This month, the American Academy of Pediatrics (AAP) published its, “AAP Principles Concerning Retail-Based Clinics,” regarding the AAP’s view on the appropriateness of a retail-based clinic (RBC) as primary care for a child.
What is a “retail-based clinic”? Think, “convenient care clinics,” opening in stores such as Walgreens, Target and Wal-Mart that have names such as RediClinic, MinuteClinic, HealthStop and MedPoint Express. They advertise heavily on the TV, touting convenience and being always available in a pinch. The clinics, are usually staffed by nurse practitioners or physician assistants, and offer a limited range of services—from cholesterol screenings to immunizations to care for a poison ivy rash, at a cost of between $40 and $70. These clinics have popped up in a nation where there are more than 40 million uninsured people, any of whom could end up in an emergency room because they are without insurance or a “medical home,” i.e. their own personal physician.
The AAP views retail-based clinics (RBCs) as an inappropriate source of primary care for pediatric patients, as they fragment medical care and are detrimental to the medical home concept of longitudinal and coordinated care.
Keep in mind, this discusses using RBC’s for “Primary Care”—using them as your regular physician.
What is a retail-based clinic, and why would I go there?
Since the original RBC opened in 2000, it is estimated that the number of RBCs has grown to more than 6,000 as of 2012. Polls indicated that 15% of children were likely to use an RBC in the future, although the majority of patients seen in RBCs are adults.
These clinics generally follow a model of staffing by adult medicine or family practice trained physician assistants or nurse practitioners, who are not always trained in pediatric medicine. These health care providers are given off-site supervision by physician medical directors. Protocols are followed that dictate conditions and patients who can be seen as well as suggested treatment regimens to be followed. RBC protocols often restrict pediatric ages and conditions that will be seen by the physician assistants/nurse practitioners.
Patients cite convenience as the most important reason for using RBCs. No appointment time is needed, wait time is often minimal, and they are open for extended hours, often on the weekends.
Charges for minor illnesses treated are often less than a physician office and much less than an emergency department. Many RBCs can bill insurance carriers, and some are able to bill Medicaid. The care, at first blush, appears competent. Data on outcomes specifically looking at pediatric patients is limited, but minor illnesses, such as acute pharyngitis (sore throat), show no significant issues when the child had an early return visit to their primary care physicians.
The AAP strongly believes children’s health care is ideally delivered or coordinated through the child’s “medical home”—by your child’s own pediatrician, and RBCs do not meet those criteria. The concerns expressed by the AAP were based on the following issues that the Academy feels influence the health care received by infants, children, and adolescents in RBCs:
- Fragmentation of care.
- Possible decreased quality of care.
- Provision of episodic care to children who have special needs and chronic diseases, who may not be readily identified.
- Lack of access to and maintenance of a complete, accessible, central health record that contains all pertinent patient information.
- Use of tests for the purpose of diagnosis without proper follow-up.
- Possible public health issues that could occur when patients who have infectious diseases are in a commercial, retail environment with little or no isolation (such as, fevers, rashes, mumps, measles, strep throat).
- Seeing children who have “minor conditions,” as will often be the case in an RBC, is misleading and problematic. Many pediatricians use the opportunity of seeing the child for something minor to address other issues in the family, discuss any problems with obesity or mental health, catch up on immunizations, identify undetected illness, and continue strengthening the relationship with the child and family. Visits for acute illnesses are important and provide an opportunity to work with patients and families to deal with a variety of other issues.
American Academy of Pediatrics recommendations regarding retail-based clinics
- RBCs Are an Inappropriate Source of Primary Care for Pediatric Patients. The AAP continues to oppose RBCs as a source of primary care for pediatric patients, because they risk increasing care that is fragmented and detrimental to the medical home concept of longitudinal and coordinated care.
- Financial Payment. The AAP is opposed to payers offering lower copays or financial incentives for patients to receive care at RBCs in lieu of their pediatrician or primary care physician.
- Support the Pediatric Medical Home. If pediatricians and the pediatric medical home wish to or need to use the services of an RBC within their community as a means to expand access for acute care outside of the medical home, both the medical home and the RBC should develop a formal collaborative relationship, which should include, but not be limited to: use of evidenced-based pediatric protocols and standards; pediatric quality review; prompt communication with the pediatric medical home of pertinent information for all visits of patients to RBCs; referral of all patients back to their pediatric medical home or arrangements to establish one for those who do not have one; and formal arrangements for after-hours coverage or emergency situations that may occur during a patient visit to an RBC.
