Big-Box Store Clinics and Children's Health

Howard Markel, MD, PhD

Disclosures

November 29, 2006

Last weekend I strolled through a big-box store with my daughters in search of some good deals on diapers, breakfast cereal, and assorted household supplies. However, what took me by surprise were not the low prices advertised at the door; instead it was the presence of a medical clinic in the back of the store offering special deals on ear infection checks and fever evaluations. In one stop, a brightly decorated poster proclaimed, a busy parent can have their child's symptoms diagnosed and treated quickly all for a low, low price!

Like millions of American shoppers, I have become increasingly used to bundled marketplaces; this is to say, large stores that also house a bank branch, a pharmacy, an optician, a mortgage broker, and even realtors who rent space from the larger store. However, I must confess that I was somewhat surprised, if not outright troubled, to find a clinic that offered pediatric care. This concern only doubled when I learned that the majority of this care is offered by nonpediatric healthcare providers.

The formal name for this new shopping opportunity is the retail-based clinic (RBC), and it is, not surprisingly, of great concern to the American Academy of Pediatrics -- so much so that the Academy commissioned a special panel, the Retail-Based Clinic Policy Work Group, to develop a policy statement, "Principles Concerning Retail-Based Clinics," which will appear in the December 2006 issue of Pediatrics.[1]

As predicted, the eminent group of pediatricians studying this new development in convenience shopping found a number of significant or potential problems with such facilities, including:

  1. Fragmentation of care;

  2. Possible effects on the quality of care;

  3. Providing episodic care to children with special healthcare needs and/or chronic diseases, some of which may not be readily identifiable;

  4. Lack of access to and maintenance of a complete, accessible, central health record containing all of a patient's pertinent information;

  5. The application of medical tests for the purposes of diagnoses without proper follow-up;

  6. Potential public health issues that could occur when patients with contagious diseases are in a commercial retail environment (eg, mumps, measles, fevers, chicken pox, strep throat, etc); and

  7. Problems in addressing concerns that require anticipatory guidance, long-term counseling, and medical supervision, such as obesity, nutrition, behavioral issues, and even immunization schedules.[1]

At present, there are approximately 150 RBCs doing business around the United States -- with an estimated 1800 more slated to open by 2008. Clearly, acute minor healthcare for children is a big and burgeoning business. One company in particular, the Minute Clinic, which is the largest operator of RBCs, summarizes the philosophy in Madison Avenue manner with their slogan: "You're Sick, We're Quick."

The price is right, too. On average, RBCs take the copay amount from those with health insurance and charge about $50-$75 from those without. Insurers especially like RBCs because the inherent costs are markedly less than if a parent took the child in question to an emergency department or urgent care facility.

Now, I am a fan of convenience as much as any harried parent, but consider the fact that these RBCs are typically staffed by nurse practitioners without specific training in pediatrics. Despite such a paucity of training, these providers routinely diagnose and treat a wide variety of common illnesses and skin conditions for children aged 18 months or older, ranging from bronchitis and mononucleosis to ear infections and strep throat.

The American Academy of Pediatrics is right, of course, to question the medical prudence of this convenience and to criticize insurance companies for supporting the cheapest means of providing care that may not necessarily be the best form of medical care for children.

It may be difficult to stop the rising tide of RBCs in big-box stores, shopping malls, and supermarkets that are slated to open and will likely proliferate even more in the years to come. We all love convenience, and everyone is so busy these days. So let's not throw the baby out with the bathwater.

It is up to all pediatricians and children's healthcare providers to insist that specific guidelines be developed that support a model of care in which the RBC refers the patient back to his or her own pediatrician for follow-up and future care; in which the RBC provides communication with that patient's primary physician in regard to what transpired at the RBC within 24 hours of the visit; that medical researchers apply evidence-based studies to assess the quality and utility of clinics; that contagious disease precautions be mandated and evaluated; and that insurance companies not waive or lower copays, or offer other financial incentives for visits to RBCs instead of visits to one's designated children's healthcare provider.

Parents need to express their concern, too, and talk about RBCs with their child's healthcare provider. As that great Latin proverb warns: Caveat emptor!

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