After state regulators cleared the way yesterday for store-based medical clinics,
The vote by the Public Health Council marked a signal and controversial shift in the healthcare landscape: The CVS MinuteClinics will be for-profit operations staffed by nurse practitioners only, in a state where medical treatment historically has been the province of not-for-profit hospitals and physicians working in mostly large group practices. Other pharmacy chains and retail stores, as well as hospitals and community health centers, could also open limited service clinics.
The members of the council, which sets policy for the Department of Public Health, anguished over their decision, torn by a desire to improve patients' access to routine care - the clinics will be open nights and weekends - but not to substitute episodic treatment in a store for an ongoing relationship with a doctor.
Still, the eight members of the panel who voted in favor of the clinics and even the five who abstained said this was the right time to expand access. There is a shortage of primary-care physicians, leading some patients to turn up in hospital emergency rooms for routine care - and that was before nearly 300,000 previously uninsured Massachusetts residents gained coverage as part of the state's near-universal health insurance initiative, expected to spur even greater demand.
In approving the clinics, the council insisted on strict patient safety provisions and required that each clinic be individually licensed by state overseers.
Ronald Preston, a former top health official in Massachusetts, described the clinics as "an entirely reputable business."
"If they're well-run and they stay within certain parameters, they fill a need," said Preston, now a private healthcare consultant who is also on the faculty at the University of Massachusetts Medical School.
"My issue with them," he said of the clinics, "is what they say about the whole healthcare delivery system: The primary-care delivery system in this country is dying. The reason why these things have become important is because there's this big hole in the delivery system."
CVS, a national pharmacy chain based in Rhode Island, opened its first MinuteClinic nearly eight years ago in Minnesota's Twin Cities, and now operates 466 in-store clinics in 25 states.
The first facilities in Greater Boston should open by the start of flu season next fall, MinuteClinics chief executive officer Michael Howe said in an interview yesterday. Executives are still deciding which stores will get clinics, Howe said, but they plan to have 100 to 120 clinics in stores stretching from Cape Cod to the Berkshires within three to five years.
The type of clinic approved yesterday will treat minor problems such as sore throats, ear infections, and poison ivy, but not chronic diseases such as cancer or diabetes, nor serious emergencies. Nurse practitioners at MinuteClinics are trained to spot patients with more severe illnesses or needing specialized care and send them to a doctor or emergency room.
No appointments are made, and visits typically last 15 minutes. Treatment for common illnesses typically costs $59 or $69 at MinuteClinics in Connecticut. In Massachusetts, Howe said, he expects insurance companies to cover the visits as they do in other states.
"Being located in a CVS, the nice thing about it is if there's a wait time, they can go ahead and do some of their shopping and complete some of their other errands," Howe said.
CVS's pursuit of the Massachusetts market, first signaled to the state last May, triggered an extensive review by healthcare regulators, who focused on assuring that the in-store clinics would not sacrifice quality in the name of expediency. The regulations drafted are not limited to CVS; instead, the rules apply to any retail company, hospital, or community health center that wants to open a limited-service clinic outside traditional settings.
Public Health Council members had earlier expressed a number of concerns, seeking guarantees that health professionals in the facilities would be qualified, for example, to treat children, and that nurse practitioners would have prompt access by telephone to physicians who are under contract to provide consultations.
The panel's members also wanted hand sanitizer available at the clinics and restrooms adjacent to the facilities so that patients don't have to walk across the store. All these provisions were incorporated in the regulation adopted yesterday.
At the council's meeting yesterday, some members, especially physicians who sit on the board, called for even tighter regulation of the clinics, leading other members to question whether the rules would become too burdensome.
"This is a new model; how much of this is necessary for this type of thing to operate?" said board member Harold Cox, an associate dean at the Boston University School of Public Health. "I want to make sure we're not doing something so complicated and onerous" that potential operators of limited-service clinics would be deterred from opening.
Dr. Michael Wong, an infectious disease specialist at Beth Israel Deaconess Medical Center who sits on the council, said he abstained from voting because while he endorsed the goal of expanding access, he would have preferred if the initial push had emerged from a health advocacy group.
"What worries me," he said, "is this is a for-profit organization coming in saying we want to set up these limited-service clinics in a retail facility."
Critics said the facilities would further fragment care.
Debra A. Geihsler, chief executive of the major group practices Atrius Health and Harvard Vanguard Medical Associates, said in an interview that she was dismayed by the decision to allow the clinics, although she acknowledged that "our patients are clearly expressing they are looking for quicker, and more, access, and that's what we're hearing loud and clear.
"But I am disappointed because high-quality, coordinated care is through the physician's office and that's better care and ultimately more cost-effectivethan in-store clinics, she said.
Howe, the MinuteClinics executive, said fragmentation of care predated in-store clinics. He promised that the clinics will actually "promote continuity of care" by sharing records of visits with patients' primary care physicians.
Representatives of other retail outlets with in-store clinics elsewhere said yesterday they have no immediate plans to move into Massachusetts.
Stephen Smith can be reached at firstname.lastname@example.org.