Tuesday, January 15, 2008


"Allowing restaurant owners to make money off of hungry people is wrong too."

One of the problems with the US health care system is that doctors tend to be expensive even for a short visit for a minor ailment. Because of that, people like me tend to just stay home unless something catastrophic has happened, unless we've got comprehensive health insurance.

Here's what I mean: say you get poison oak and are miserable. If you have no insurance to cover this, you'll buy a bottle of something like Calamine lotion for five bucks and smear it on, then suffer for a few days knowing it will eventually go away. If you have insurance, you go to the doctor who checks you out, maybe does a test, and gives you a cortisone shot. That ends up a couple hundred dollars and then you go home and suffer somewhat less a few days knowing it will eventually go away.

The insurance actually makes people spend money on health care they otherwise would not, which increases the costs for everyone in the system. To make matters worse, some parents will go to a doctor with their kid for the slightest sniffle or skinned knee, at which point the doctor uses antibiotics and tests to make sure he doesn't miss anything and get a million dollar malpractice lawsuit. This in turn increases costs even more. So what's the solution?

Clinic menuWell, one such choice is MinuteClinic, started in Minnesota which is a chain of in-store clinics where minor medical care of this sort can be done without having to go to your doctor.
...payers note that primary care is less expensive when delivered at in-store clinics than when provided in a doctor's office or emergency room, patients value the convenience and low price, entrepreneurs see a profitable business model, and proponents of consumer-driven health care see services that can be paid for out of health savings accounts. Physicians, however, express concern about the quality of care and the potential impact on their businesses.
Physician care is limited, a nurse-practitioner is present to handle the issues, which are limited to a menu of different specific remedies. The stores handle some of the costs and the overall result is quicker, cheaper care for patients in areas they don't need a full doctor to handle.
The services listed are highly standardized interventions and require no physician evaluation. Diagnoses are made by using a simple binary test (such as for a streptococcal throat infection) or by applying a rigid, protocol-based decision rule. In some cases, no diagnosis is required (such as for a hepatitis vaccination). In addition, the conditions treated and therapies offered require no or minimal follow-up (for instance, clinics offer diabetes screening but not treatment), and decisions can be guided by highly specified protocols. More important, the conditions can be diagnosed and treated quickly.
At Ace of Spades HQ, Gabriel Malor posted on the topic, and I followed the blog chain back to its origin to get information and comments from each. Here's what each blog offered:

The Agitator was the first to pull this article out of the New England Journal of Medicine, and the writer was none other than Radley Balko from yesterday's Libertarians and Prostitutes article. On the 11th, he pointed out the Boston mayor's opposition to these clinics in his town (claiming it's wrong for stores to make money off sick people), and commenters there responded:
I lived in Boston and the surrounding area for 11 years. Profit-as-evil is as ingrained in the culture as rude driving.
-by MKiely

An excerpt from the linked article:
Still, members of the commission said clinics inside retail stores might only exacerbate long-standing problems in the healthcare system. Dr. Paula Johnson, a board member and physician at Brigham and Women’s Hospital, said episodic visits to a drug store clinic could defeat efforts to provide patients with a reliable continuum of care.

“We could be setting ourselves up for some real problems,” she said.
–Ok, so what problems is Dr. Johnson concerned with? How do “episodic” visits deter from a reliable continuum of care, especially if you are not able to get care under the current system?

I could see, maybe, that recurrent issues or trends may not be diagnosed properly, but those type of issues (based solely on my personal experience) will only be solved by the determination of the patient. How many times has a patient with chronic symptoms be mis-diagnosed only to be cured or treated properly when the patient seeks other answers? I know I have with issues relating to esophogeal ulcers. Had I continued with my “continuum” of care, I would probably be dead. I found answers by NOT being seen by the same Joe every time and challenging the answers given.

I think this is a wonderful idea for the Boston area. I look forward to see such clinics pop up in my local CVS type places.
-by Mike Leatherwood

I’ve worked in emergency care for several years. Two considerations that came to mind immediately:

1. The immediate distinction between these clinics and an ER is the availability of advanced diagnostic procedures and treatments. For the sorts of minor things people go to in-store clinics for, the clinical judgment of a trained professional is likely to be adequate without all the extra tests that drive up costs.

2. When that is not the case, a good professional will refer the patient to a higher-level facility. This is, and has been, standard practice for urgent-care facilities for years.
-by Graham
Meanwhile, the next step in the chain was Coyote Blog on the 13th and there Warren Meyer notes that this is...
a great example of politicians doing exactly the opposite of what is needed to making US health care even more convenient and affordable.
Readers there responded as well:
If profit is the problem than it's not just the new little in store clinics that area problem. Selling over the counter remedies are also an issue. Why weren't they railing on those 20, 30, 50 years ago?

And why is for-profit heath care seem to be what they're going after? Why not food?

Either way, this thinking is driven by people who actually think that they can just legislate things to happen.
-by Allen

My wife went to one of these clinics on a Sunday with an ear infection. While I was a little taken back by the cost ($150 for the visit), I can't imagine what our local emergency room would have eventually charged me or my insurance. Plus, the wait was all of 10 minutes to be seen (try that at an emergency room if you don't show up bleeding or dying). Also, she would have had to wait until the week days to see her regular doctor.

These are great services and well worth the cost (which I am appying back to my Health Care Spending Account).
-by Moby
And finally from there I go to the Ace of Spades HQ where on the 14th, Gabriel Malor compares the business model with other previous attempts:
More than that, as all those stores in the front of Wal-mart prove, convenience turns out to be a good way to reduce costs because it makes a service more immediately responsive to the market.
Ace readers discussed the story:
Allowing retailers to make money off of sick people is wrong.
I think this is code that their pet crisis issue is about to be Welfare Reformed.
-by Topsecretk9

This is totally the wrong (Moron) venue to do this, but if we're ever to put a stake through the heart of socialized medicine, don't we have to come up with an alternative vision? And mine would be just this sort of thing. Lots of private clinics to treat minor ailments run for profit like the major drugstore chains.

In contrast to Hillary's "Force Healthy People to Pay For Socialized Health Care to Keep the Cost Down" version of Health Care Fascism.
-by V the K

It reminds me of all the folks who bitch and moan about taking care of the poor folks and the need for health care 'reform' but then bitch and moan and pciket Wal Mart to keep them out of their neighborhoods. Forget the poor folks who have to take a bus to go shopping or the $4 prescriptions that can save them money, They'll be damned if they're opening a Wal Mart within five miles of my house.

No way. no how.
-by jmflynny

About a year ago, I was on a long road trip and I came down with bronchitis. I was able to look up a walk-in clinic in the next major town, walk in, get treated and pick up my prescriptions all in about 2 hours. And that was including getting a burrito for lunch from the mexican restaurant next door. Very convenient. It's the way medicine ought to be.
-by Maetenloch

Gosh, in the good old days, you walked into a pharmacy, you said you had a sore throat or poison ivy and the kindly old pharmacists directed you to the aisle with the throat lozenges or the calamine lotion, then sold it to you. done and done.

Now they're going to charge for that same service and this is somehow better? Or is that we, as a society, just can't believe that we would ever get something so mundane as a simple sore throat, and whatever we have requires 12 prescriptions and 3 shots to be cured?

I had a cold a week or so ago and someone in my office suggested I take antibiotics. I told her that a) antibiotics don't do anything for colds and b) taking them for a cold actually reduces the effectiveness of any antibiotics I might need to take later on for something else. Her answer was "well, you should take them, just in case."

-by Weiserbud

Speaking of convenient health care, my company is the primary care division of a major health care system, and we recently acquired 2 acute/urgent care centers to determine if this is a feasible means of lowering our Hospital ED intake rates. The ultimate goal if this is successful is to place similar centers close to our 5 hospitals and use them as a triage locations to stem the tide of non-emergency cases into the ED. The current centers are open 20 hours a day, 7 days a week, but if this project moves forward then the hospital centric locations would be 24/7. We also got all the major insurance companies to treat these locations as a regular after hours office visit which reduces the co-payments for most patient by at least $50.

As for the complaints from His Honor the Mayor, one of the good Catholic Nun-type ladies who used to run a large non-profit here once said, "No Margin, No Mission". Money is always the bottom line in any business, even one as noble and idealistic as healthcare.

Wiserbud: I just finished an excellent book on the rise of "Premium Medicine" and its effects on the cost of health care in America. The title is Crisis of Abundance, by Arnold Kling, and it might be something you'd be interested if you want to see how your health care dollars are really wasted.
-by Flsptsgod

I was billed $380 for a tetanus shot at a "hospital" a few years ago. The "treatment" lasted a grand total of maybe 3 minutes. Filling out their forms took much longer than the treatment.

None of the walk-in clinics or doctors in the Albany NY area had tetanus vaccine, it was only available at the hospitals.

F@#(ing thieves. Administering a $20 shot like that is something I think I can trust WalMart to do. Brain surgery...not so much.
-Purple Avenger

I live in Costa Rica. Every drugstore has a resident doctor on staff. You can walk in off the street, be diagnoised and treated within minutes. I had a minor motorcycle accident last year and pinched my cyatic nerve. Ten minutes, $10.00 and one shot later, I was on my feet, out the door and down the road.
-by Gulermo
As several commenters pointed out, the complaint that retailers ought make no money off of the sick means they'd have to shut down the entire over the counter drug aisle, get aspirin and cough medicine off the shelves, and so on. Further, you'd have to ban doctors from making any money over what they absolutely need to stay in business because, heavens, they make money off the sick, too!

When I went to college had a clinic much like this, a nurse with a limited list of things she could address. Many large companies have just such a setup in their building for minor injuries. It's good policy because you save money for the company and keep people in building in case they cut a finger or have some other mild malady. This system is well-tested, works quite effectively, and is in my opinion exactly the right way to go in terms of keeping health care costs down - and lowering insurance costs for everyone in the process.

My only real concern would be that stores might try to cut corners for profit or to keep costs down, such as what happened with this commenter from Ace:
Last time I was at a walk-in clinic, they gave me an expired antibiotic. Other than that...very convenient! Great for people who get sick while out of state on vacation.
-by Joanie
Now, an expired antibiotic will still work in most cases, it just isn't as reliable as one that's within its expiration time. Yet when companies and the bottom line become the primary concern, it is not impossible to see these little clinics being forced to this kind of extreme. So that's a valid worry, but not one that is unique to such clinics, as many stories of health care around the world can attest.
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Anonymous said...

Great post, C_T. I agree, things like this are an important part of the solution (insomuch as there is a solution) to the healthcare problem. I took a long look at my family's insurance situation last year and changed to a high deductible plan with a Medical Saving Account. Before, we had a very expensive plan that covered almost all of our medical costs. The idea witht the new plan was, with the much lower premium, we would save money even though we have to pay for most of our medical care out of pocket. It worked out: we saved close to $1000last year as compared to 2006 (and that is before I factor in the tax benefits of the HSA).

In part, we are relying on the market to make our healthcare cheaper. Things like Wal-Mart's $4 generic Rx plan and our local doctor's walk-in clinic ($100 for a visit, no insurance accepted) were vital to our plan to save money.

Additionally, this plan gets us to interact more with our doctor in order to find savings. When my wife goes to the doctor, she takes a list of the drugs Wal-Mart offers for $4, and if the doctor tells her she needs medicine, she asks him if she can use anything on the list. Most of the time she can, and it is cheaper than what the Dr. otherwise would have reccomended.

Anonymous said...

I also wonder how we can translate this approach to medicine into other, more costly, aspects of health care. A big part of the "trick" is to get people to engage the market outside of their insurance plans. I saw a doctor on the local news the other night who was discussing how the price for an MRI has increased over the years in spite of the fact that the technology has remained basically the same. He contrasted this to the price for another medical technology: laser eye surgery. It costs about 1/3 as much to have your eyesight surgically corrected as it did 10 years ago, and additionally, the technology behind this procfess has dramatically improved.

He attested the price difference between these to technological "medicines" to be rooted in how the free market accesses each technology. To get an MRI, you have to wind your way between many gatekeepers, both at a hospital and at your insurance company, who control both access and pricing. To get laser eye surgery, you usually deal directly with the person or company who owns and operates the technology. Result: it's cheaper.

Another trend I see that might spur price competition in US medical care is the "outsourcing" of medical care. If you need knee replacement surgery it is about a $20,000 procedure in the USA. In Bali, India you have oceanside "resort" clinics with US trained doctors and clean facilities that are offering roundtrip service to get the same procedure performed for around $6,000. When American clinics start loosing serious money to these types of businesses, they will have to control costs in order to compete (assuming the government doesn't bail them out).

Unknown said...

Excellent find.

I already use WalMart's optical clinic. I made the change when my family optometrist started charging $300+ for just the visit, and required you to buy contacts/glasses there for an increased price.

To heck with that.

Now I see a very competent optometrist who sees me in 10 minutes, charges me $90, and gives me a prescription to go shopping online with.

If medical clinics were available in the same vein, I would definitely use them, for simple convenience as well as price. I'd also much rather be checked out at a set price at a 24-hour store clinic and referred to the hospital for a problem of questionable seriousness than waste my money and the ER staff's time up front.