MMS Comments on Minute Clinics at Board of Medicine

Bruce A. Auerbach, M.D., president-elect of the Massachusetts Medical Society, delivered these remarks today (July 25) at a public meeting of the Board of Registration in Medicine on the application of Minute Clinics to open a limited health clinic at a CVS store in Weymouth.

The Medical Society and the physicians of Massachusetts welcome innovations in health care. We need innovations in our health care. We all know that much in our current health care delivery system is dysfunctional. Therefore, the only intellectually honest position to take -- especially in a state which is committed to making care accessible to everyone -- is to support innovation. But those innovations must ensure safety, improve the quality of care, and deliver care efficiently and in a coordinated manner.

My brief comments today will focus on only two areas – the supervision of the care delivered and the continuity of care after a patient encounter at one of these facilities.

First, on the supervision of care:

The business model of the Minute Clinic is to have nurse practitioners deliver all, or almost all, of the care. Certainly, for the limited scope of conditions that these clinics are designed to accept, this is not inappropriate, on its face. Nurse practitioners have adequate training to treat many of the conditions outlined in the original application to DPH. I have great respect for and value the skills of nurse practitioners. In fact, they are used extensively in the delivery system in which I practice.

Training is not our issue -- collaboration and supervision is. The original application by Minute Clinics outlined -- and I stress “outlined” -- an arrangement that does not appear to ensure the integrated high-quality care for which we strive.

In what most consider the ideal model, the one that ensures quality, safety and continuity, the nurse practitioner has constant, ready access to their supervising physician. The patient also knows with which physician their nurse practitioner has a supervising relationship and to whom they can turn for issues beyond the scope of the nurse practitioner.

In other words, there is a physician-patient relationship and accountability. In many cases, these providers are in practice in close physical proximity to each other, again supporting the collaborative, consistent relationship and the consultative, supervisory role. This type of model supports quality, safe practice.

Patients do not present with a diagnosis, similar to the list of “accepted” problems for the retail clinic. They present with complaints. Every patient who presents with a sore throat does not have Streptococcus pharyngitis. Every patient presenting with red eye does not have simple conjunctivitis. Having the ready, consistent access to a physician colleague helps ensure that the sore throat that is a peritonsillar abscess and the red eye that is a herpes lesion are not missed. My 25 years of experience working alongside physician assistants and nurse practitioners has provided me with more than anecdotal examples of similar cases.

The Minute Clinic model does not attempt to mirror this ideal model nor does it appear to even meet the standards that this Board has supported in other instances when physicians who are not always on site are called upon to supervise care by nurse practitioners. The current standards not only create a mandate for a consistent supervisory relationship with the nurse practitioner, but support the link between the patient and the supervising physician.

This does not appear to be the case with the Minute Clinic model, where the physician seems to be responsible for only a sampling audit of the nurse practitioner’s activity. There does not appear to be any attempt to establish a relationship with the patient or be available for consultation. We believe the relationship intended by the Board’s standards is the one that is in the best interest of safe, high quality patient care. It should not be altered.

Second, some comments on how these clinics should relate to the rest of our health care system.

One of the historic scourges of our health care delivery system has been its fragmented nature. Thankfully, we are starting to make some headway in reversing this direction. Chapter 58 promises to bring us even closer to our objective of providing care along an effective, efficient continuum to every resident of our Commonwealth.

One example is the concept of the Advanced Medical Home, proposed by the American College of Physicians. It’s an excellent step in the right direction. It includes a large role for nurse practitioners in settings like this -- but in close association with the physician’s practice. A number of pilot programs for the Advanced Medical Home could be implemented in the Commonwealth within the next year.

Some questions that might be posed are:

• Who will be responsible if the patient worsens after their Minute Clinic visit?
• How will the entity assuming any follow-up care, scheduled or otherwise, be made aware of the evaluation and treatment rendered by the clinic.
• Will records at the, now closed, retail-based clinic be available for those providing after hours follow-up care?
• How will follow-up or more extensive care be facilitated if the patient does not have a primary care physician?

This is just a small sampling of the types of issues that concern provider groups with the proposed model. To reiterate, these are all issues with the potential to impede our progress towards the most integrated, comprehensive, coordinated, safe and high quality health care system we can devise.

Without significant changes in its plans for physician supervision and connecting to the larger health care community the Minute Clinic model would be a step backwards, in the wrong direction -- towards more fragmentation, and away from collaboration and continuity of care. This model would undo much of the progress that the Board, our hospitals, and our physicians have made to ensure that care is not only effective, but efficient, coordinated and patient-centered.