Volume 27, Issue 463

March 20, 2006

ARE MINI-CLINICS A GOOD THING? STATES INCREASE THEIR SCRUTINY

Georgia may become the last state in the nation to grant prescription-writing privileges to advanced practice registered nurses (APRNs) – and the first state in the nation to curb the rapid spread of “mini-clinics” that use APRNs to diagnose and treat patients with simple ailments.

Over the past five years, mini-clinics have multiplied across the country, offering patients access to APRNs and other health-care professionals without first requiring an appointment. The Minneapolis, Minnesota-based MinuteClinic is among the oldest of these operations. The clinics that are located in eight states (including Georgia) have fielded more than 400,000 patient visits. The clinics treat only patients with minor ailments such as sore throats and ear infections; patients with serious complaints are referred to their physicians. The clinics offer convenience, reasonable prices and high-quality care to insured and uninsured patients, said Dr. James Woodburn, MinuteClinic’s chief medical officer. A typical visit to a MinuteClinic takes only 15 minutes.

The State Capitol building in Minneapolis houses a MinuteClinic, as does the University of Minnesota campus. But most clinics are located in retail outlets such as Target stores and CVS pharmacies, and their growth is drawing legislative and regulatory scrutiny, as well as complaints from the medical establishment.

Legislators want to protect patients and the broader health-care system, said Georgia Senator Don Thomas, a medical doctor who chairs the Health and Human Services Committee. “Obviously the reason the drug stores want them there is so that they’ll write a lot of prescriptions for expensive medication and they’ll be filled right there in that drug store,” he said. “We’re concerned about the monopoly these stores have.”

Thomas sponsored a bill (SB 603) that would grant prescription-writing privileges to APRNs – but it also would prohibit nurses from writing prescriptions at mini-clinics that are located inside retail establishments that also house a pharmacy. The bill was passed by the Georgia Senate.

The Georgia House passed a similar bill (HB 395) that also would grant prescription-writing privileges to APRNs. It does not contain the prohibition on APRN practices within retail establishments.

As SHN went to press, the two measures were in a conference committee. If the conference committee adopts the Senate version and the measure is signed into law, it could significantly curtail the spread of mini-clinics such as MinuteClinic. If either measure is passed, Georgia will join the other 49 states in having granted prescription-writing privileges to APRNs.

Some states regulate mini-clinics by requiring physician ownership. In Indiana, MinuteClinic acts as a kind of franchisor, selling outlets to local doctors.

Woodburn is adamant that MinuteClinics are not replacing primary-care physician practices. But the clinics appear to have gained a following among the insured as well as the uninsured. About 80 percent of MinuteClinic’s customers have commercial insurance, Woodburn noted. He added that the time savings and reasonable prices have drawn “tremendous support from large, national employers,” many of whom recommend and reimburse MinuteClinic’s services. “We absolutely increase access to care,” he said. “Our prices are posted, they’re good prices, and we provide good-quality care.”

By Paul DeYoung, an intern with NCSL’s Forum for State Health Policy Leadership

CHILDHOOD OBESITY: STATES TACKLE A TOUGH ISSUE

Over the last few years, states have been enormously active in trying to prevent and reduce childhood obesity.

They’ve got enormous incentive to do so: over the past three decades, the share of children who are considered overweight or obese has doubled from 15 percent to nearly 30 percent today, according to a new childhood-obesity-focused issue of The Future of Children journal. Overweight kids are much more likely to develop type 2 diabetes (once known as adult-onset), hypertension and depression.

Obese children also are much more likely to become obese adults than are normal-weight children, and treating conditions related to obesity is costly. According to one study, in 1998 the United States spent between $51.5 billion and $78.5 billion on health-care services related to excess weight and obesity among adults. Medicare and Medicaid paid for roughly half those costs, which don’t include related expenses such as time lost from work.

The human costs are enormous, too. At a recent forum on childhood obesity, held by the Brookings Institution and Princeton University in Washington, D.C., Texas Sen. Leticia Van de Putte, a pharmacist by profession, said that every day, she sees parents who come in to fill prescriptions for vials of insulin and blood pressure medications for their children. The parents are “mortified” that they did not do more to prevent their child’s now serious health condition and would do anything to turn back the clock, she said. “It’s not a wake-up call; it’s a death sentence for these children.”

Texas Senator Leticia Van de Putte speaks at the forum.

At the same forum, Eric Bost, under secretary at the U.S. Department of Agriculture (USDA), noted that in 2005, 600 Texas children underwent amputations because of complications caused by type 2 diabetes.

States are taking a wide variety of approaches to the problem, such as mandating or recommending that the nutritional value of the food served and sold to children at schools be improved. In 2005 alone:

Seventeen states enacted legislation to improve the nutritional quality of school foods and beverages;
Hawaii, Massachusetts, Missouri, New Jersey and Pennsylvania considered (and Texas enacted) legislation to help prevent, diagnose or treat type 2 diabetes in school children (California and Illinois had previously enacted laws requiring non-invasive screening for type 2 diabetes);
Twenty-two states either considered or enacted bills requiring that school curriculums include nutrition education; and
At least 21 states enacted legislation or passed resolutions relating to the physical activity or physical education in schools. Forty-eight states continue to require physical education in schools, but the scope of the requirement varies. For more on state legislative activities And policy options pertaining to childhood obesity, go to this NCSL Web site.

Reporting to Parents

One of the techniques being considered by states is to mandate that schools measure a child’s body mass index (BMI) and inform parents confidentially of that number. The BMI measures a child’s risk of being overweight or obese by calculating body fat based on weight and height. In 2003, Arkansas became the first state to mandate that schools inform parents about their child’s BMI. In 2005, 12 states considered BMI legislation; three states – Missouri, Tennessee and West Virginia – enacted legislation.

Getting such legislation passed may be difficult, Van de Putte said. In 2005, she sponsored a bill that would have required schools to send annually send parents information about their child’s fitness, including whether the child was overweight or obese. But, the senator noted, the proposal was met with fierce opposition. Parents were irate that the Legislature would consider informing them as to whether their child was overweight – as if the parents didn’t know.

In fact, research shows that one of the biggest hurdles in reducing childhood obesity is that parents tend to recognize obesity in other parents’ children – but not in their own.

The senator switched tactics. Going through the Senate Education Committee instead of the Health and Human Services Committee, she backed legislation that gives school districts the option of sending parents “fitness grams” about their children’s health. The grams, which are being used by 112 of Texas’ 1,037 school districts, inform parents about their child’s BMI, resistance strength and flexibility. Nurses perform the screening, and the cost to the schools is minimal: less than $200 per school, most of which goes to pay for a computer program.

One of the difficulties states face in their fight against childhood obesity is that federal food programs tend to be located in different “silos,” Van de Putte noted. The WIC program is in the health department, food stamps in the human services agency and children nutrition programs in education authorities.

To combat this fragmentation, NCSL launched a Hunger and Nutrition Partnership, sponsored by the UPS Foundation. The partnership helps legislators understand how they fit into this fragmented system and can bridge existing gaps. For more ways to approach childhood obesity, go to these NCSL Web sites on Hunger and Nutrition; Healthy Community Design; and Access to Healthy Food.

WINNING THE GOLD

States aren’t the only ones acting for children’s health.

In St. Tammany Parish, Louisiana, food service preparers decided that they wanted to become part of the nutrition education team – “not just little old ladies who served food,” said Sylvia Dunn, nutrition education supervisor of the Louisiana State Department of Education, said at the Brookings forum.

They started “tasting parties,” during which children could taste different foods and learn about nutrition, installed self-serve bars where children could select only as much food as they wanted, replaced cakes and cookies with fruit – “billed as nature’s candy” – and allowed no “ala carte” sales of products other than milk. The food service team also developed the award-winning “Go-Glow-Grow” program that educates children about which foods help you “go,” which ones help your skin “glow,” and which ones help you “grow.”

In 2005, one of the parish’s elementary schools received the USDA’s Healthier U.S. Challenge Gold Award, and the parish has received four USDA Best Practice Awards. “The next step is to get the high schools on board,” Dunn said.

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ARE MINI-CLINICS A GOOD THING? STATES INCREASE THEIR SCRUTINY

CHILDHOOD OBESITY: STATES TACKLE A TOUGH ISSUE

Reporting to Parents

© Copyright 2005, State Health Notes