In-Store Clinics Compete with Primary Care

To the Editor: Your May 2007 article, "In-Store Clinics: Threat or Help to Primary Care," read more like marketing materials from the clinics themselves rather than like a balanced independent assessment.

There should be no mistake—these clinics aim to compete for patients and their healthcare dollars. Their primary goal is to generate profits. These are not necessarily bad things, as I strongly believe that profit is an incentive for innovation and improvement in a competitive marketplace.

Their business plan, however, should make traditional primary care physicians pause to reconsider their own practices.

In-store clinics target the most profitable patients. They tend to be largely healthy, are willing and able to pay in full at the time of service, and can receive care that from start to finish is encapsulated in a relatively brief visit, with low malpractice risk and no obligation for future care. Time-consuming but unreimbursed activities, such as coordination of care, prescription authorizations, patient recalls, notification of test results, and care provided via telephone, are eliminated.

In-store clinics will avoid complex, seriously ill, elderly patients who have high needs and expectations but for whom reimbursement is disproportionately low. Sophisticated information systems will allow them to flag these patients and, in Ms Scott's words, deem them "no longer a candidate for this retail clinic."

These clinics will succeed by targeting profitable patients, just as insurers reap record profits by jettisoning "unprofitable covered lives," and pharmaceutical companies seek "blockbuster" drugs rather than "orphans."

If you like doing hard work that is poorly compensated while others reap profits, then you'll love in-store clinics.

—Marc Kozam, MD
Olney, Md

Primary Care Is Dying

To the Editor: I have just read your editorial comment, "Internal Medicine—Poised for a Face Lift" (May 2007). I too was at the San Diego meeting of the American College of Physicians (ACP), but my conclusions are different.

Primary care is dying, and those in the ivory towers need to start beating the drum. One cannot tell the true vitality of internal medicine by what one saw and heard in San Diego. For one thing, probably more than half of the members of the ACP are subspecialists, not general internists. We can continue to have a dynamic annual meeting of the ACP, even if no general internists ever came to it again. True, the ACP did author "The Impending Collapse of Primary Care" and came up with the Advanced Medical Home concept. However, only 11% to 15% of third-year internal medicine residents are going into general internal medicine, and the vast majority of internal medicine residents are becoming hospitalists, not outpatient physicians.

The American Academy of Family Physicians has documented a continuous drop in family medicine residents for the past 10 to 12 years, and more than half are now foreign medical graduates. Medical students finish their training with a debt ranging from $125,000 to $150,000, look at their choices, understand the hard work and low pay of outpatient general internal medicine and family medicine, and run like hell to something else.

I ask you and everyone that I contact about this, "Who will be your doctor?" If you do not have one now, you better get one. Thirty percent of US primary care physicians will be retiring over the next 10 years. With only 11% of new physicians going into general internal medicine, and likely 90% of these going into hospitalist positions, then we have a big problem. Also, 50% of new physicians are women, and likely more than 50% of new internists are women. I am not biased here (both of my parents were physicians), but most women will not work as much as men in medicine, becasue they will have to help raise the family.

Just try to answer one question: Who will be staffing this Advanced Medical Home, as we are graded on our pay for performance? Not many of us. Nurses cannot do it. There is already a shortage of them, and there are not enough nurse educators to educate the ones we need.

Basically, our patients are going to end up in line at the local emergency department or urgent-care center. There will not be a network of primary care physicians to handle all the patients who need to be seen. Therefore, primary care is dying.

Solution: Separate the evaluation and management (E/M) coding for general outpatient internal medicine and family medicine from other E/M coding, and double the reimbursements. This is basic supply and demand. No one will do the job, no matter how needed, if the pay is too low to cover overhead. And make a decent salary commensurate with one's training and skills.

It will only happen if Congress and the health insurance companies start to get the message. Na?ve editorials that do not understand the future shortage will get us nowhere. Unfortunately, my solution will cost too much without taking away from someone else, or taking away drug, home health, hospice, or durable medical equipment benefits. So nothing will get done until the crisis is beyond fixing, or as one might say, until there is blood in the streets. It does take 7 years to make a primary care physician, so there are not any shortcuts.

If you are interested to read more on this topic, you could find the paper I have written about this at www.scmanet.org/Downloads/e-Journal/July06/Black.pdf.

?John G. Black, MD, FACP
West Columbia, SC

The Editor Replies: I agree that primary care as we know it is crumbling, but so is the US healthcare overall. I may indeed be na?ve, but I believe change is inevitable (and often painful). Your solution is one possible way; others may also be feasible. The delivery of healthcare in our country has to change, not only because doctors are running away from primary care but also because leaving 47 million people without healthcare is in and of itself a crisis, just as is denying treatment based on nonclinical judgment to those with insurance. So we are already in a crisis situation that requires a major overhaul of the system. Perhaps it's time to take the care of average Americans out of managed care and place it back in the hands of willing physicians. Money is important, but it cannot be the only determinant in medicine. This certainly sounds na?ve, but should it be?

—D.B.