In areas of the country where competition among practices is high, many practices have established extended office hours on evenings and weekends, and many practices have instituted drop-in times to avoid the hassle of appointment-making. These innovations have apparently not been seen in the St. Louis practices – perhaps the offices are full already and they see no need to please patients with more convenience.

The RBCs lack of integration into the system is dismaying but not surprising. Beyond their fragmenting effect, RBCs also undercut the viability of primary care practices by siphoning off the most profitable segment of their business (not that the practices do not contribute to their own difficulties by not being adaptable to consumer needs.) Thus, when primary care is under such pressure that few graduates are choosing that pursuit, RBCs exacerbate that problem.

Most dismaying, however, is the finding of how many antibiotics were prescribed in clearly inappropriate clinical situations, if the parents' accounts can be believed. 67.7% of patients with colds or flu were treated with antibiotics! 28.6% of patients with a negative rapid strep test were treated with antibiotics! This is clearly not a definitive study, but informal reports nationwide make this finding disturbingly not unexpected.

In a system that is so entrepreneurial, defining the role for government is especially difficult and crucial. Gathering and evaluating information would seem to be very important to help people make individual choices, and to help policy makers choose wisely. In the case of RBCs, government should stimulate studies that further explore the provocative findings of this study to see to what extent it reflects nationwide conditions. Deciding what to do about it can be a joint concern of the profession of pediatrics, federal and state governments, and the larger entities that are so powerful in our system.

Budd Shenkin


  1. Budd, thanks for this thoughtful discussion of the study.

    The issues raised are ones many of us suspected but, without the data, couldn't be sure about. In fact, the issue of continuity of care and connection to the home PCP or practice concerns me as much, if not more than, the lower-quality medicine being practiced.

    In the case of pediatric patients, issues often evolve so rapidly that the lack of coordination keeps me up at night. These families are expecting their professional HC clinic provider (often recommended by their insurance) to followup as expected. When they don't get a call from their home PCP, they might assume, "All is well," and go on about their days.

    I welcome your further thoughts and any ideas about what can be done to inform, educate, and communicate about this issue. How can we help the busy practice develop guidelines for their patients using these clinics? How can we help patients choose wisely and, in cases of emergency, initiate some followup of their own?

    Very best, Joe Babaian, Sugar Land, Texas

    1. Hi, Joe:

      Thanks for your comment on my blog post on RBCs. You're so right - what is a person to do to help our patients and the populace at large? Just today I saw an article about e-visits -- if there is a buck to be made, be sure some entrepreneurs and the insurance companies will be right there. That's the problem with our system - no feedback.

      I think that the primary care professional societies would be the best ones to weigh in, and get some money from government to do the studies and write the articles. Unfortunately, at least in the case of pediatrics, their focus is too diffuse, and they are not able to go forward very far in health care organization policy. They are diverted by a myriad of other issues, all important, but diffuse -- and, they are conflict-avoiders. It's such a shame - if they were a stronger organization, they could do much more.

      The AAFP is much stronger as an organization, but once again, how many issues can they take on at once? The AMA has been toothless and diverted for years.

      So, I'm not terribly hopeful. Maybe a strong, independent organization that took on the monitoring of health care organization innovations could do it - but I don't see any such organization on the horizon.

      So, I suppose we will just see a proliferation of efforts without good feedback, until horror stories emerge and finally action is taken.

      Let me know if you will be in SF sometime and let's get together!


      Budd Shenkin