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Are we ready for retail healthcare?

I’ll be the first to admit, I’m a huge fan of retail healthcare. I want nothing more than to see consumers rip control of their health out of the hands of an industry that is both patronizing and self-serving. The truth, however, is that for every American who is both motivated and capable of assuming the responsibility for their own health, there are fifty others who are not. It’s a strange dichotomy.

In case you haven’t noticed, the consumerization skirmishes are getting louder and closer. At Healthdatapalooza (HDP), a panel discussion on the role of retailers in healthcare was co-opted by a few vocal providers who challenged retailers’ inherent conflicts of interest:

“Retail clinics over prescribe antibiotics.” (False - Research from Rand shows that retail clinics have very similar prescribing patterns to primary care, urgent care and emergency departments. In fact, separate research by Johns Hopkins shows that ALL clinicians prescribe more antibiotics in wealthier communities, presumably in response to competitive pressures.)

“Retail clinics don’t provide the same quality of care.” (False - While retail clinics do not currently have the same quality reporting requirements as other providers, research indicates that retail clinics perform as well if not better than other care settings on quality indicators for three common conditions - otitis media, pharyngitis, and urinary tract infections.)

“Can an organization that sells care also sell harm, such as cigarettes?” (Good question - CVS made a splash last year with its decision to stop selling tobacco products, and forego $2b in revenue in the process. But where does a retail store draw the line? What about candy and soda? Is it enough to sell the vice and then offer counseling services to those with addiction? Also, why not turn that question back around to the provider community? How many unnecessary services and procedures are performed every year based on the counsel of doctors, whose outcome at best is unnecessary expenditure and at worst is injury or death?)

“Is it a conflict of interest for a pharmacy clinic to prescribe a medication and then turn around and fill it?” (This is my favorite question. This is no more a conflict of interest than health system-based physicians referring patients to other system-based physicians. And how do health systems justify such closed-looped “self-referrals” - better coordination of care. The exact same thing can be shown for clinics that both prescribe and fill scripts - higher medication adherence. The central argument should really be based on: are the clinicians behaving professionally and ethically; and, are there firewalls to prevent the financial incentivization of inappropriate behavior? I would expect the answers to be yes for all clinicians regardless of where they work or who employs them.)

And the debates are not restricted to retail clinics. What about telemedicine? In a maneouvre reminiscent of Sherman’s March, Teledoc seems poised to single-handedly oust, state by state, restrictive legislation that currently limits broader adoption of virtual consultations and visits.

Let’s not forget about the complete overhaul of the lab market. If Theranos can back-up Elizabeth Holmes’ claims, then a good segment of the population may soon be paying out-of-pocket for regular tests, purchased at their local Walgreens. A single drop of blood could well reduce the entire wearables industry to a plaything. And, the mere fact that LabCorp is racing into the direct-to-consumer space suggests that Elizabeth might have more up her sleeve than hyperbole.

These are great times, indeed, for consumer advocates. Yet, I have to wonder: are we really ready for this? Brad Fluegel from Walgreens made a comment near the beginning of the HDP panel discussion that really stuck with me. Since I didn’t record the event, I won’t try to quote him verbatim. He said something to the effect that retail clinics, like Walgreens, are in a great position to provide care to their customers because they understand them. They treat them like customers, which means listening to their needs, and not telling them what to do.

Brad, I apologize in advance if this in any way misrepresents what you said. It’s what I took home with me, and remains in my mind after unpacking. I don’t think there is anything wrong with this. In fact, I think in many ways it is a very true statement and really hits on why I am such a huge fan of consumerization. People want to be treated with respect, and the healthcare establishment seldom does that.

Yet, I have personal experience starting a primary care medical practice and building it from scratch with my now ex-wife, a family medicine doc. Notwithstanding our own differences, I think she is a great physician. She’s as stubborn as they come, and probably has some mild form of Asperger’s. My daughters compare her to Dr. Temperance Brennan on the TV show Bones. She’s precise and clinical, but not always entirely attuned to the emotions and feelings of others. For some patients (and people), this is pretty off-putting. Nevertheless, she has a legion of devoted patients who adore her. I suspect that if you were to poll them, they would confirm that the one thing they most like about her, other than her competence, is her honesty.

She tells people what they need to hear, no matter how upsetting it might be. When you consider that nearly all of the major diseases and chronic illnesses we face today are directly attributable to poor lifestyle choices, who is going to hold people accountable in a consumerized world? Their pocketbooks? Maybe.

A recent report from the Hastings Center, a nonpartisan research institute dedicated to bioethics, suggests that the patient-satisfaction survey currently used by Medicare to assess healthcare providers is seriously flawed. According to the report, “good ratings depend more on manipulable patient perceptions than on good medicine.” It further suggests that, in an effort to increase patient satisfaction numbers, clinicians are under increasing pressure to give patients what they want, which may include inappropriate and unnecessary tests and procedures.

If I didn’t know better, I would be tempted to cast aside these claims as predictable push-back from an industry under fire. However, even as a committed consumer advocate, I have to take pause: where do we draw the line to separate self-determinism from self-destruction? And, how do we make clinicians understand that our experiences as customers should simultaneously and paradoxically mean everything and nothing?

What do you think? Are we ready?