The Physician's Corner
By Henry Tulgan, M.D.,
FACP
Massachusetts
has now joined 25 other states in allowing MinuteClinics to be
established in a number of CVS pharmacies across the
Commonwealth. Several years ago, MinuteClinics began as an independent
organization providing walk-in care. It was then purchased by CVS
Caremark in 2006. In other states, similar clinics are operated by a
number of other retailers including Walgreen’s, Wal-Mart, Target
and Kroger’s. These clinics have arisen as a clear response to the
serious shortage of primary care physicians (PCPs). They are also a
response to the overutilization of hospital emergency departments and
the often prolonged delays and staggering costs involved in their use.
The average cost for a visit to a MinuteClinic for a “common
family illness” is $59 and wellness and screening visits are
$29.
Other minor
services such as flu shots and other vaccinations are also available.
Patients can pay with cash, a credit card or submit the bill to
insurance. In-store limited service clinics are regulated by the
state Department of Public Health, which has defined appropriate
conditions that may be treated. They are staffed by nurse practitioners
who are supervised by off-site physicians. The relationships between
them are delineated by The Board of Registration in Nursing. These
nurses may also attempt to contact a patient’s primary physician.
Does this arrangement have the potential to raise medicolegal issues? It
most certainly seems that the answer is yes.
Patients who
are seen at these clinics are at a distance from the supervising
physician and their PCPs, and both the treating nurses and the
physicians may be vulnerable to lawsuits. In addition, if a patient
visits one of the clinics and fails to disclose an ongoing treatment
plan from his or her primary physician, it opens the door to possible
liability for all parties involved. Any practitioner that wants to become a
supervising physician should employ several safeguards. First and foremost, the physician must be certain that CVS or
other operators of such facilities will assume coverage for any
malpractice actions.
In addition,
policies should be in place for the clinic to refer patients back to
their primary care physician as needed or, when necessary, to an
emergency department. Clinics and PCPs must also have mechanisms for the
PCP to receive prompt reports of patient visits at the clinic. This
places an additional responsibility on the PCP to follow through with
recommendations made at the clinic visit. Hopefully, as electronic
medical records become more readily available and easier to share among
health care institutions, communication about patients will also become
smoother.
Another concern
is that many clinics are not open 24 hours and therefore they cannot
obviate emergency department usages at times that are usually busy. It
is still early in the era of in-store limited service
clinics and their congeners. Time will likely clarify their
usefulness and sort out some of the potential legal issues. But the
clinics are now a presence in the health care delivery system and
expected to grow rapidly, so we will have to continue to observe them
carefully.
Risk Management Strategies
For Supervising Physicians
-
Verify that coverage is provided by the
retailer for medical malpractice claims.
-
Establish protocols and guidelines for nurse
physician relations.
-
Share information with the patients’
regular provider.
For Primary Care Physicians
Next: CME
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