Time for Boston to open up to limited service clinics

As a little girl I have a dim memory of my mother taking me to a medical “dispensary” in what was then not-very-trendy East Boston. I remember it being really convenient; it was just down the street from where we lived, had short wait times, and a nominal cost, if any at all. This was during a time when physicians made home visits. I guess my mother couldn’t reach our family doctor, so off to the dispensary we went.

Medical dispensaries—we might call them “clinics” —were quite common in Boston beginning in the early 1800s. (That is not when I went!) Most were operated as charities for people who could not afford private physicians or were not sick enough for hospital facilities. In addition, these clinics served as training grounds for medical students and physicians. Hospitals, such as Mount Sinai, predecessor to Beth Israel, operated a number of “storefronts” in areas like Boston’s old West End. Over time, these neighborhood facilities were absorbed into the sponsoring institutions and eventually ceased to operate as a community-based venue for general medical needs.[1]

Fast forward a couple hundred years to 2000 and the idea of a convenient, neighborhood walk-in clinic to serve nonemergency, minor acute and routine healthcare services resurfaced in the Minneapolis-St. Paul area. These were called QuickMedx centers and the first one opened in a supermarket. At the time they treated several common medical conditions on a cash pay basis only and were more affordable than emergency rooms or urgent care centers.

In 2002, QuickMedx became MinuteClinic, and by 2005 an expanded MinuteClinic began its relationship with CVS Corporation. Presently, there are 1,100 MinuteClinic locations in 33 states and the District of Columbia.[2]  Services have expanded to include almost 80 minor illnesses and injuries, physicals, wellness, screenings, vaccinations, chronic disease monitoring and more.[3]

The model is simple. Patients sign up at kiosks and are taken in order. Prices and procedures are prominently posted at the site and online. There are also written brochures available listing the conditions that are treated at the clinic. Most clinics are open 24 hours a day, seven days a week, and when a clinic is closed for an afternoon or a few hours, a sign directs patients to the next nearest location. The clinic is staffed by a nurse practitioner who has authority to write prescriptions. CVS clinics cannot refer patients to the pharmacy to fill scripts.

Despite the fact that neighborhood clinics or dispensaries have deep historic roots in the City of Boston, and although there are 56 such clinics throughout Massachusetts, there are no CVS MinuteClinics or anything similar in Boston.[4]  So, how did this come to be?

In 2007, when CVS tried to enter the Massachusetts market with its MinuteClinic concept, it made a few material blunders. First, at the time it offered only a limited number of medical services, not the more complete array it does today, and it sought a waiver from state health authorities not to have to comply with existing regulations covering full-service medical walk-in clinics. Naturally, the request was denied, as anyone who knows anything about the dynamics of the Massachusetts healthcare market could have predicted. In a short time, however, the Massachusetts Department of Public Health established a regulatory framework for so-called “limited service clinics,” and cleared the way for CVS and others to enter the Massachusetts marketplace and install MinuteClinics in its pharmacies.[5]

During those early days, there was fierce opposition from many entrenched providers, such as the Massachusetts Medical Society (MMS), which passed a resolution at its 2008 annual meeting calling on insurance companies not to permit MinuteClinics to charge co-pays lower than those for physician visits.[6]  It’s hard to imagine this was for the benefit of consumers.

There was also opposition from the administration of Boston’s Mayor Tom Menino and local community health centers. They were concerned that these for-profit clinics, among other deficiencies, offered too limited an array of services, would steer patients away from coordinated primary care, result in fragmented health care delivery, deprive a patient’s primary care physician of necessary information, and be staffed by practitioners who were not medical doctors. At the time there was also opposition from the American Academy of Pediatrics and the American Academy of Family Physicians, which raised concerns about conflicts of interest, quality of care, and staffing by nurse practitioners rather than physicians.[7]

Practically all these complaints were addressed in regulations issued by the Massachusetts Department of Public Health and changes in the MinuteClinic healthcare service delivery system itself. Despite opposition from the City of Boston, the 2008 regulations were adopted. Among other requirements, limited service clinics have to:

• Develop clinical practice guidelines for their services and for determining when patients’ needs are beyond their scope of services
• Develop policies for referring patients and for obtaining outside physician consultations
• Maintain a roster of primary care physicians (PCPs) who are accepting new patients and willing to accept referrals
• Provide a copy of the medical record of each visit to the patient as soon as possible, and, with patient consent, to the patient’s primary care practitioner; not act as a primary care physician, and not treat children younger than 24 months old.

There are numerous other requirements in the DPH regulations that protect consumers and regulate the scope of practice of limited service clinics.[8] In addition, the clinics accept most insurance, Medicare, and Medicaid. In practical terms, any patient who does not have a PCP is given a referral and a list of PCPs willing to accept new patients.  In recent interviews with the nurse practitioner at a local MinuteClinic and an executive at CVS MinuteClinic headquarters, I was told that the clinic does not seek to replace the patients’ PCPs, but rather they consider themselves a “seeding source” for PCP groups in the neighborhood.[9]

At the time that CVS sought to enter the Massachusetts healthcare market with its MinuteClinic model, the average wait time for a new patient to see a family practice physician in the metropolitan Boston area was 63 days, and for most specialists it was almost 50 days.[10] Today, in a Merritt Hawkins & Associates 2017 survey, the wait time for a new patient to see a family practice physician in Boston was an astounding 109 days, while the wait time for a new patient to see a specialist in Boston was 52 days.[11]

There is some dispute in medical circles about the validity of these surveys.  For example, Ezekial Emanuel, MD., Ph.D., an architect of the Affordable Care Act, and his colleagues argue that the average wait time for a family doctor is about 20 days.[12] However, even a 20-day wait can seem an eternity if a patient is in distress, and under such circumstances patients may turn to hospital emergency rooms or urgent care centers.

The Boston area wait time issue will not be solved by limited service clinics, but they are one more option for consumers to turn to when a minor medical issue surfaces. Nationally, CVS MinuteClinics logged over 18 million visits as of 2015, but not one of those was in the City of Boston.[13]

In 2016, the City of Boston had an estimated population of about 670,000.[14]  In addition, we know that nearly 800,000 people commute in on a daily basis.[15]

It is also fair to point out that Boston has many neighborhoods with lower-income, minority, elderly and student populations where access to convenient and efficient care for non-emergency needs would be especially welcome. There are 25 CVS pharmacy stores in Boston. Any number of them could accommodate a limited service clinic within its walls. Given that the limited clinic model is not to take over the role of the PCP, Boston’s fine network of community health centers should not fear such services. In fact, some health centers have lengthened their hours to better accommodate their members. It is also possible that health centers and limited service clinics can work in partnership to bring greater access to Boston residents.

Although there are no limited service clinics in the city, there are at least four urgent care centers, all owned by major Boston hospitals. In addition, there are 8 other urgent care centers within 20 miles of Boston including nearby locations such as Cambridge, Somerville, and Chelsea. Urgent care sites are staffed by physicians and other health workers and offer patients with urgent medical issues—not emergencies—an alternative to doctors’ offices and emergency rooms where wait times can number in the hours.[16] Urgent care centers, because they are staffed by doctors, have x-ray machines and can draw blood, providing care that in many cases cannot be provided in a MinuteClinic.  While urgent care centers are not as expensive as emergency rooms, they cost more than limited service clinics. Ideally, urgent care centers would not overlap in the care provided by clinics.

In the years since the MinuteClinic concept came to Massachusetts a lot has changed in the way physicians and hospitals seek to provide care. Some physician groups hold office hours in the evening and weekends. Hospitals are partnering with urgent care centers. There is a move to go where consumers are, such as shopping malls and their vicinities. Even some major downtown hospitals are allowing patients to book ER appointments online.  Large community hospital walk-in clinics are expanding their hours to cover nights and weekends, mirroring a national trend. Elsewhere, supermarkets, and other large pharmacy and big box store chains are building clinics or partnering with established healthcare facilities.

Although some in organized medicine remain skeptical, there is some positive movement toward clinic acceptance. In 2014, the MMS reported that “one physician practice recently indicated that upon informally surveying patients, they found that their patients required access during nights and weekends.”[17] Although it is unfortunate that a survey had to be done to reveal that patients want convenience and easier access to healthcare, it is encouraging that the MMS urged its members to try and learn why their patients are using limited service clinics rather than the physician’s office.  Members were urged to extend office hours, offer walk-in hours and same day appointments. They were told to follow up with patients to see how to serve them better.[18]

In a 2014 blog, pediatrician Dr. Claire McCarthy said limited service clinics are not going away and the medical profession may be stuck in old habits. She pointed out that care has been delivered in a way that worked for the profession. But now, she says, consumers have a choice and the profession needs to think more about ways that work for consumers.[19] Unfortunately, in 2014, the American Academy of Pediatrics renewed its opposition to limited service clinics. But there are physicians like Dr. McCarthy who are focused on the changing needs of their patients.

The clinic movement has come a long way since 2007, when it first sought to enter the Bay State. To their credit, the Massachusetts Department of Public Health issued regulations that both protect the public and allow for increased competition. In 2012 MinuteClinics got an added boost from state government when new cost containment legislation, known as “Chapter 224,” expanded the definition of limited service clinics to include all services within the scope of practice for nurse practitioners.  This change included, in particular, prevention and wellness activities which nurse practitioners are especially trained to provide. Chapter 224 also encouraged these clinics to ensure that patients select a PCP, if they do not already have one.

In 2017, it seems like the time has come for Boston to revisit its opposition to limited service clinics. There are hundreds of thousands of residents and workers who do not have ready access to convenient, accessible, and transparent healthcare for many routine problems that may otherwise go unaddressed or be treated at greater expense.

As for that little girl from East Boston, I have frequented Minute Clinics—on weekends or in the evening—and the first question I was asked was the name of my PCP.  By the way, everything went fine.

[1] “Healthcare.” The West End Museum. http://thewestendmuseum.org/history-of-the-west-end/healthcare-history/.

[2] “CVS Health 2016 Annual Report.” CVS Health. Page 11. http://www.annualreports.com/HostedData/AnnualReports/PDF/NYSE_CVS_2016.PDF.

[3] “Price List.” CVS. http://www.cvs.com/minuteclinic/services/price-lists.

[4] “Clinic Locator: Massachusetts.” CVS. https://www.cvs.com/minuteclinic/clinics/Massachusetts.

[5] Limited Service Clinics. 105 CMR 140.000 et seq.

[6] Robeznieks, Andis. “MinuteClinic struggles in Mass., still not welcome in Boston.” Modern Healthcare. August 10, 2009. http://www.modernhealthcare.com/article/20090810/MODERNPHYSICIAN/308109995.

[7] Johnson, M. Alex. “Study: Retail health clinics as good as the doctor’s office.” NBC News. September 04, 2009. http://www.nbcnews.com/id/32681973/ns/health-health_care/t/study-retail-health-clinics-good-doctors-office/#.WV_L_4TythE.

[8] “New Massachusetts regulations pave the way for ‘limited service clinics’.” Ropes & Gray. February 14, 2008. https://www.ropesgray.com/newsroom/alerts/2008/02/new-massachusetts-regulations-pave-the-way-for-limited-service-clinics.aspx.

[9] In person interview conducted with Nurse Practitioner, local CVS MinuteClinic, June 2016, and telephone interview with high level CVS Executive, Woonsocket, RI, May 25, 2016.

[10] “2009 Survey of Physician Appointment Wait Times.” Merritt Hawkins & Associates. https://www.merritthawkins.com/pdf/mha2009waittimesurvey.pdf.

[11] Terry, Ken. “Wait Times for New-Patient Appointments Rise 30%.” MedScape. March 22, 2017. http://www.medscape.com/viewarticle/877616.

[12] Ibid.

[13] “History.” CVS. http://www.cvs.com/minuteclinic/visit/about-us/history.

[14] “Boston Population 2017.” World Population Review. http://worldpopulationreview.com/us-cities/boston-population/.

[15] Conti, Kathleen. “Boston commute is as congested as it was 10 years ago.” The Boston Globe, September 17, 2015. https://www.bostonglobe.com/metro/regionals/2015/09/17/zocommute/6oAfphVXJRcUJYM4RAFTWK/story.html.

[16] Dayal McCluskey, Priyanka, and Taryn Luna. “Walk-in clinics force big medicine to rethink.” The Boston Globe, August 08, 2015. https://www.bostonglobe.com/business/2015/08/07/walk-clinics-are-forcing-big-medicine-rethink-retail-health-care/DUdP4usrTuVA2AIiJJfUHJ/story.html.

[17] Goldsmith, Talia. “The Retail Clinic Movement: A Disruptive Threat or Opportunity for Physician Practices?” Massachusetts Medical Society. August 2014. http://www.massmed.org/News-and-Publications/Vital-Signs/The-Retail-Clinic-Movement–A-Disruptive-Threat-or-Opportunity-for-Physician-Practices-/#.WV_UW4TythE.

[18] Ibid.

[19] McCarthy, Claire. “Why doctors worry about Minute Clinics–and what they should learn from them.” Boston.com. February 24, 2014. http://archive.boston.com/lifestyle/health/mdmama/2014/02/why_doctors_worry_about_minute_clinics–and_what_they_should_learn_from_them.html.