The Business-Think Rationale for In-Store Clinics

An urban legend that has haunted health care in the last 20 years, to its great detriment, is that the application of business-like thinking, business-think for short, to health care (not just financing health care), will yield enormous improvements.

One of the latest health care fads generated by business-think appears to be in-store clinics. We have blogged several times, (most recently here, here, here, and here) about these clinics. Such clinics are situated in retail stores, such as drug stores, staffed by nurse practitioners, but usually not doctors, and claim to treat a limited number of ailments quickly for reasonable prices. They have been touted as the latest business-like solution to the decline of primary care.

My biggest concern is that these clinics may fail to provide good care to some of their patients, particularly patients who have more serious problems masquerading as or accompanying one of the limited ailments which the clinics claim to handle.

KevinMD just put it more graphically.

I've said it before and my stance hasn't changed. In their zeal for speed, convenience, and profit, someone will screw up.

A 'bronchitis' will actually be a PE [pulmonary embolism]. Chest pain caused by an 'anxiety attack' will be an MI. The inevitable malpractice suits against a retail clinic will no-doubt put a damper on things. Bet on it.

I am afraid that the people touting in-store clinics and similar business-think based fads are too preoccupied with the brilliance of their business models to appreciate how the health care context may make the model unworkable. For example, I noted that the initial designs of the MinuteClinics proposed for Massachusetts including no plumbing in or adjacent to the clinics. No doubt eliminating plumbing would cut construction and maintenance costs. However, in an era when practitioners are urged to always wash their hands to prevent the spread of new, contagious, and treatment-resistant infectious diseases, neither practitioners nor patients in these clinics would have easily been able to wash their hands. And some of these nasty new contagious diseases could masquerade as some of the limited ailments the clinics claim to handle.

The Boston Globe just published a commentary by Steve Bailey that (probably inadvertently) disclosed some more of the fallacious thinking used to justify the concept of in-store clinics. Selective quotes from the article are below, in sequence, and I don't believe out of context,

In the business schools, the personal computer and Southwest Airlines are taught as case studies of what has come to be known as 'disruptive innovation.' Now, with CVS Corp. poised to open as many as 30 medical clinics in their stores in the Boston area alone this year, local primary care doctors and neighborhood health clinics worry they could be next. They may be right.

America spends more money per capita on healthcare than any nation, but continues to lag behind many less affluent countries when it comes to benchmarks like infant mortality and life expectancy. The problem, says Harvard Business School professor Clay Christensen, is that so much of the money goes to maintain the status quo because it is given to organizations wedded to their current solutions, including the old delivery models.

Christensen literally wrote the book on the kind of disruptive innovation that the PC and Southwest Airlines represent. His landmark 1997 book, "The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail," turned Christensen into a rock star of the start-up revolution during the dotcom boom. Now in a book due out in August, Christensen and coauthor Jason Hwang examine how the disruptive innovation model can be used to cure what ails our healthcare system.

CVS's MinuteClinics get an entire chapter in the book. Physicians' associations typically oppose MinuteClinics on patient-safety grounds, Christensen and Hwang write. In about half the states, the business model is illegal because regulations mandate that doctors supervise nurse practitioners and physicians' assistants. But the regulations haven't caught up with the science, they say. Today, the diagnoses for a host of illnesses - from sore throats to ear infections to the flu - are precise and the therapies predictably effective.

'These regulations now trap care in high-cost models when there are much more affordable and accessible business models available,' they write. 'About $15 billion is spent each year in high-cost physicians' offices for the care of acute, rules-based disorders. Delivering even half of this care through a disruptive business model such as the MinuteClinic could easily save $7 billion a year. . . . A billion here and a billion there soon amounts to serious money.'

Maybe it is too snarky to being a "rock star" of the dotcom boom, which became, of course, the dotcom bust, does not seem to be a good credential to tout as a redesigner of health care.

Moreover, the commentary exposed Christensen's fallacious thinking: in-store clinics are a disruptive innovation that will improve quality and save money by using the latest cutting-edge technologies that are not available in old school physicians' offices.

His notions of the capabilities of the latest cutting-edge technologies, however, are seriously misguided. Christensen declared that the diagnoses of illnesses such as sore throats, ear infections, and influenza are "precise" and their treatments are "predictably effective." That's plain wrong.

One reason medicine is still a challenging profession is that the situation is exactly the opposite. There are no practical, quick and accurate diagnostic methods for these diseases.

Let me use sore throat as an example. Most sore throats are are self-limited, and are probably due to a variety of pathogens, most viral. Streptococcal pharyngitis ("strep throat") is caused by a specific bacteria, can last longer, and rarely can produce severe complications. There is no way to quickly and accurately diagnose strep throat. Signs and symptoms do not clearly differentiate strep. Using multiple signs and symptoms in a statistical diagnostic model (most notably the "Centor model") can categorize patients by their risk of strep, but can neither rule it in nor rule it out. The various rapid strep tests are not very accurate. The throat culture is generally thought to be specific, but it takes at least 24 hours to provide results. (References for all the above provided on request.)

Similarly, there are no quick, practical, accurate ways to diagnose bacterial ear infections There are rapid tests that can diagnose influenza, but they have variable and imperfect sensitivity and specificity.

Furthermore, there are no "predictably effective" treatments for sore throats, ear infections, or influenza. Antibiotics at best may shorten symptom duration and decrease the likelihood of complications from strep throat, but have side effects. There are no specific treatments for "viral" sore throats, or most ear infections, or "flu-like" illnesses. The newer antiviral agents for influenza can shorten symptom duration, but only on average by one day.

I'm sure such details about the imperfections of existing diagnostic and therapeutic technology might seem tedious to a "rock star" like Christensen. The sort of business-think he embraces seems to demand a big-picture view that neglects all the devils lurking in the details. But his notion that in-store clinics will bring miracle technologies to "customers," that the dinosaur physicians in their offices do not use is just nonsense, to use the most polite term.

I still hope that exposing the dubious logic and evidence underlying the in-store clinic movement will slow it down before, as KevinMD feared (see above), the malpractice suits start.

Post Title → The Business-Think Rationale for In-Store Clinics

Will MinuteClinics be a Wash?

We have blogged several times, (most recently here, here, and here) about one of the latest health care fads, in-store clinics. Such clinics are situated in retail stores, such as drug stores, staffed by nurse practitioners, but usually not doctors, and claim to treat a limited number of ailments quickly for reasonable prices. They have been touted as the latest business-like solution to the decline of primary care.

A lot of people have objections to this concept. My concerns center around how the clinics will be able to manage patients whose problems are not so simple as they first seem.

Sometimes what a patient thinks is a simple problem is not. For example, a patient may come to the clinic for the treatment of a sore throat, but actually have an exacerbation of chronic obstructive pulmonary disease.

Sometimes a patient with a simple problem has other, not so simple problems of which they are unaware. For example, a patient with a bladder infection may also have undiagnosed, but uncontrolled diabetes.

Why would in-store clinics not cope well with such patients? One reason is that nurse practitioners, no matter how able and well intentioned, do not have as extensive training and experience as most primary care physicians. They may not know all the possible causes of common complaints, and not recognize subtle symptoms and signs that indicate more complex problems.

Another reason is that the people who developed the in-store clinic model may not understand the health care context well enough to appreciate these issues. Many people pushing in-store clinics seem to be business executives with no on the ground health care experience. For example, we previously noted that Michael Howe, the CEO of MinuteClinics, a subsidiary of CVS Caremark, was "recruited for his leadership experience," but this experience mainly seemed to be in the restaurant business. Howe was the former CEO of Arby's Inc./Triarc Restaurant Group, and before then an executive for KFC, according to this article in the Minneapolis/ St Paul Business Journal.

My concern about how well the people designing in-store clinics understand the health care context was highlighted by today's Boston Globe article that described how Massachusetts state regulators have just cleared CVS Caremark to open MinuteClinics in the state. Here are the crucial two sentences:

The panel's members also wanted hand sanitizer available at the clinics and restrooms adjacent to the facilities so that patients don't have to walk across the store. All these provisions were incorporated in the regulation adopted yesterday.

This article implies that CVS Caremark MinuteClinics will not have any plumbing within the clinics proper. They will not have sinks and soap dispensers, and they certainly will not have toilet facilities. How adjacent such facilities would be is unclear.

Why is this a big problem?

Take a look at the list of conditions which MinuteClinics claim to be able to treat. They include "bladder infections," "pink eye and styes," and a variety of skin infections.

Diagnosis of bladder infections requires a urinalysis, and usually a urine culture. How will MinuteClinic patients provide urine samples? If patients are required to go out into the CVS store to find a bathroom, produce their sample, and go back to the clinic, how many would refuse out of embarrassment? If patients with bacterial urinary tract infections fail to provide urine samples, they might not get needed treatment. If patients without such infections fail to provide urine samples, they might get unneeded antibiotics. Also, would waiting for patients to provide urine samples slow down patient flow so that MinuteClinics become HourClinics?

It gets worse. "Pink eye" is often caused by viral conjunctivitis, which can be highly contagious. Health care professionals can cut down on its spread by thorough hand washing after seeing affected patients. (This is one of many reasons that you will almost never see an American doctor's office examining room without a sink and soap.) But MinuteClinic nurse practitioners will not have a sink and soap within their clinic, and will have to go out of the clinic, and wash their hands in whatever facilities CVS provides. Because of this inconvenience, and the time pressure inherent in the MinuteClinic concept, would the nurse practitioners sometimes fail to wash their hands when indicated? If they would not wash their hands, they would be at risk of transmitting viral conjunctivitis to other patients, and acquiring it themselves.

It gets still worse. MRSA (methicilin-resistant staphylococcus aureus) infections have been on the rise. MRSA can cause skin infections that are not specific in appearance. It is likely that some patients going to MinuteClinics for one of the common skin infections that the clinics are supposed to be able to treat will really have MRSA. For the reasons above, would the nurse practitioners fail to wash their hands after every such patient they see? If they would not wash their hands, they would be at risk of transmitting MRSA to other patients, or acquiring it themselves.

The failure of the executives of MinuteClinics to make sure that every one of their clinics has an in-clinic sink and toilet suggests that these executives really do not understand the health care context well enough to appreciate what they are getting into. I worry about what unrealistic assumptions have gone into the development of the in-store clinic concept.

The common business school notion that an executive does not need to know anything specific about the nature of the business he or she leads will continue to plague health care, maybe this time, literally.

Post Title → Will MinuteClinics be a Wash?

The AMA, "Prescription Data-Mining," In-Store Clinics, and Patients' and Physicians' Interests

OK - I'm back from Geneva and it's time to catch up.

Last weeek, two commentaries from the US east and west coasts slammed the American Medical Association. From the west coast, in the San Francisco Chronicle, Robert Restuccia from the Prescription Project and Lydia Valas from the National Physicians Alliance criticized how the AMA sells information on individual physicians to be used in pharmaceutical company marketing.

One of the less obvious but more intrusive marketing tools is the drug rep's hand-held computer, which contains a detailed profile of your doctor's prescribing history. Armed with the knowledge of each doctor's individual prescribing habits, pharmaceutical sales representatives tailor their pitches to each physician.

The AMA sells information from its physician "Masterfile" to health information organizations that pair the identifying information with prescribing records from pharmacies and sell the whole package to pharmaceutical companies, a practice commonly called "prescription data-mining."

The AMA profits handsomely from this agreement. In 2005, the AMA made more than $44 million from the sale of database products, approximately 16 percent of its budget.

Despite representing less than 30 percent of all U.S. doctors, the AMA keeps identifying information on all licensed physicians - and sells it all. Even so, only 60 percent of physicians surveyed by the Kaiser Family Foundation were aware of the sale of their information. Once told, 74 percent disapproved. Even a survey by the AMA itself found a 66 percent disapproval rate.

A number of policymakers, physician groups and medical societies have come out against this practice in recent years. Leaders include the National Physicians Alliance, the American Medical Student Association, the Vermont Medical Society and the New Hampshire Medical Society. Unfortunately, the AMA has a financial incentive to keep selling this information without regard to how it is being used or the impact it has on patient care and health-care costs.

By continuing to profit from the sale of physician data, the AMA has shown itself to be at best, slow-to-act, and at worst, opportunistic at the expense of professional boundaries. The AMA should put medical ethics before profits and stop licensing its Physician Masterfile for pharmaceutical marketing purposes.

From the east coast, in the Washington Post, Regina E Herzlinger from the Harvard Business School and the Manhattan Institute, criticized the AMA for spending so much effort fighting in-store clinics, but also had more global criticisms.

Physician incomes, when adjusted for inflation, declined 7 percent from 1995 to 2003, while those of professional and technical workers rose. But unlike other professionals -- lawyers, architects, authors and economists -- doctors' work is dictated by the policies of insurers and governments. Increasingly, independent physicians, accountable only to their patients and the Hippocratic oath, have been replaced by salaried doctors who are accountable to the hospitals or insurers that employ them. Salaried physicians are closely policed for productivity, leading to ever-shorter and more numerous appointments per day.

Meanwhile, academic medical journals routinely publish studies that supposedly document the cupidity and ignorance of practicing physicians while lauding the virtues of single-payer health-care systems, such as those in Canada or Britain, in which the physician is paid only by the government. German physicians unhappy with their salaries and work hours under this kind of system had no recourse against their monopolistic bosses but to go on strike last year.

Small wonder that applications to medical schools have declined by nearly 20 percent in the past decade.

You might expect that the AMA would fight the insurers, hospitals, government bureaucrats and ivory tower academics who have diminished physicians' incomes, besmirched their ethical reputations and compromised their professionalism -- but you would be wrong. No, instead, at its annual meeting last month, the AMA declared war on retail medical clinics....

Unfortunately, while the AMA engages in trivial turf warfare, physicians are increasingly forced to become salaried employees of hospitals and insurers and are constrained by recipes for the practice of medicine that are cooked up by government and insurance company bureaucrats.

The cycle is bringing about the imminent collapse of the medical profession -- which gravely endangers our health-care system. We and doctors deserve better advocates.

In my humble opinion, Prof Herzlinger's criticism of the AMA's concerns about in-store clinics is not well justified. (See our last post on such clinics here.) But her more global concerns are substantive. Clearly, a lot of physicians are disgruntled, and as we have posted repeatedly, primary care and cognitive physicians appear to be an endangered species. The increasing domination of medicine by large organizations, including the hospitals and hospital systems and insurance companies and managed care organizations she mentions clearly has a lot to do with these problems. The AMA has, in my experience, at times stood up to the power of these organizations, but not with much effect.

On the other hand, the increasing power of pharmaceutical, biotechnology, and device manufacturers, fostered in part by the complex financial webs these companies have woven to reach individual physicians, academics and academic institutions, and medical associations, also has a lot to do with the problems of health care. The first editorial suggests that the the AMA, representing only 30% of American physicians, but getting 16% of its revenue from the sale of these physicians' data to be used in part by pharmaceutical marketers, may now be too entangled in these webs to always put the interests of patients and physicians first.

For more on the relationships between medical associations and commercial sponsors, see Chapter 12 of the excellent Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry, by Howard Brody, and Kassirer JP. Professional societies and industry support: what is the quid pro quo? Perspectives Biol Med 2007; 50: 7-17 (see our relevant post here).

Post Title → The AMA, "Prescription Data-Mining," In-Store Clinics, and Patients' and Physicians' Interests

Quick In-Store Health Care Clinics: "You're Sick. We're Quick!" but Will You Really Get Better?

There has been a lot in the media lately about quick in-store health care clinics, an issue which we blogged about previously here and here. In Illinois, as reported by the Chicago Tribune, the state medical society is pushing for more regulation, which is predictably not making clinic operators happy.

The Illinois State Medical Society, which represents more than 13,000 doctors, is pushing a proposed law to more closely monitor hundreds of in-store clinics being opened by retail giants Wal-Mart Stores Inc., Walgreen Co. and CVS/Caremark Corp.

The doctors claim the clinics, staffed by advanced-degree nurses and physicians' assistants, are largely unregulated and therefore put patients' health at risk.

The potential loss of business for doctors is great because most health insurance companies are beginning to cover retail clinic procedures.

Doctors say they are concerned about the quality of care if the clinics uphold their promise to treat patients in less than 15 minutes. The doctors said that is not enough time for consultation, and that follow-up may not be adequate.

Facing off against the doctors' powerful lobbying organization are the powerful pharmacy and retail industry lobbyists, who are trying to block the proposed legislation. Retailers say the clinics are staffed by licensed health professionals who track their patients' health in medical records and make referrals.

'Increased regulation has the potential to restrict access to these health-care services and create more costs to patients,' Walgreens spokesman Michael Polzin said. 'That would work against the growing concern over affordable, quality health care that our Health Corner Clinics are directly addressing.'

There is a paean to quick in-store clinics in a today's Wall Street Journal by free market health care booster Grace-Marie Turner.

It's Friday evening and you suspect that your child might have strep throat or a worsening ear infection. Do you bundle him up and wait half the night in an emergency room? Or do you suffer through the weekend and hope that you can get an appointment with your pediatrician on Monday -- taking time off your job to drive across town for another wait in the doctor's office?

Every parent has faced this dilemma. But now there are new options, courtesy of the competitive marketplace. You might instead be able to take a quick trip on Friday night to a RediClinic in the nearby Wal-Mart or a MinuteClinic at CVS, where you will be seen by a nurse practitioner within 15 minutes, most likely getting a prescription that you can have filled right there. Cost of the visit? Generally between $40 and $60.

These new retail health clinics are opening in big box stores and local pharmacies around the country to treat common maladies at prices lower than a typical doctor's visit and much lower than the emergency room. No appointment necessary. Open daytime, evenings and weekends. Most take insurance.

Much like the response to Hurricane Katrina, private companies are far ahead of the government in answering Americans' needs, this time for more accessible and more affordable health care. Political leaders across the country seeking to expand government's role in health care should take note.

This industry is in its infancy and will hardly register in our nation's $2 trillion-plus health care bill. But just as Nucor overturned the steelmaking industry with a faster-better-cheaper way of making low-end rebar, these limited service clinics could be the disruptive innovator in our health-care system. Package pricing for more complex treatments, like knee replacement surgery, may not be far behind.

Government can get in the way, of course, with protectionist policies that throw up more regulatory barriers to entry. But retail clinics could be just the beginning of consumer-friendly innovations....

What bothers me about all this? It seems to me that in-store clinics (of this type) could embody what goes wrong when the business managers and bureaucrats who are now in charge of health care treat health care as a commodity, a standardized service that can be provided quickly in a formulaic way by "mid-level providers." But won't the service be quick, cheap and to the point?

My concern is that health care is rarely as simple as it seems, especially to people whose health care training was reading financial statements from health care companies. Let's look at an example. One of the maladies which the quick clinics advertise they can treat is the common sore throat. I have actually done some research on this problem, and what I have learned from reading the clinical literature, and my own clinical and research experience is that even this seemingly simple health care problem isn't.

Sure, most, maybe the majority of people with sore throats just have self-limited viral illness, and only need symptomatic treatment (aspirin or the like, maybe throat lozenges, maybe cough syrup, maybe an anti-histamine, fluids and rest). Such people do not even need to visit a clinic. The first problem is that neither the patient nor the practitioner can reliably determine from the patient's symptoms and physical exam whether the patient just has a viral sore throat, or streptococcal pharyngitis (strep throat).

Strep throat can at times lead to serious complications if not treated with antibiotics. Yet the antibiotics used in treating it can have side effects. So even for the "routine" sore throat, the health care professional needs to look at the probabilistic balance of benefits of treatment and harms of treatment. The relevant probabilities, and the importance and value of the particular benefits and harms will vary for different patients. To some extent, this balancing can be rendered formulaic (although the formula may not be simple.) But a failure to understand that the problem is actually somewhat complex and probabilistic could lead to trouble: a patient with a viral sore throat getting a needless antibiotic complication, a patient with strep throat not getting an antibiotic and getting a complication of the disease.

Things get even more complex for a patient with another condition which may affect the likelihood of complications of strep, or of antibiotics. Some common examples of such conditions are asthma, diabetes, chronic obstructive lung disease, and heart valve problems. There are other, less frequent problems on the list. If a health care professional fails to appreciate that the patient with a sore throat has one of these problems (and patients with these problems are not always fully aware of them), then the potential for something major going wrong is even higher. It becomes much harder to set up a formulaic approach that would efficiently screen for such problems, especially because not every patient with them knows he or she has them.

And then there is the issue of rare causes of sore throats....

Other "simple" problems, like urinary tract infections and ear infections, may not always be simple either. And we physicians feel we really earn our money by figuring out when an apparently simple patient isn't.

My real concern about the "quality of care" delivered by quick health care clinics is that the "mid-level providers," good, well-intentioned people with substantial training, but still years less of training than that given to physicians, operating in isolation with corporate pressure to do things quickly and cheaply may miss some of these not so simple patients. And that would be quite bad for the patients. (And when the lawyers figure it out, it would be quite bad for everybody involved.)

Again, those concerned with decreasing costs and improving access might better first focus on the really expensive parts of health care (look at Health Care Renewal and the blogs on our blogroll for some examples). But of course those costs will be heavily defended by vested interests. And the relatively poor, beleaguered primary care docs probably won't make such a fuss about quick quick health clinics, that is, until there own patients end up having bad experiences resulting from such clinics' care.

Of course, it may be possible that quick in-store clinics are just a symptom of larger social ills, and hence may be hard to stop. Let me conclude with quotes from a recent column by Brian McGrory in the Boston Globe:

Oh, I know, I know, every harried mother and overwrought father within Route 495 is undoubtedly thinking that these fast-serve clinics are a going to be a godsend in their mile-a-minute lives. The kid has a rash -- head out to see the nurse practitioner at the CVS, and hey, pick up some Tide while you're at it.

Because that's all we have time for these days, impersonal drive-through treatment centers offering medicine by slogan. As the chief executive officer of MinuteClinic said, 'You're sick. We're quick!'

What's next in their ad campaign? How about 'You've got ills. We've got pills!' And conveniently, you can fill the prescription written by the nice CVS nurse practitioner with the equally nice CVS pharmacist.

It wasn't all that long ago when the average Jane and Joe would take the time to establish relationships with their doctors, who would get to know them inside and out, and doctors would take the time to nurture relationships with patients.

But now look what's happened. Modern technology was supposed to free people up, to give everyone more time.

We can have all the information in the world, but rather than creating the luxury of time, it's causing a constant frenzy. Technology hasn't allowed people to leave their responsibilities behind; it's made people bring their obligations every single place they go.

And thus, the MinuteClinics, guaranteed to be as popular as they are impersonal. So back to my first question: They are merely a symptom, not a cause.

Post Title → Quick In-Store Health Care Clinics: "You're Sick. We're Quick!" but Will You Really Get Better?

Ousted CEO of Columbia/HCA Now Runs In-Store Clinic Chain

One of the latest trends in US health care appears to be, for want of a better name, "in-store clinic chains." We had discussed this trend here, focusing on the MinuteClinics version of the concept. In-store clinics are small clinics are set up in retail outlets, particularly those that already have pharmacies. The clinics are usually staffed by nurse practitioners, and offer limited services, like treatment of sore throats and immunizations, for prices lower than that charged by physicians’ offices or emergency rooms. The clinics are not meant to treat complex, serious, or chronic problems. Supposedly, patients with such problems would be referred to physicians or hospitals. My biggest clinical concern about the concept was the ability of the clinics’ practitioners to truly distinguish patients whose problems are beyond their capabilities.

An article last month in the New York Times discussed several contenders in the field. These include RediClinics, run by CEO Stephen M Case, who used to be chairman of AOL, and Take Care Health Systems, run by Hal Rosenbluth, who used to run a chain of travel agencies. This raises a concern that such chains may be run by people with no obvious background in health care, who may not fully understand the clinical issues involved, or share the values of health care practitioners.

Speaking of values, though, the most interesting example in the Times article was a company called Solantic, whose CEO is Richard L Scott. Solantic is a bit of a variation on the theme, since its clinics will be staffed by physicians, and be thus somewhat more pricy than its competitors, although still offering limited services.

CEO Scott does has previous experience in health care, albeit not hands on. He is the former CEO of Columbia, which became Columbia/HCA Healthcare Corp. An article in the Business Journal of Jacksonville narrated his rise and fall.

After working on health-care mergers and acquisitions as an attorney, Scott began Columbia in 1988 by buying two hospitals in El Paso, Texas. In less than a decade, the company grew so large that it had 285,000 employees working in 343 hospitals and more than 700 surgery centers and home health-care offices.

‘In a field supposedly fueled by humanitarian desires to heal, objectives devoted to financial gain are rarely applauded’ the trade publication Medical Laboratory Observer reported in 1997. ‘His aggressive management style, high growth targets and quest for market share made enemies.’

The accusations against Columbia that would eventually lead to Scott's ouster were detailed in numerous New York Times stories, starting in 1996, that scrutinized the company's business and Medicare billing practices.

In the spring of 1997, as federal agents began conducting document raids on several Columbia facilities, Scott did not admit any wrongdoing. 'Mr. Scott's grudging responses apparently contributed to his downfall,' noted a story that ran five days after Scott and Chief Operating Officer David Vandewater resigned.

Scott left with a $10 million severance package and 10 million shares of stock, most of which were from his initial investment before the company was taken public. At the time, those shares would have been valued at more than $300 million.

In 2001, HCA reached a plea agreement with the government that avoided criminal charges against the company and included $95 million in fines. Four mid-level executives were brought to trial but two were acquitted and two more had guilty verdicts overturned.

Scott said prosecutors never attempted to question him.

Civil suits have cost HCA more than $1.7 billion, said attorney Peter Chatfield, a partner with Phillips and Cohen in Washington, D.C., who spent seven years working on a Columbia-HCA civil case brought by two whistleblowers.

Although Scott was never the subject of a law-suit, and never convicted of a crime, clearly major things went wrong at Columbia/HCA on his watch. Yet he left with a golden parachute, and now is a leader in the latest health care trend, in-store clinic chains.

There is a striking contrast between the ethical standards to which nurses and physicians, including those working in in-store clinics, are held, and those to which the managers and executives of health care organizations are held. For the latter, the standard appears to be anything goes, as long as it does not result in serious jail time.

Maybe, given the mess that the leadership of large health care organizations has made of health care, we ought to rethink who should lead such organizations, and to what standards they ought to be held.

Thanks to the Health Care Blog for the tip!

Post Title → Ousted CEO of Columbia/HCA Now Runs In-Store Clinic Chain

The Rush to In-Store Health Clinics

The Wall Street Journal published an interesting article (subscription not required) about what appears to be the latest fashion in US commercial health care, "in-store health clinics."
The major players include the pharmacy chains. "Rite Aid Corp., Brooks Eckered Pharmacy and Osco Drug - have announced plans to open health clinics in the coming months. All three have partnered with a Pennsylvania-based health care start-up called Take Care Health Systems LLC that will lease space inside the pharmacies and operate the clinics." "CVS and Target are working with Minneapolis-based MinuteClinic.... Wal-Mart is working with InterFit Health and other companies...."
The motivation, of course, is money. "While the retailers don't profit directly from the new services, the hope is that the clinics will boost business if patients fill their prescriptions at the store pharmacy, or pick up other items on their way out."
US health insurers seem to "have embraced the concept because the clinics promise considerable savings. While a typical doctor visit for a basic illness costs an insurer about $110, a visit to one of the clinics usually costs under $60." "Some insurers are actively encouraging patients to use the clinics by lowering the co-pay. In Minnesota, companies including Blue Cross Blue Shield of Minnesota and Graco Inc. have reduced or eliminate co-pays for employees who opt to use a MinuteClinic instead of a doctor. Take Care has deals in place with several insurers in Portland."
It is revealing that "the management teams behind both of the leading companies in the field - Take Care and MinuteClinic - have experience in other consumer focused industries. MinuteClinic's new chief executive officer (CEO), Michael C. Howe, is the former president and CEO of the Arby's fast-food chain, and previous worked for KFC. Hal Rosenbluth, chairman of the board of Take Care, is the former CEO of Rosenbluth International, a travel company acquired by American Express Co...."
Take Care, run by the former travel agency executive, is pioneering novel use of computer technology, "a computer software program will be involved in actually diagnosing illnesses. The patient's sign-in information will be transmitted electronically to a computer terminal inside the treatment room.... The software system will eventually generate a diagnosis and recommend course of treatment. If the nurse practitioner disagrees with the computer-generate diagnosis, he or she can opt to over-ride the system."
Some patients seem very happy with the whole concept. The Wall Street Journal quoted on Terri Whitesel, a 56-year old marketing consultant in Minneapolis. "I didn't want to go to the doctor and sit around waiting with a bunch of people who are really sick."
But Edward Hill, President of the American Medical Association, tried to throw some cold water on the concept. "Serious illness sometimes presents with simple symptoms. A cough may be something as simple as a cold, or something as serious as congestive heart failure. The ability to ferret out the 20% of serious illnesses that present with simple symptoms is what we went to medical school for."
I have posted about MinuteClinics before. Dr. Hill's concern that even apparently simple complaints may sometimes stem from serious problems is a real one. It is amplified if, as reported in the earlier post, the in-store clinic may not have adequate facilities for the nurse practitioner to do some basic parts of the physical examination. It is further amplified if the diagnosis and decision making will actually be entrusted, not to a nurse practitioner, but to some piece of computer software, whose accuracy and reliability are unknown.
This report again emphasizes how managed care companies and insurers are quick to try to save money at the expense of primary care, when they seem reluctant to confront high prices of drugs, devices, and procedures, especially those that are seemingly high-technology, regardless of their effectiveness. (Some recent posts about such prices are here, here, here, and here.)
Finally, this attempt to siphon off the least sick patients may further disrupt an already fragile primary care/ generalist infrastructure in the US. Yet in most countries, primary care is the bed-rock of the health care system. In the US, we have less and less capacity to take care of the patients with more than one real illness, or with undiagnosed problems. Will patients with five chronic illnesses (who are not rare) have to go to five different sub-specialists? Will patients with chest pain have to guess whether their problem is cardiac, pulmonary, gastro-intestinal, or musculoskeletal before they can figure out what doctor to see? How will a system without primary care cope with health care crises from terrorist attacks, to hurricanes, to avian flu?
These aren't, of course, the sort of questions likely to be asked by former executives of fast food companies and travel agencies, until they become the patients in question. And by then, it may be too late.

Post Title → The Rush to In-Store Health Clinics