There are so many reasons the health care system and health reform are complex. Among them is the fact that very few changes are unambiguously for the better. Trade-offs are hard, if not impossible, to avoid. This might be called the first (stylized) rule of health reform: you can’t make the system a little better in one dimension without harming it a bit in another. That’s another way of saying there’s no free lunch, and that fact is among the reasons the status quo is hard to change.
With that in mind, what do we make of the recent boom in retail clinics? A recent HCFO-funded paper by RAND researchers in the Journal of General Internal Medicine highlights a trade-off: retail clinics seem to enhance access to preventive care but they also seem to disrupt relationships between patients and primary care physicians practicing in more traditional settings.
From the abstract, here’s what the investigators did:
OBJECTIVE: To assess the association between retail clinic use and receipt of key primary care functions.
DESIGN: We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009.
PATIENTS: We identified patients who had a visit for a simple acute condition in 2008, the “index visit”. We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic.
MAIN MEASURES: We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice–Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias.
Comparing the experience before and after an acute condition visit for patients who had that visit at a retail clinic vs. with a PCP, the researchers found that retail clinic patients experienced reductions in continuity of care and in contact with PCPs for acute care. That might be a bad thing. On the other hand, they found no association between retail clinic visits and a host of preventive care including screenings for breast, cervical, and colon cancer, as well as diabetes management.
This being one observational study and with acknowledgement of the limitations of its methods (propensity score weighting and a difference-in-differences design), it’s hard to draw strong conclusions about these findings. As the authors put it,
Some might contend that continuity is the cornerstone of primary care and, therefore, retail clinics’ negative impact on continuity is critical. Others might argue that continuity and first-contact care are less important than preventative care, especially for a healthy patient population [such as that more likely to visit a retail clinic]. In this light, retail clinics’ impact on primary care may not be as great as feared.
Of course, as the authors point out, there is a sense in which it is possible to reap preventative care benefits of retail clinics without experiencing all of the potential consequences to decreased continuity. Improved coordination between retail clinics and PCPs might be fostered through better use of inter-operable electronic medical records, for example.
Then again, returning to the first rule of health reform, health IT has its drawbacks too.