Retail Medical Clinics: Opportunities and Concerns

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Retail Medical ClinicsOpportunities and
Concerns

• Ken Ferrucci
• Director Of Government Relations
• Connecticut State Medical Society
• August 12, 2008

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Connecticut Access

• 2800 physician offices throughout the state
• 30 Acute Care Hospitals
• 35 Emergency Departments
• 45 Federally Qualified Health Centers
• More than 625,000 patient visits to primary care
  clinics (does not include physicians offices)
• 900,000 visits to FQHCs
• Over 1.5 Emergency Room visits in 2007
• Source CT Economic Resource Center
• Office of Health Care Access

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American Medical Association PolicyH-160.921
Store Based Health Clinics

• Store-Based Health Clinics must have a
  well-defined and limited scope of clinical
  services consistent with state scope of practice
  laws.
• Store-based Health Clinics must use standardized
  medical protocols derived from evidence-based
  practice guidelines to insure patient safety and
  quality of care
• Store-Based Health Clinics must establish
  arrangements by which their health care
  practitioners have direct access to and
  supervision by MD/Dos, as consistent with state
  laws
• Store-Based Health Clinics must establish
  protocols for ensuring continuity of care with
  practicing physicians in the local community.
• Store-Based Health Clinics must establish a
  referral system with physician practices or other
  facilities for appropriate treatment if the
  patients conditions or symptoms are beyond the
  scope of services provided by the clinic
• Store-Based Health Clinics must clearly inform
  patients in advance of the qualifications of the
  health care practitioners who are providing care,
  as well, as the limitation in the types of
  illnesses that can be diagnosed and treated.
• Store-Based Health Clinics must establish
  appropriate sanitation and hygienic guidelines
  and facilities to ensure the safety of patients.
• Store-based Health Clinics should be encouraged
  to use electronic health records as a means of
  communicating patient information and
  facilitating continuity of care
• Store-Based Health Clinics should encourage
  patients to establish care with a primary care
  physicians to ensure continuity of care.
• Health insurers and other third-party payers
  should be prohibited from waiving and/or lowering
  co-payments only for patients that receive
  services at store-based health clinics

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Connecticut State Medical Society Policy

• Oppose the Unregulated establishment and
  expansion of Store-Based Health Clinics
• Support AMA Policy H-160.921 as baseline for
  state regulation of Store-Based Health Clinics
• Acknowledge lack of consistency in
  regulatory/statutory structure among states and
  seek regulation appropriate to Connecticut.

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Potential Connecticut Regulatory Entities

• Office of Health Care Access (OHCA)- Any
  Mechanism that can be developed to offer more
  affordable health care to our patients is
  welcomed- need to be aware of the impact on the
  system at large.
• Operational Concerns
• Experimental testing phase- Based on literature
  clinics need to be in operation for 3 years to
  become profitable. Limits the ability to measure
  or determine success
• Business model designed to provide basic medical
  care at a lover cost by reducing overhead costs
  by,(1) using non-physician providers, (2)
  limiting services offered, (3) eliminating the
  process of billing, raising concerns of
  physicians groups.
• Cites literature raising concern of setting
  quality standard and reviewing regulatory
  oversight to address patient safety and patient
  privacy.
• Broadening of scope of clinical services as
  clinics may expand offerings to increase volume.
  May grow beyond original scope of practice
• Office of Health Care Access June 26, 2008

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Office of Health Care Access (Continued)

• Potential Benefits
• Improved Access
• Lower Cost of Care
• No Appointments
• one stop shopping approach
• May reduce some ED utilization
• May Address the issue of primary care physician
  shortage
• Office of Health Care Access June, 26, 2008

• Potential Concerns
• No Follow up care
• lack of continuity with other providers-
  increased fragmentation
• How referrals are handled when a patient is not
  eligible to receive care.
• Missed opportunities for preventive care
• Private practice will be left with the complex
  case and lose many low cost-high revenue cases
• Increased utilization of prescription medicine

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Office of Health Care Access (continued)

• Potential Policy Issues
• Will insurers offer a financial incentive to use
  a retail clinic versus a more expensive physician
  visit or urgent care visit?
• How will these clinics connect with the other
  providers in the community (i.e. hospital,
  physician office, FQHC, etc)
• Will the clinics accept Medicaid and Medicare in
  the future?
• Office of Health Care Access June, 26, 2008

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Connecticut Department of Public Health

• Department of Public Health is State Entity for
  Licensing of Physicians, Clinics and Ancillary
  Health Care Professionals
• Store-Based Health Clinics operate under the
  license of a Connecticut Licensed physician
• Required to maintain same standards as a
  physician office- care and service is being
  sought in the same way as a physicians office
• Not regulated as Health Care Facilities
• Would investigate practitioners if complaints are
  lodged
• Facilities are not inspected
• Not identified and regulatory issues within the
  current regulatory scheme
• Must balance access with patient safety
• Transfer of records and information needs further
  consideration
• After care instructions?
• Is transfer of information to PCP adequate?
  Similar to ER transfer?
• Department of Public Health June 26, 2008. Wendy
  Furniss, Bureau Chief, Health Systems Branch

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CSMS Concerns

• Licensing of professionals within clinics but no
  direct oversight of facilities-
• No specific state entity charged with complete
  oversight
• No requirement for direct association with State
  based physician office
• Lack of integration into the health care system-
  participation in development of statewide EMR
  system.
• RFP for state employee health insurance contract
  mandated inclusion of CVS MinuteClinics in
  network. Leap before looking?
• CSMS follow-up with State Comptroller
• Facilities are not similar to physician offices
• Sale of tobacco
• Pharmacy Ownership/Self referral
• Advertising

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Pitfalls on non-specific regulation?

• Cash, coupons, items of value to incentivize use?
  (CVS coupons to state employees)
• Does it violates C.G.S. Section 53a-161c(a)(2)
• A person is guilty of receiving kickbacks when he
  knowingly solicits, accepts or agrees to accept
  any benefit, in cash or in kind, from another
  person upon an agreement or understanding that
  such benefit will influence such person's conduct
  in relation to referring an individual or
  arranging for the referral of an individual for
  the furnishing of any goods, facilities or
  services to such other person under contract to
  provide goods, facilities or services to a local,
  state or federal agency
• Does it violate federal anti-kickback statute (42
  U.S.C. section 1320a-7b(b)(1)?
• Similar language

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Greenwich Planning and Zoning

• Planning and Zoning Staff Amendment
• 6-5 (38.6) Pharmacy A retail use located within
  the commercial zones where prescription drugs are
  sold and are constantly supervised by a licensed
  pharmacist. An accessory use to a Pharmacy is
  permitted where it is an activity or use of space
  that is clearly secondary to the pharmacy
  pursuant to the following
• 1. Shall be less than 150 square feel, including
  customer waiting area, that is physically
  separated from the remainder of the retail space
• 2. Shall be a use characterized by having limited
  facilities and personnel, which functions without
  an appointment system to provide on-the-spot
  medial aid to persons who present
  non-life-threatening problems, but who need or
  want the convenience of immediate medical
  attention for common family illnesses such as
  strep throat, ear, eye, sinus, bladder, and
  bronchial infections.
• 3. Shall be staffed only by a nurse practitioner
  or physicians assistant in accord with
  Connecticut General Statutes and who can
  diagnose, treat and write prescriptions. No
  physician shall be on staff otherwise such a
  facility will be considered medical office use
  under the Building Zone Regulations.

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Bottom Line

• Connecticut Health Policy Project
• To ensure patient safety and protect
  Connecticuts healthcare system, the state should
  design comprehensive regulations requiring Retail
  Medical Clinics to be licensed and inspected as
  clinics.