Journal of Nursing

The Nurse Practitioner Will See You Now


SAUSALITO, CA (ASRN.ORG) -- When Melanie Klein needed a vaccination recently to attend community college, she had few affordable options. She is a German citizen working as a live-in nanny for a Westchester family and says she has only emergency health coverage.
Including the physical examination she would need as a prelude to the shot, she said, ''I was told it would cost about $300.''
Then a friend told her about MinuteClinic, inside a CVS drugstore in Larchmont, N.Y. There the vaccination cost $65. (An exam is not required, according to a clinic employee.) When Ms. Klein, 27, developed a bladder infection about two weeks ago, she returned to MinuteClinic for an antibiotic. She made a third visit after developing side effects a few hours after starting the drug and got a new one.
''I went back at about 7:30 p.m. and she gave me a different medicine,'' Ms. Klein said.
MinuteClinic is one of several companies that offer health care in more than two dozen of the region's drugstores and supermarkets. The clinics, which are staffed by nurse practitioners, say they are a low-cost answer for minor health problems for the uninsured, as well as for people who want after-hours or speedy care. Nurse practitioners, who are registered nurses with advanced training, can do many things that doctors do.
Treatment at retail health clinics is limited to about a dozen illnesses. Fees range from about $50 to $70 or are often covered after an insurance co-payment. The only drugs that can be prescribed are those like antibiotics, rash cream and cough syrup.
People with more serious symptoms, like a high fever, are referred to an emergency room or an urgent care center, which also sees walk-in patients.
Critics say that the clinics could undermine the importance of the doctor-patient relationships and that follow-up care will be lacking. And some insurers do not cover visits.
The clinics' numbers are increasing. Nationwide there are about 300; the Convenient Care Association, a trade group, says it expects the number to double by the end of the year.

Ten MinuteClinics are open in New Jersey CVS stores, joining 13 in New York and Connecticut; the company wants to add more in the region.
And this week, MiniMedCare of Chester, N.J., and Pathmark supermarkets will announce their entry into New Jersey, in Pathmark stores. One clinic will open in Weehawken in March, and 11 more are planned.
''We're physicians and we know how to deliver convenient care because we've been doing it at our three urgent care centers,'' said Dr. Lawrence Earl, who owns MiniMedCare with Dr. Roger DiRuggiero.
Like other retailers who have welcomed the clinics, Pathmark hopes patients visiting for a sore throat may also pick up cough drops.
''You have a convenient setting with flexible hours with hopefully some of the products you might need if you are sick,'' said Rich Savner, a Pathmark spokesman.
But Dr. Edward J. Volpintesta, a Connecticut family-practice physician for 30 years, called the clinics ''the ultimate commodification of health care.''
To illustrate the dangers of losing the doctor-patient relationship, Dr. Volpintesta recalled a patient in his 70s who was normally healthy but called to complain of shortness of breath. Dr. Volpintesta, whose office is in Bethel, said he recommended an emergency room visit; it turned out the man had had a heart attack.
That was an extreme case, Dr. Volpintesta said, but ''I knew for him to call up and say he didn't feel right, something was really wrong.''
Furthermore, he said, it may be disconcerting for store patrons to run into a sick person at the checkout line.
AtlantiCare Health Services, based in Egg Harbor Township, N.J., said it hoped to avoid those concerns with its in-store HealthRite clinics because of its affiliation with 400 doctors in South Jersey. The first clinic opened in August in a ShopRite in Somers Point, and six more are planned by the end of the year.

''We can refer to our member doctors for more serious conditions, and they can refer to us for the minor problems,'' said Don Parker, the president of AtlantiCare.
New Jersey's largest health insurer, Horizon Blue Cross Blue Shield, pays for visits only to AtlantiCare centers. Horizon is negotiating with other retail clinics but wants to see how HealthRite works before signing with others, said James Dell'Arena, director of Horizon's network operations.
The Convenient Care Association argues that the clinics save insurers money, noting that an emergency-room visit for an ear infection costs about $300 while a clinic visit is no more than $70. And, the group said, 40 percent of its patients said they would have headed for the emergency room if not for the clinics.
Still, Horizon is concerned.
''It is a cost-effective setting, but we still don't know what the true impact will be,'' Mr. Dell'Arena said.
MinuteClinic is an in-network provider for Aetna and Cigna HealthCare, but not New York's largest insurer, the HIP Health Plan. Cigna said it signed up because the clinics save money for the company, members and their employers. Members ''want flexible hours, convenience, quick and affordable access to a clinician and more choices in how they handle minor medical conditions,'' said Wendy Sherry, associate vice president for product development. She also said that MinuteClinic, like other operators, has a system to forward records to a patient's own doctor.
Some insurers may be holding back because they worry that retail health clinics will increase costs when patients go to them more frequently, precisely because they are so convenient, said Uwe Reinhardt, a health economist at Princeton University. ''The insurers will do business with them once they get to know them better,'' Mr. Reinhardt said.
A spokeswoman for the New York Medical Society, Lynda Adams, said that when the clinics first cropped up, the medical society was worried that insurers would pressure patients to go to the clinics instead of doctors because they were cheaper. The Medical Societies in New Jersey and Connecticut listed a lack of follow-up care as their main concern.

Last June, the American Medical Association set nine guidelines for retail health clinics, including one saying patients should be urged to establish a relationship with a primary care doctor. The clinics operating in the area meet the A.M.A.'s standards.
Even as the number of these clinics grows, many operators say they do not expect to make a profit for at least a year. On a recent Tuesday the Larchmont MinuteClinic served only two patients in 12 hours.
Pathmark is willing to give up valuable space until MiniMedCare turns a profit, in part because the clinic shares space with the pharmacy and does not take up much room, Mr. Savner said. And, like many clinics, MiniMedCare will pay rent.
The future may bring an even larger role for retail clinics, said Richard Datz, the senior vice president for business development at CareClinic of Montvale, N.J. There are 8 CareClinics nationwide and 20 in the works, and the company is considering North Jersey for expansion.
''Look at how everyone is talking about universal health care,'' he said. ''Certainly these clinics could be part of the solution.''



Copyright 2012- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved


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Editor-in Chief:
Kirsten Nicole

Editorial Staff:
Kirsten Nicole
Stan Kenyon
Robyn Bowman
Kimberly McNabb
Lisa Gordon
Stephanie Robinson

Kirsten Nicole
Stan Kenyon
Liz Di Bernardo
Cris Lobato
Elisa Howard
Susan Cramer