On-call goes retail: Defining the doctors' role

When the country's largest operator of retail-based health clinics approached Christopher Thompson, MD, about supervising nurse practitioners, he had questions about the clinics' quality of care, about how continuity of care would be ensured and about who would cover liability.

The Nashville, Tenn., family physician learned that MinuteClinic pays for liability insurance, that its nurse practitioners use evidence-based referral protocols and treatment guidelines, and that it asks patients to OK automatic sending of visit documentation to their regular physicians. So he signed up as a part-time independent contractor for the Minneapolis-based company.

There are approximately 150 retail-based health clinics operating inside supermarkets, pharmacies, shopping malls and other retail-based locations. They are staffed by nurse practitioners or physician assistants who treat non-urgent conditions. Market watchers predict industry growth, fueled in part by a looming physician shortage and an increasing popularity of consumer-driven care. Some experts estimate that 2,000 clinics will be operating by 2009.

Those clinics will need physicians -- not for on-site staffing, but in a supervisory role for the extenders. Although no one knows how many doctors will be hired, every clinic is expected to have a supervising physician. All states require physician extenders to have collaborative practice agreements with physicians.

Collaborative practice is consistent with AMA policy. Acknowledging that store-based clinics are expected to proliferate, despite some physicians' misgivings, the House of Delegates during its 2006 Annual Meeting pledged to ensure that physicians stay involved.

Physicians who contract with clinics -- most likely family physicians, internists, pediatricians and emergency medicine specialists -- are expected to be available by phone to whenever nurse practitioners or physician assistants are staffing the clinic, said Peter Miller, CEO of Take Care Health Systems LLC, of Conshohocken, Pa. Take Care operates clinics at Rite Aid stores in Portland, Ore., and Walgreens in Kansas City, Mo., and St. Louis.

Because the clinics treat minor conditions and employ experienced NPs, the call volume for physicians is low, Miller said.

When patients have conditions that fall outside the clinic's scope, don't responded to treatment or need follow-up, clinic operators say they refer them to a community physician.

"If they don't have a doctor, we try to find a doctor for them who is accepting new patients," said Sue Pierman, spokeswoman for Aurora Health Care, a Milwaukee hospital system that operates 14 in-store clinics in Wisconsin. "But if somebody already has a PCP and they need to go the doctor, then that's a no-brainer. We tell them, 'Go back to your physician, because this is something that can't be handled here.' "

The supervising physician's duties vary by state but generally include reviewing a set percentage of random charts.

Physicians aren't required to pre-approve prescriptions written by nurse practitioners, said James Woodburn, MD, MinuteClinic's chief medical officer, though they will review prescriptions during chart reviews. MinuteClinic, which pioneered the wave of in-store clinics, and now has 83 clinics in 10 states, recently was purchased by pharmacy chain CVS.

As part of the supervisory role, some states or firms require doctors to visit the clinic.

Texas, for example, requires supervising physicians to be on-site 20% of the time the clinics are open, said Webster Golinkin, CEO of InterFit Health, which includes as an investor Steve Case, co-founder of America Online. The health screening firm broke into the retail clinic business with RediClinic, which is open in groceries and pharmacies in Texas, Oklahoma, Arkansas and New York.

"We're open an average of 70 hours a week, so our physicians are on-site at each clinic at least 14 hours a week," Golinkin said. InterFit partners with local hospital systems for physician supervision and referrals.

Other clinics also are finding that partnerships are an efficient way to hire physicians.

Advocate Health Partners has agreed to supervise and act as a referral service for a dozen clinics that Take Care will be opening inside Walgreens stores in the Chicago area. The first clinic is slated to open this fall, said Lee B. Sacks, MD, president of Advocate Health Partners. The care management and managed care contracting joint venture is owned partly by Oak Brook, Ill.-based Advocate Health Care, which owns 10 hospitals, and partly by the 2,800 physicians on staff at those hospitals.

Advocate physicians indicate whether they want to participate in the clinics; final selection is made by Advocate's quality improvement committee, Dr. Sacks said.

While some hospitals and physicians are looking at partnerships to ensure that they don't lose business, Dr. Sacks said Advocate expects to gain business, even though Take Care employees, to avoid Stark violations, will not automatically refer patients to Advocate physicians.

"The reality is many of the patients at these clinics are patients who don't have existing physician relationships," Dr. Sacks said. "So this is an opportunity to get exposure to new patients and grow business."

Some hospital systems are opening their own clinics. AtlantiCare, based in Egg Harbor Township, N.J., planned to open an in-store clinic this month, said Kevin McDonnell, administrator of the subsidiary AtlantiCare Health Services. The first clinic is to be supervised by an AtlantiCare-employed physician certified in family and emergency medicine. Each clinic also will contract with a local pediatrician.

No company will say exactly how much physicians get paid for supervising in-store clinics. "The agreements vary from market to market and from partner to partner, depending on what we're asking them to do," Golinkin said.

How pay is distributed also can vary widely.

"Clinics don't have a standard policy of compensation," said Mary Kate Scott, a principal at Scott & Co., Los Angeles, who recently wrote an overview of in-store clinics at the behest of the California HealthCare Foundation. "The concept is so new and so nascent that people are trying all kinds of different alternatives in terms of everything -- the business model, what are the services offered, their location, the hours and the physician referral and compensation."

Depending on a physician's preference, MinuteClinic could pay doctors per call, by the hour, per week or per month, Dr. Woodburn said.

Physicians working with Take Care will be compensated a "fair market" hourly rate, Dr. Sacks said. Advocate's participation is an investment. "We're doing this because [in the short-term] we think it's good for our physicians and can help support them in growing their practices," he said. "Long term, if our physicians' practices thrive and have more patients, there's going to be more referrals to specialty physicians and ultimately more referrals for testing and work in the hospital. But that's a very small piece and way downstream."

Back in Tennessee, Dr. Thompson said a key reason he signed up is that he believes the company can help improve access to care and lower health care costs. AMA policy states that in-store clinics are consistent with support of a plurality of ways to access the health care system.

"There's a lot of issues [in Nashville] per se with respect to the ERs being full of patients who aren't necessarily emergency criteria patients because they have an inability to get in to see their primary care physician or they just don't have a PCP," Dr. Thompson said.

The AMA report on retail clinics says some doctors have reacted to the fear of losing patients by extending office hours into the evening or on weekends. But Dr. Thompson said he believes the clinics actually can take pressure off physicians who want to keep their evenings free.

"I see MinuteClinic as an extension of the physician's practice. Most of us talk about the desire for [a better] quality of life, not seeing this enormous number of patients, not missing dinner with our families and kids' activities, and not working Saturdays and Sundays," he said.