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- Issue 81: April 2009
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Primary Care Clinics and Self-Care Environments

Neil Johnston
Management Consultant Perspective

Issue 78: December 2008
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There has been a revolution in US health care service provision that has occurred in very recent years. It is called the Retail Clinic, a service that started cautiously only a few years ago in the US, but now numbers in the thousands.
It is based on a clinical service product relating to common ailments, and sold at a competitive price in a convenient location.
It is the same product that Australian pharmacists used to service – and do the job very well.
You could almost say that product profile also fits that of a product that would find success in a supermarket environment.

And it does, even though the majority are found in supermarket pharmacies, a significant number are just located in convenience-type retail spaces.
Consumers, it seems, do not have the hang-ups that doctors and other health professionals have in terms of setting up in such a location.
Consider also that you would not have expected to see the following headlines:

“Doctors stretching schedules, resources to keep up with retail clinics”,

but they appeared recently in the e-newsletter, Drug Store News.
It’s an unfamiliar situation for GP’s to find themselves at the rough end of a competitive situation, and have to actually move from their rigid position of absolute control of primary care, to hit the ground running to keep up.
The story continues:

“More doctors, nurses and other healthcare providers are stretching their time and resources so they can be even more accessible to patients to stay competitive against the growing retail clinic business, The New York Times reported today.Many physicians and other providers have reworked their schedules and started adding Web-based services in order to meet the immediate needs of patients, the report said. The higher demand for walk-in and retail-based clinic services stems from cutbacks in healthcare coverage that are causing more people to cover expenses out-of-pocket, the report stated.Professional general practice and family medical groups are encouraging doctors to open up their practices to more relaxed scheduling—many are being encouraged to accept walk-in patients. The American Academy of Family Physicians, for example, plans to spend $8 million for consultants who will analyse and advise doctors in how to more efficiently provide and offer patient care, reports said.Furthermore, the American College Of Physicians has begun a push for patient-centric care—the focus of a policy paper—which urges more flexibility for patient scheduling, and advancing practices with electronic records and e-prescribing.”

The interesting aspects of this story is that it has taken competition in the core business of GP’s for them to become more flexible, and move to a scale of web based services to provide a scale of economy, plus a service that is considerate to patients.
The one major difference between the US primary health system and the Australian system is the Medicare subsidy.
The US retail clinic system flourishes because patients have to pay privately for their health services and be reimbursed through private health insurance, if they actually can afford a health insurance policy.
Retail clinics are more convenient and are cheaper.
If a similar service were to start up in Australia run by nurses or pharmacists, it would not currently attract the Medicare rebate, although some nurse practitioners could make a claim in their narrow specialty.

In the last decade, much to my annoyance, I have seen pharmacy pushed aside from primary care and dumped in with allied health.
This has been systematically promoted by the medical profession at all levels, and very successfully too. Even political announcements today exclude mention of pharmacy in a primary health role, and this can be attributed to the poor leadership of the PGA. They have been asleep at the wheel for far too long and they need to get out of everyone’s way – particularly those pharmacists they don’t have a mandate to represent.
When I first started my pharmacy career, the core business of pharmacy could be described as:
1. Extemporaneous dispensing (now called compound dispensing).
2. Ready Prepared Dispensing.
3. Counter Prescribing that became a major component of pharmacy business, which further involved professional patient engagement, consultation/counselling services and education for patient self-care.
Payment was covered through the compounding of a product suitable for the patient’s condition, and this was perhaps the only mistake made with the original business model – there should have been a separate payment for the counselling/consultation process.
And this model just described would have been the genesis of a pharmacy staffed retail clinic because the markets serviced in the US model today are identical to the markets serviced when I first entered pharmacy.
I once had the opportunity to test this model through my own management consulting practice and a range of community pharmacies, and it did work-even without Medicare subsidies.

Over the years I have seen shrinkage of extemporaneous/compounding business with a corresponding increase of ready prepared dispensing.
I have also seen counter-prescribing fall away to levels that are only just visible, also due to time shortages created by ready prepared (mainly PBS) dispensing.
It was always the counter prescribing that won pharmacy its kudos in the Gallup Poll stakes because the pharmacist was seen as the person who did take an interest in individual and family health, and could be trusted.

Because the PGA has been asleep, there is now a realisation that something must be done. Hence the rush to get a foreign system that was developed in the US, adapted to fit the Australian culture (Mirixa) so as to be seen to do something.
This is a system that could have been developed here in Australia with Australian pharmacists at the helm. The expertise is here already but we seem to prefer driving new pharmacists into other professions because we cannot provide the work to match their skills.
And one must wonder where the PSA is in all this because they should be the leaders in the provision of clinical services, not the tail wagging the dog.
Despite the fact that the PSA have been politically “done” in the sense of not having control over government grant monies, they should have stood up for their rights long before today.
Let us hope that we are just seeing the calm before the storm, because heaven help pharmacy’s professional future if leadership is not soon demonstrated.
Properly planned, the Australian pharmacist workforce should have been anticipating a shortage of skilled pharmacists rather than the surplus now forecasted, because put very simply, paid professional services would not have to be funded out of a PBS profit margin doomed to be forever under pressure.

And in another story published in Drug Store News headlined:

H-E-B, RediClinic open largest U.S. retail clinic in Houston area”

We see retail clinics not only expanding in number, but in size as well.
This latest clinic covers an area equivalent to a small Australian pharmacy.
The story continues:
“Clinic operator RediClinic has opened its 15th Houston-area convenient care clinic in the new H-E-B store that, according to the Convenient Care Association, is the largest retail-based clinic in the United States.The 926-square-foot clinic features three exam rooms and a room specifically for blood draws.“We are delighted to be expanding out footprint in our home market with the opening of our 15th Greater Houston clinic,” said Web Golinkin, chief executive officer of RediClinic. “The larger clinic design in H-E-B’s new Bunker Hill store enables us to treat more patients and gives us more flexibility in adding new services.”RediClinic operates 21 clinics in H-E-B stores in Houston and Austin; and 15 clinics in Wal-Mart stores in Atlanta, Ga.; Fayetteville and Rogers, Ark.; Richmond, Va.; and Tulsa, Okla.”

Retail clinics in the US are mostly based in pharmacies, but there are some located in supermarkets and department stores.
Being based in larger stores they are in a position to negotiate for the same rental that is applied to that store. That scale of economy could also be applied to a full pharmacy inside a supermarket and may have to be faced sooner, rather than later.
Retail Clinics have flourished despite all the criticisms thrown at them e.g. doctors have complained that the services are poor quality and incomplete because they are staffed by nurses; It is bad to mix sick patients with healthy customers in stores (despite the fact that this already occurs as a matter of course).

The lessons have been long available for Australian pharmacists to study.
Get involved with genuine primary health and self care services…or get out!

There is no future in the current system models or the PGA proposed models (being imposed from a foreign culture through a top-down process) with a system that excludes a majority of pharmacists.

The sooner we can have Medicare funded services provided by any pharmacist, the sooner we can get on with developing clinical practices that will be relevant, be attractive to recently qualified pharmacists and turn a looming pharmacist workforce oversupply into one that requires a continuing demand for skilled pharmacists.


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