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Volume 27, Issue 473 |
August 7, 2006 |
Rachel Burton
They may be coming to a store near you—retail clinics that treat common ailments like sore throats and ear infections. Located in drugstores, grocery stores and “big box” super-centers such as Wal-Mart, the clinics are spreading like celebrity gossip across the country—and some lawmakers are considering whether legislation is needed. In 2006, Florida enacted legislation that could slow their growth; Missouri debated a similar bill. Georgia considered legislation that would have made the clinics illegal.
Operated by outside companies to comply with some states’ physician-ownership requirements, the clinics are expected to increase in number from about 90 today to several thousand by the end of 2007, according to an industry survey released in July by the California HealthCare Foundation.
The clinics offer consumers convenience, as they are open on evenings and weekends, provide 15-minute consultations and display prices prominently (ranging from about $40 to $70 for most visits, or a co-pay if the clinic accepts insurance, as 40 percent now do). Patients with complex problems are referred to doctors in the community.
Usually staffed by nurse practitioners (NPs) or physician assistants, the clinics are licensed as physician practices in many states, and so they are regulated by state medical boards. For many lawmakers, the main issue surrounding the clinics is the quality of care—specifically, whether to leave the degree of physician oversight of clinic personnel to the medical boards, or to step in and legislate it.
Twenty-two states and the District of Columbia currently allow NPs to treat patients without physician involvement, while 28 require documented physician involvement (in the form of a doctor’s presence some or all of the time, availability for consultations by phone or written protocol agreements), according to the American College of Nurse Practitioners. States also vary in whether they require supervising physicians to reside in-state or not.
In 2006, three states considered laws that would affect retail clinics’ practice, according to Jan Towers, director of health policy for the American Academy of Nurse Practitioners. In Florida, where NPs must be supervised by physicians, Gov. Jeb Bush on June 20 signed legislation (HB 699) limiting the number of clinic sites that a primary-care physician may supervise to four. Specialists may supervise only two clinic sites.
“I was concerned about physicians taking on too many satellite offices that they didn’t have the capacity to adequately supervise,” explained Rep. Joe Negron, the bill’s sponsor. “In some cases, we had individuals being treated for an entire course of treatment and never seeing a doctor.” In the case of dermatology clinics, which Rep. Negron was particularly concerned about, patients may require treatment for potentially cancerous lesions. “At some point, they actually need to see a medical doctor,” he said. He hopes the law ultimately will “strike the delicate balance between patient access while also assuring quality care.”
Elsewhere, Missouri failed to pass a bill (SB 1124) that would have limited the number of physician assistants that a physician could supervise to three. Georgia failed to pass a bill (SB 603) that would have made retail clinics staffed by NPs illegal by banning NPs from practicing in retail locations that also house pharmacies.
Physician Shortage Could Boost Use
Some experts believe the retail clinics are catching on because of the shortage of family physicians. Within the next 15 to 20 years, the deficit is expected to reach as many as 200,000 physicians—20 percent of the needed workforce, according to Dr. Richard Cooper, a professor of medicine at the University of Pennsylvania. “Retail clinics may have happened anyway—there was a failed attempt to establish ‘store-front clinics’ in strip malls some years ago—but the success of the new retail clinics (now) is more likely because there's a doctor shortage,” he said.
“[The spread of retail clinics] will mean that [family physicians] will have to evaluate how convenient their practices are for patients, and will most likely need to make some changes to be more user-friendly,” said Dr. Larry Fields, president of the American Association of Family Physicians (AAFP).
Doctors have the potential to lose business to retail-based health care and have raised concerns about quality and continuity of care in the retail clinics. Still, physician groups have not come out against the clinics, but are instead issuing guidelines (AAFP guidelines / AMA guidelines) that they hope the clinics will follow.
Contact NCSL’s Tara Lubin for state-by-state information on NP regulations or other health-care workforce issues.
Matthew Gever
On July 1, Idaho began to enroll people in its newly redesigned Medicaid program, using the flexibility made possible by the Deficit Reduction Act of 2005 (DRA). The redesign of the program was authorized in March, when Gov. Dirk Kempthorne signed HB 776, adding the Gem State to the ranks of West Virginia and Kentucky.
Like those two states, Idaho plans to create new benefit packages tailored to specific populations, a change previously allowed only under a waiver from federal rules. Idaho’s plan will divide Medicaid enrollees into three groups, offering a different benefit package for each.
Intended to promote long-term health by emphasizing preventive care, the reforms will enable the state to “treat an individual as an individual, and not as a lump sum group,” said Sen. Joyce Broadsword.
Healthy, low-income children and working-age adults are eligible for the Benchmark Basic Plan, which will cover most of the traditional Medicaid benefits. Not covered will be long-term care, organ transplants and intensive mental health treatment. Children under 19, however, will still receive these benefits under the Early, Periodic Screening, Diagnostic and Treatment program. Families earning more than 133 percent of the federal poverty level will have to pay $10 monthly premiums.
Individuals with disabilities and more complex health needs may qualify for the Medicaid Enhanced Plan. This program will cover all of Medicaid’s traditional services, including long-term and institutional care. The Enhanced Plan also provides greater incentives to find a job. Previously, employment could lead to a loss of benefits for those with disabilities.
The final category is the Coordinated Benchmark Plan, which will not go into effect until Oct. 1. This plan targets dual eligibles, and will provide financing for long-term care and all other traditional Medicaid services. Enrollees will be required to sign up for Medicare Part D.
The state plans to phase in further reforms, including co-pays for inappropriate use of emergency departments and ambulances, and for missed appointments; personal health accounts, with credits for healthy behaviors such as losing weight; expansion of the premium assistance program; grants to enable primary-care providers to establish electronic health records; and support for caregivers. “As changes are made, we have to find changes that are humane and fair…and not an excuse to slash programs,” added Rep. Elmer Martinez.
Lawmakers don’t expect immediate savings, but over the long run they hope to slow the growth of Medicaid spending. Left unchecked, Medicaid spending in Idaho—which now consumes 15 percent of the state budget—could surpass spending on public schools by 2021, according to the Governor’s office. “It’s going to take awhile to see if it achieves the (hoped-for) savings and efficiencies…but I’m optimistic,” said Rep. Bob Ring.
Idaho began planning to modernize Medicaid in mid-2005, and submitted an application for a Section 1115 waiver last spring. Because the DRA had been enacted, however, the Centers for Medicare & Medicaid Services recommended that the state simply amend its state plan instead of going through the waiver process. The state complied.
(West Virginia has delayed implementation of its Medicaid reforms, which were scheduled to commence in July. The reforms were authorized by a state plan amendment as allowed under the DRA, but were not given the nod from the Legislature, and lawmakers want to review them. For more information on West Virginia’s plan, see SHN, Vol. 27, Issue 469, June 12, 2006)
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