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In Store Clinics


“Rope A Dope”


Stanley Feld M.D.,FACP,MACE


There are many issues involved in healthcare reform. The major issues to decrease defensive medicine with malpractice reform, rapid affordable installation of electronic health records, control of the obesity epidemic, effective chronic disease management and a change in the healthcare insurance model are not on the radar screen of the President or Congress.

The issue with effective healthcare reform is about money. In order to save a significant amount of money the above problems must be solved. As President Obama plan progresses in the congress the battle is all about political tactics and positioning for the midterm elections in 201

On the one hand, President Obama and his party say they’re hoping to strike a good-faith compromise on health care. On the other, they’re threatening this "budget reconciliation" maneuver to coerce Republicans into rubber-stamping liberal policy.”

The Democrats want to get a handful of GOP Senators to support the bill before in gets to the floor. The goal is to short circuit a bloody debate before it begins. The Democrats are to join their fold. Chuck Grassley, Orrin Hatch, Susan Collins and Olympia Snowe voted for expanding the state children’s insurance program (Schip).

SCHIP was a compassionate bill and logical. However it is a bill that does not create patient incentives. It is difficult to imagine Republicans defecting to the poorly constructed bill that will created greater costs and more dysfunction to the healthcare system.

“This new entitlement — like Medicare but open to all ages and all incomes — would quickly crowd out private insurance as people gravitated to heavily subsidized policies, eventually leading to a single-payer system. So Democrats are trying to seduce diffident Republicans with a Potemkin compromise.”

All the the Democrat’s rhetoric in nonsense. Without a change healthcare insurance healthcare costs will continue to rise . We need only to look at the Massachusetts experience.

The administration is prepared to make promises to Republican such as the government healthcare plan would only be sold to the uninsured and small businesses that can not afford to provide employees with healthcare insurance because of the costs. Once the Republicans on on board and the bill is past the administration could modify this proposal and make it all inclusive.

“ The White House strategy is to dilute the healthcare plans proposal just enough to win over credulous Republicans. That is what has always happened with government health programs:”

President Obama is playing a game of got uh. Some one wrote to me and called it Rope A Dope.

“When Medicare was created in 1965, benefits were relatively limited and retirees paid a substantial percentage of the costs of their own care. But the clout of retirees has always led to expanding benefits for seniors while raising taxes on younger workers”.

Medicare’s cost to seniors has also risen with a base month cost of $99 per month per person or $2400 per year per couple. The catch is the deductible are $999 for hospital admission and and 80/20 deductible. The monthly payment per person is means tested and can go to $275 per month per person with after tax dollars. The a senior has to by Medicare Part F for deductible coverage. Its cost is 170 per month per person. Medicare Part D at it least expensive is $47 per month per person with high deductible.

In order to get full coverage the cost can be as high as $15,000 per year in after tax dollars.

Congressional actuaries expected Medicare to cost $3.1 billion by 1970. Medicare today costs $455 billion and rising.

Medicaid was intended as a last resort for the poor. It now covers one-third of all long-term care expenses in the U.S.. Its annual bill is $227 billion, and so far this fiscal year is rising by 17%.

Over time end stage renal disease and disabled person have been added to the Medicaid roles Other person also have been included.

“SCHIP was pitched a decade ago as a safety net for poor kids, and some Republicans helped sell it as a free-market reform. But Schip is now open to families that earn up to 300% of the poverty level, or $63,081 for a family of four. In New York, you can qualify at 400% of poverty.”

A common denominator to all of this unsustainable increases is the way the healthcare insurance industry controls the healthcare dollars. This leads to abuse by other stakeholders. Incentives must be aligned with the consumer controlling their healthcare dollars.

The Lewin group estimates that 119 million more persons with private insurance could be added to the 90 million already on Medicare and Medicaid. Health habits must be changed to combat obesity. The only way it will be changed is a change in farm policy and the consumers owning their healthcare dollars. Otherwise we are doomed to every increasing premiums and overuse of the healthcare system.

Any new federal health plan will inevitably follow the same trajectory, no matter how much Republican Senators might claim they’ve guaranteed otherwise.

President Obama is going to mount a public opinion campaign for his plan. The Republicans are going to cave in. They are trapped

Republicans would spend the rest of their days deciding whether to vote for tax increases to finance this, or stand accused of denying health care to the middle class.

President Obama will have successfully “Roped A Dope” Who is the Dope? All of us unless we get wise quickly.

The only way to Repair the Healthcare System is to enable consumers to own their healthcare dollars and to provide incentives to consumers to be responsible for their health. The government should make the rules to level the playing field and empower consumers to drive the healthcare system to their benefit.

These actions allow healthcare affordable to all including the government.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

  • Nari Kannan

    You raise a very important point that has in fact proven success stories around the world. Singapore makes healthcare consumers directly responsible for their healthcare dollars, although the Government and Employers chip in also. But eventually YOU are responsible for your own healthcare dollars there and it seems to be successful.
    Read “The Singapore Model”

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Health Clinics Inside Stores Likely to Slow Their Growth

Stanley Feld M.D.,FACP,MACE

In 2006 I stated "the creations of free standing retail clinics (convenient care clinics) are complicated mistakes.” I thought they would distort the healthcare system even further. I believed it would also be difficult to establish positive cash flow quickly or ever. When investors realize these clinics will have a difficult time making a profit they would be closed.

I said “I think Wal-Mart and CVS are indeed putting their reputation and good will on the line and are going to get a nose bleed.”

The boom in walk-in health clinics located inside pharmacies, supermarkets and big-box retailers is showing signs of slowing.”

Hailed as an inexpensive option for treating minor health ailments like sore throats and rashes, the retail clinics have grown in number to 963 as of May 1 from just 125 three years ago. The clinics typically feature nurse practitioners who can prescribe basic drugs. The price for a visit ranges from $50 to $75.

“ But in recent months, retail health- clinic operators based in New York, Nevada, Indiana and Alabama have closed their doors, shuttering 69 clinics in 15 states, including ones operating inside outlets of Shopko Stores, Meijer Inc., in New York, Nevada, Bi-Lo LLC, Wal-Mart Stores Inc, and the Medicne Shoppe unit of Cardinal Health Inc."

“Now, the biggest retail-clinic operator, CVS Caremark Corp., says it is scaling back expansion plans for its MinuteClinic brand.”

The math is easy. It is very difficult to generate a profit with uncomplicated cognitive services. The In Store Clinics investors did not realize the resistance from primary care physicians and the communities they service. If these clinics have any chance for success they would have to be a direct extension of the community physicians’ care.

“Tom Charland, the owner of industry consultant Merchant Medicine LLC says the venture capitalists and private-equity firms that backed many of the retail clinic operators failed to appreciate how complicated and expensive the clinics are to operate. Research shows that patients are enthusiastic about the clinics' convenience and quality of care, but acceptance has been slow.”

I do not think the consultants understand the problem. There is a difference between medical care and healthcare. When someone is sick he wants to see a doctor and not a healthcare provider. Another problem is these clinics can not be profitable if they do not provide ancillary services. Ancillary services are not within the scope of practice for nurse practitioners in most states. A third problem is that if these clinics were seeing enough patients to create positive cash flow they would have the same long waiting times and become as inconvenient as community emergency rooms.

“Some operators are finding that the clinics are complex to manage. Earlier this year, CheckUps, a clinic operator based in New York, abruptly closed 23 clinics that it operated inside Wal-Marts in Florida, Mississippi, Alabama and Louisiana. It was stretched thin by operations in multiple states, says company spokesman William Armstrong.”

"You have to have a critical mass of stores seeing a high number of patients to get somewhere," he says. He adds that new clinics need to spend a lot of money on marketing to build public awareness and that the clinics become expensive quickly. "We ran out of operating funds," he says.

The big box stores and pharmacies opening In Store clinics are on the verge of another complicated mistake. Rather than affiliate with the convenient care companies, who have not done well, they are reaching out to hospital systems well known in the community.

"Tina Galasso, an analyst who follows the retail clinic industry for Verispan LLC, says the cost of setting up an in-store clinic runs about $500,000. That is one reason why much of the future growth in walk-in health centers is expected to come from big companies with deep pockets and from hospital systems that are already well-known within a community and don't have to spend so much on marketing."

Hospital systems tried to establish “DOC In the Boxes” in the mid eighties as a strategy to capture patients in the surrounding area. They failed in the mid eighties because they were competing with local physicians who were hospital system staff members. The establishment of these clinics was a strategic move to “increase the hospitals’ product line.” The practice of medicine is more than a product line and a commodity. No one seems to understand this.

In a strategy that combines both elements, Wal-Mart plans to partner with hospital systems to open as many as 400 co-branded store clinics by the end of 2010, up from about 50 sites in operation now. That approach is a departure from an earlier strategy under which Wal-Mart leased space to operators like CheckUps that weren't associated with hospital systems.

It amazes me to see local hospital systems competing for the Wal-Mart contract. Where is their corporate memory? Where is the building of trust between physicians and hospital administrators to create stronger institutions? If physicians do not know how to provide convenient care, the hospital system teach them how to provide it. Hospitals are always saying they want to create partnerships and trusted relationships with physicians in order to provide better care for the patients in the community. Do it and don’t create more dysfunction in the healthcare system.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

  • Nurse Practitioner

    Dr. Feld, What are these “ancillary services” that you speak of that NPs cannot do and are scope of practice issues? With all due respect, I think you aren’t very familar with nurse practitioner practice. There are states that allow NPs to practice autonomously and most states require a collaborative relationship. In these majority of states, there is very little that NPs cannot do.
    And as far as folks wanting to see a doctor and not a “healthcare provider” when they are sick: I think you are mistaken. People want care that is conveinent, high-quality and affordable. I’m going to assume that your statement isn’t a slap to the 120,000+ currently practicing NPs that work in all areas of healthcare: from retail clinics to oncology units to emergency departments and critical care and so on.
    There are certainly plenty of patients to go around and it is very obvious that physicians can’t do it alone.

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