AMA meeting: Delegates seek more oversight of retail clinics

Chicago -- Citing concerns that retail-based clinics may be too much retail and not enough clinic, the AMA House of Delegates at its Annual Meeting last month approved resolutions that call for an investigation into the growing industry.

During testimony before the reference committee addressing medical practice, many AMA members expressed concerns with patients getting prescriptions written and filled under the same retail roof.

"Maybe MinuteClinic should change its name to Nurse Kiosk," quipped Raj Lal, MD, a thoracic surgeon from Oak Brook, Ill., referring to one of the largest retail clinic chains, now owned by Providence, R.I.-based CVS Caremark Corp.

The AMA house adopted policy that calls for state and federal probes into a possible conflict of interest between the clinics and the pharmacies that own or host them. The new policy also opposes the waiving of state and federal regulations for retail clinics that do not comply with standards for medical practice facilities, and opposes the practice of insurers reducing or lowering co-pays to encourage the use of the clinics.

Members expressed concern that insurers and state regulators might be giving the clinics favorable treatment, placing traditional practices at a competitive disadvantage.

A year ago the AMA board acknowledged that retail health clinics were controversial but ultimately decided the clinics fit long-standing AMA policy that encourages "multiple entry points" into the health care system. It also developed guidelines that clinics must follow.

In July 2006 there were approximately 90 clinics across the U.S. Today there are more than 400. As the clinics grow in popularity, some retailers, such as CVS Corp. and Walgreens, have stepped beyond the role of host and bought out entire chains.

Some societies are already entrenched in fights over state governments considering waiving medical practice laws for retail clinics. Three Massachusetts medical societies are asking the Massachusetts Dept. of Public Health to hold public hearings before making a decision on MinuteClinic's request that it waive certain requirements, such as the size of the clinics and sanitation requirements.

The House of Delegates also opposed the practice of insurers lowering or waiving co-pays to encourage use of the clinics, 40% of which accept traditional health plans. Some plans, such as Blue Cross Blue Shield of Minnesota, have already begun waiving co-pays.

No other issue sparked as much discussion at the reference committee meeting. The majority of speakers favored an all-out opposition to retail-based clinics.

"Mayo Clinic, Cleveland Clinic, MinuteClinic? I don't think so," said Robert Goldberg, DO, a physical medicine and rehabilitation specialist from New York, who is also the president of the Medical Society of the State of New York.

Dr. Goldberg said the clinics would be fine if they were owned by doctors, "but they aren't."

Laws vary in each state regarding scope of practice and the role of physician assistants and nurse practitioners, who normally staff retail clinics without a physician on site. As part of its resolution, the AMA also resolved to work with state and specialty societies in developing guidelines and model legislation.

Other testimony dealt with concerns for patient safety and the implied conflict of interest between the clinics and the retailers who own and host them.

"The AMA is concerned that when patients go to retail-based clinics they get the same quality of care that they get in a physician's office," said board Trustee Peter W. Carmel, MD, a pediatric neurosurgeon from Newark, N.J.

When Rebecca Hafner, MD, a family physician from Minneapolis, stepped to the microphone, she admitted being nervous. Then she introduced herself as medical director for strategic alliance for MinuteClinic.

She said the testimony she was hearing was "all based on fear and unsubstantiated evidence."

In a prepared response to the AMA's action, MinuteClinic CEO Michael Howe said, "MinuteClinic follows nationally accepted, physician-developed treatment guidelines that ensure prescriptions are only issued when evidence-based testing demonstrates a need and where clinically appropriate."

Dr. Hafner said less than 50% of patients receive a prescription at all.

"Convenient care clinics have proliferated in retail settings throughout the country due to a widespread lack of access to high-quality, affordable health care in America," said Tine Hansen-Turton, executive director of the Convenient Care Assn., a trade group for the retail-based clinic industry, in a prepared statement.

"We are surprised that the AMA would take the position that it has, because so many physicians and other health care professionals have accepted this new model and see it as part of the solution to our broken health care system," she said.

Despite the overwhelming feelings against the clinics, the AMA board stopped short of calling for complete opposition.

Rochester, N.Y., orthopedic surgeon William A. Dolan, MD, reference committee chair and a newly elected AMA trustee, said despite the dislike of retail clinics, "We have to treat them legally." He said a call for an all-out ban could result in an antitrust judgment similar to one by chiropractors in the 1980s when the AMA attempted a boycott of chiropractic services.

"I think it would be naïve to think that [fear of litigation] wasn't a factor," Dr. Carmel said.