If Emergency Room Overuse is Really a Problem, Why Aren't MinuteClinics Being Allowed?

For a while now, I have been hearing that the inefficient delivery of routine healthcare, especially through the over-use of emergency rooms, is a primary source of America's runaway healthcare costs. If this is true, CVS’ proposal to place “MinuteClinics”, staffed by a nurse practitioner, in a number of their stores, should at least an incrementally improve the existing healthcare system. Felice J. Freyer of the Projo described “MinuteClinics” in a Projo article from last year…

Say you've got a sore throat and you've heard that strep is going around. You're really busy at the office and want a quick answer on your health.

Then imagine you could just stop at the drugstore, where within minutes a nurse practitioner could give you a strep test -- and, if it's positive, a prescription for antibiotics. Which you could then buy at the selfsame drugstore.

Such convenience has obvious appeal for consumers.

Of course with this being Rhode Island and “MinuteClinics” being different from the established way of doing business in the state, there is an organized movement afoot to stop them from ever beginning operation here.

Allen Dennison, chairman of the Urgent Access Committee of Rhode Island Primary Care, had an op-ed in Sunday’s Projo arguing that Rhode Islanders already have access to all the urgent healthcare services they need. If they want improved access and convenience, well, they’re wrong to…

As to the issue of consumer convenience, the concept of the Urgent Care Center first arose in Rhode Island in 1975. According to the Web site of the Urgent Care Association of Rhode Island (urgentcareri.com) there are 20 Urgent Care Centers in Rhode Island, at most a 15-minute drive from anywhere in the state. Also, around the state, there are five Walk In Clinics that offer similar if simpler facilities with extended hours for the working sick who can’t get an appointment with their primary-care practice.

Five clinics with “extended hours” for a state with a million people. How dare Rhode Islanders think they might need anything more!

The immediate question that arises from this is why anyone in any business should be allowed to shut down a competing practice because it might attract people through increased convenience and better access. The fact that CVS thinks there's a market for MinuteClinics in Rhode Island implies that people will choose a facility other than an emergency room for simple medical needs, when another choice is readily available. Maybe there are problems with opening a clinic inside of a drugstore (what's the plan, for instance, for dealing with someone who thinks they can get a prescription for OxyContin right away, and is disappointed to find out that they can't?), but if Dr. Dennison really wants to help doctors and patients, shouldn't he be looking for ways to improve access to existing non-ER facilities, rather than shutting down any new alternative facilities before they open?

Having said all this, in a precise economic sense, I'm still not sold on the idea that emergency room overuse is a true driver of rising healthcare costs. Dr. Dennison bolsters my skepticism, when he admits that Doctors over-charge for simple procedures in order to subsidize other parts of their practice...

To put it frankly, simple visits make us money. The work required by the time-consuming complex patient, on the other hand, is poorly reimbursed by Blue Cross, United Health Care and Medicare.

I suspect, as Megan McArdle has suggested, that hospitals do the same thing: over-charge patients with simple problems and lots of insurance in order to subsidize uninsured patients and more complex cases. If so, then emergency room usage isn't really raising the cost of healthcare, it's only raising its price -- for those who are actually paying for it. A more rational insurance system than exists now, one that allows more people to participate by offering a range health savings accounts plus high deductible plans, is the needed beginning to more fairly allocating the costs of healthcare to patients who seek treatment.

Anyway, if Rhode Island politics plays out as usual, expect the lobbyists on Dr. Dennison's side to win, MinuteClinics to be stopped from entering RI, prices to continue to be inflated, urgent care access outside of emergency rooms to continue to be limited, and maybe the MinuteClinic system to eventually open branches in Attleboro and Seekonk.