Customer Health Care

It's Friday evening and you suspect that your child might have strep throat or a worsening ear infection. Do you bundle him up and wait half the night in an emergency room? Or do you suffer through the weekend and hope that you can get an appointment with your pediatrician on Monday -- taking time off your job to drive across town for another wait in the doctor's office?

Every parent has faced this dilemma. But now there are new options, courtesy of the competitive marketplace. You might instead be able to take a quick trip on Friday night to a RediClinic in the nearby Wal-Mart or a MinuteClinic at CVS, where you will be seen by a nurse practitioner within 15 minutes, most likely getting a prescription that you can have filled right there. Cost of the visit? Generally between $40 and $60.

These new retail health clinics are opening in big box stores and local pharmacies around the country to treat common maladies at prices lower than a typical doctor's visit and much lower than the emergency room. No appointment necessary. Open daytime, evenings and weekends. Most take insurance.

Much like the response to Hurricane Katrina, private companies are far ahead of the government in answering Americans' needs, this time for more accessible and more affordable health care. Political leaders across the country seeking to expand government's role in health care should take note.

Thousands of free-standing primary care clinics have been operating for years in malls and main streets around the country, often staffed by physicians and many offering a broad range of health services. The retail health clinics are creating a new model with more limited services at lower prices and almost always staffed by nurses. The Convenient Care Association estimates there are about 325 of these retail clinics operating nationwide today. Seventy-six of them are in Wal-Marts in 12 states, but the company announced last month it will expand to 400 clinics by the end of the decade and 2,000 in five to seven years. They will be run by outside firms, including for-profit ventures like RediClinic as well as local and regional health plans and hospitals.

The industry is rapidly expanding. You can find a MinuteClinic in the CVS on the Strip in Las Vegas. But you also will find many locally-run clinics in pharmacies and food stores across America, such as the Express Clinic in Miami, MediMin in Phoenix, and Curaquick in Sioux City, whose motto is "Get well soon."

Prices vary for services from flu shots ($15-$30), to care for allergies, poison ivy and pink eye ($50-$60), and tests for cholesterol, diabetes and pregnancy (less than $50). Competition already is starting to drive prices down.

Of all patients who have visited the clinics, almost half went there for a vaccination, and one-third received treatment for ear infections, colds, strep throat, skin rashes or sinus infections. Ninety percent said they were satisfied with the care they received. The nurses staffing the clinics are under physician supervision and follow strict protocols to refer patients to physicians or emergency rooms if problems are more serious.

Internists and family doctors are watching. Some see the clinics as useful in providing efficient care for a limited number of uncomplicated ailments, freeing physicians and hospitals to deal with more complex cases. But others are worried about lost business, fragmentation of care, and the quality of care if the clinics miss something serious.

Rick Kellerman, president of the American Academy of Family Physicians, concedes, "The retail clinics are sending physicians a message that our current model of care is not always easy to access." The threat of competition from the in-store clinics means some doctors are keeping their practices open later and on Saturdays and holding an hour open for same-day appointments. Competition works.

And competition also worked to force prescription drug prices down: When Wal-Mart announced last year that it was dropping the price of several hundred generic medicines to $4 for a month's supply, other pharmacies, from Target to corner drug stores, followed suit. Wal-Mart now says that a third of all prescriptions filled at its pharmacies are for the $4 generics, and 30% of them are filled by people without insurance.

Take note, Congress: The market is providing cheaper medicines, more affordable care -- and it is also helping the uninsured. A Harris Interactive poll conducted in March for The Wall Street Journal said that 22% of those visiting the clinics were uninsured. Wal-Mart says that half of its clinic visitors are uninsured.

Retail clinics are particularly attractive to 4.5 million people with Health Savings Accounts who have health insurance with higher deductibles and want an affordable option for some of their routine care.

And the clinics are working to solve another problem that is vexing Washington -- creation of electronic medical records. Most retail clinics create computerized patient records, with the goal of making the records accessible throughout the chain. The records also can be emailed to a hospital or to the patient's regular doctor -- or sent by fax if necessary.

Critics of engaging private competition in the health sector will argue that the vast majority of health-care dollars are spent on a relatively small percentage of patients with serious illness, especially those with multiple chronic conditions.

But even coordination of care for those with chronic illnesses lends itself to patient-friendly solutions. The City of Asheville, North Carolina, cut its costs in half for employees with diabetes by teaming up with local pharmacists who did routine exams and got patients to their doctors or hospitals more quickly when they needed intervention. Employees received their medicines for free if they kept appointments, and their health improved.

Because health care is largely regulated and licensed at the state level, some states are more friendly than others at having non-physicians deliver care. California requires that clinics be a medical corporation owned by a physician. In Arizona, each site must be licensed, but in most other states, a single license will serve multiple clinics. Illinois is considering legislation to limit the number of nurses a doctor could supervise to two and restrict the clinics' right to advertise.

This industry is in its infancy and will hardly register in our nation's $2 trillion-plus health care bill. But just as Nucor overturned the steelmaking industry with a faster-better-cheaper way of making low-end rebar, these limited service clinics could be the disruptive innovator in our health-care system. Package pricing for more complex treatments, like knee replacement surgery, may not be far behind.

Government can get in the way, of course, with protectionist policies that throw up more regulatory barriers to entry. But retail clinics could be just the beginning of consumer-friendly innovations, if Congress were to change tax policies in a way that would allow people to have more control over their health spending, as President Bush has proposed.

The linchpin is giving people the same tax benefits whether they get their health insurance at work or on their own, or buy coverage through groups like churches, labor unions and professional or trade associations. Allowing people to buy health insurance across state lines would inject another dose of healthy competition into the system.

With many congressional leaders hostile to free-market solutions, these policy changes are unlikely in the next two years. But as consumers get a taste of what consumer-friendly health care is like, they may well demand that the top-down, centralized health-care delivery of the 20th century give way to a system more in tune with the demands of 21st-century consumers seeking greater value and efficiency.

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Massive closure of NHS emergency rooms in sight

Up to half of all hospital accident and emergency departments face cuts or closure under plans to improve patient care, presenting Gordon Brown with a massive dilemma as he takes over as Prime Minister. Ninety-two out of 204 A&E departments are under threat if guidance attributed to the Department of Health by NHS trusts is followed, the Conservatives claimed last night. Some NHS organisations are already using the guidance, which calls for A&E departments to serve a minimum population of 450,000 patients, to justify closures in smaller catchment areas. The average A&E unit currently serves just under 250,000 people.

But the plans are proving hugely unpopular, even though they have been promoted as in the interests of patients and NHS staff. Mr Brown, aware that the closures would come into force around the time of the next election, said last Friday that he would meet front-line NHS staff and patients to discuss health policy. It was clear last night that the Chancellor will not now face a leadership challenge as he prepares to succeed Tony Blair, having gathered a decisive 308th supporter among Labour's 353 MPs.

Last Sunday Mr Brown accepted that people were worried about the potential closure of A&E facilities and maternity services close to their homes, raising speculation that he was pondering a rethink. If so it is increasingly likely that he will move Patricia Hewitt, the Health Secretary, from her post to pave the way for changes.

The Conservative estimate of 92 nationwide cuts was based on figures in a report circulated to NHS trusts in Surrey. It states: "Current Department of Health and strategic health authority guidance suggests that, to be viable in terms of patient need, patient safety, staffing numbers and clinical training requirements, a full A&E department in the future would need to be supported by a catchment population of between 450,000 and 500,000 people." A staff briefing by Surrey Primary Care Trust in March repeated the figures, suggesting that such a catchment population was "national guidance".

Closures could mean seriously ill patients, such as those with heart problems or head injuries, having to travel longer distances to receive care in specialist treatment centres. Patients with minor injuries are expected to be treated in walk-in clinics or smaller A&E units. Such a scenario was supported by two reports published by the Government last year. These suggested that specialist high-tech centres could save 500 lives of people suffering heart attacks and result in 1,000 more stroke victims avoiding death and disability each year.

The changes are broadly supported by doctors' leaders but are fiercely opposed by patients' groups and MPs. Cuts to local NHS services have also been opposed by several senior Labour politicians in their own constituencies. The move to close A&Es comes just as demands on their facilities are rising. The number of attendances at A&E has risen by more than a million in the past three years and the average number of attendances at each is now 67,000.

A report published last year by the Royal College of Surgeons recommended that the minimum catchment population of a fully resourced A&E department should be at least 300,000. But there is debate about whether catchment areas alone should be used to allocate NHS services. Local geography, healthcare needs and staffing levels may have to be taken into account.

A Department of Health spokesman said there was no such official guidance from his department. "It is absolute rubbish to suggest that we are demanding the closure of A&E departments. "Any decisions about the shape of A&E services are taken locally so that services reflect the needs of the local population. Where local health authorities believe that patients can be better served by changing the way services should be delivered, it is right that they make those changes, and they will consult locally on any proposals."

But he admitted that the recommendations were taken from a report by the Royal College of Surgeons supported by Sir George Alberti, the former director of emergency care. He recently recommended the closure of an A&E department in North London. The remaining two A&Es serving the area will be left with catchment populations of 450,000 each.

The Tories claimed that this was evidence of central targets to close units based on the number of patients they served. Andrew Lansley, the Shadow Health Secretary, said: "Access to accident and emergency services is a vital component of the quality of NHS services. The public know that not every A&E department can provide every emergency service. But there is no clinical evidence which would justify shutting down A&E departments simply because they don't serve a catchment population in excess of 450,000. Yet that is the basis on which the Department of Health is seeking now to justify closures."

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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