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Competitive HIT Issues Emerging by Default
[By Dr. David Edward Marcinko; MBA CMP™]
Publisher-in-Chief
Health entities of the Physician Practice Management Corporation [PPMC] era might be termed the originators of corporate medicine despite contentious legal policies and prohibitions. Since then, there have been other modifications to the business model, as those PPMCs left for dead by the year 1999 made a modest comeback thru 2003-04.
They did so by evolving from first generation multi-specialty national concerns, to second generation regional single specialty groups, to third generation regional concerns, and finally to fourth generation Internet enabled service companies, providing both business-to-business [B2B] solutions to affiliated medical practices, as well as business-to-consumer [B2C] health solutions to plan members.
Prior machinations were ambulatory surgery centers [ASCs] and out-patient treatment centers [OPTCs], while the newer twists are specialty owned hospitals.
Social Transformation of Medicine
And so, I believe that Paul Starr, author of the Pulitzer-prize-winning book “The Social Transformation of American Medicine” who first predicted healthcare corporatization was more correct, than not.
But, his vision was early in the evolutionary game. And, while corporate medicine seems inevitable in 2008 and beyond, the marketplace is still struggling for the correct business mode. It needs something that bridges the gap between medical professionalism and ROI.
The Balancing Act
In-other-words, a better balancing act is needed. Slowly, like capitalism itself, the pendulum will swing back and forth between paucity and excess, until a point is reached where all concerned are moderately satisfied, ethical, and marginally profitable; while delivering quality medical care that is more needed by the citizenry-many [i.e., more pediatricians, internists, primary care doctors, OB-GYNs, nurse-practitioners, PAs, etc]; than the vital-few [neuro-surgeons, pediatric endocrinologists, super specialists, etc].
Maybe this “missing balance link” is the retail medical clinic model.
Retail Clinics
As most doctors, payers, patients and consumers are aware, the retail quick-service medical care concept has found a familiar place in national chains such as Target, Wal-Mart and CVS, where pharmacies and patients already exist, and space is inexpensive and abundant.
These clinics are typically staffed by nurse practitioners and offer a limited menu of walk-in medical services with insurance co-payments between $10 and $30. And, unlike some physician practices, private pay patients are welcomed with fees ranging from $55 to $85 cash in many parts of the country! Prescription drugs are nearby at robust generic discounts, or even for free in some cases. Office hours are extended, and convenience reigns.
HIT Issues by Default?
Ironically, as one positive side-effect of this innovative next-gen corporate practice model, may be the goading of late adopting, tight-fisted and/or refusing MD-niks to enter into the modern health-information-technology [HIT] age.
Thus, one way to get margin compressed private medical practices up and running with electronic medical records [EMRs] may be these same retail clinics.
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Projected Growth of the Retail Industry
Today, more than 800 retail clinics are open for business, and analysts predict that 85 percent of the U.S. population will have a clinic within five miles of home in five years. And, the number of retail health clinics is expected to multiply in 2009; as recently reported by the Washington Times.
Illustration
Now, ponder the current state of affairs where a retail clinic [say Walgreen’s, etc] treats a vacationing patient for $65; who then receives the medical-record instantly on a flash-drive or securely uploaded to some virtual storage facility?
Just how will that patient’s premium priced private practitioner back-home explain his/her lack of EMR technology, and ages-old anchor to the hand-written paper-based medical records of yore?
Can you say Dossia.org, HealthVault.com, etc?
Competitive Assessment
The ideological leap from technical buffoonery – to clinical distrust – will not be great in the minds of the modern, intelligent, educated and insightful patients that we all crave.
Assessment
Of course, one wonders how long will it take for EMRs to become a strategic competitive advantage for early adopting physicians. Will late adopters even survive as EMTs become main-stream?
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OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:
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- ADVISORS: www.CertifiedMedicalPlanner.org
- FINANCE: Financial Planning for Physicians and Advisors
- INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
- Dictionary of Health Economics and Finance
- Dictionary of Health Information Technology and Security
- Dictionary of Health Insurance and Managed Care
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Filed under: Information Technology | Tagged: CVs, Paul Starr, retail medical clinics |
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Rite Aid Enters the Retail Clinic Fray
Did you know that the Rite Aid Corporation has formed an agreement that will create walk-in health clinics inside select Rite Aid stores?
According to the Central Penn Business Journal, April 8, 2008, the clinics will open this summer at four locations in the Baltimore-Washington metropolitan areas. They will be staffed by physicians and provide wellness screenings and vaccinations, treatment for ailments such as strep throat and the flu, as well as minor injuries including cuts, sprains and minor fractures.
The agreement is among Rite Aid, Maryland-based MedStar Health and Consumer Health Services Inc., a manager of on-site physician-staffed health clinics. The physicians at the clinics will be credentialed by, and have admitting privileges to, MedStar Health’s hospitals.
Any other comments on this emerging, and growing trend?
Ann
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Expanded Duty Dentistry Clinics at the Retail Mall
Are you ready to see what dentistry might look like in a few years when almost-dentists start graduating with 2-year degrees from stimulus-funded almost-dental schools?
According to an MBA named Mary Kate Scott, retail dental centers staffed by expanded duty registered hygienists and others can save money by first diagnosing and then treating only the easy problems for the underserved as well as provide cosmetic dental services including orthodontics (Invisalign) “depending on demand.”
As you read some of the excerpts I (typed and) posted from “Retail Dental Clinics: A Viable Model for the Underserved?” let me ask you this: How would you like to have to play nice with “registered hygienists” and others working in a 500 square feet franchise discount dentistry outlet in the mall – just for the referrals the future dental practice will need in order to stay in business? Oh yeah, if dentists want to be part of the market, they will have to adopt paperless practices or they probably won’t get referrals. I don’t’ think MBAs like Ms. Scott realizes that x-rays can be shared in other ways than over the Internet.
As you will see, her model leans heavily on HIT solutions. What can possibly go wrong with that plan?
Please take a look at what dental care will look like without input from dentists who actually treat patients. Where are you, Dr. Ron Tankersley, President of the ADA? How come throughout your entire term you left it to me to inform ADA members of the bad news about eDRs? Why are you such a shy man?
My occasional comments appear in [brackets]
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Click to access RetailDentalClinics.pdf
Retail Dental Clinics: A Viable Model for the Underserved?
November 2009
[Prepared for California HealthCare Foundation by Mary Kate Scott, MBA]
About the Author
Mary Kate Scott is the principal at Scott& Company, Inc., a consulting firm that specializes in health care strategy.
Retail dental clinics could increase access to services for underserved populations, including the insured and uninsured, people with low to moderate incomes, and those who live in areas where there are few dentists. In this conceptual model, appropriately trained oral health practitioners would deliver a limited scope of services – prevention and/or treatment, depending on the practitioners’ training – in a small, in-store environment.
The concept introduces innovations into service delivery, business and operating practices, and patient care. Compared with traditional dental practices, it is a more streamlined, leaner, lower-cost business model in which walk-in or scheduled patients would receive moderately priced services during expanded hours. These innovations could create a more convenient, affordable, and patient-friendly option for basic dental care.
Preliminary explorations suggest that retail dental clinics would be viable in California and elsewhere if registered dental hygienists could legally provide routine care, as they can in some states, without a dentist present. Additional staff in this model might include new types of mid-level professionals, such as advanced dental hygiene practitioners and dental therapists. The model seems promising in the current economic climate: Clinics’ costs would be inline with revenues, retailers are interested in leasing space to them, and many consumers express interest in the concept. However, it is unclear if retail dental clinics would substantially improve access to services and the oral health of the underserved, since the model could evolve in various directions.
Scope of Services
The types of retail dental services at clinics would depend on practitioners’ scope of practice, patients’ oral care needs, and a combination of consumer demand and logistical or business constraints. At a minimum, clinics would have to offer essential diagnostic and preventive care, including screenings for schoolchildren, oral exams, x-rays, cleaning, polishing, fluoride varnish, and sealants. A clinic could expand its services to include teeth whitening or straightening if there were sufficient demand. For economic reasons, a mid-level oral health professional, such as a registered dental hygienist, would have to provide all of the services, excluding more complex procedures that only dentists can legally perform, such as extractions, amalgams, and complex restorative work. Mid-level scope of practice in most states does not include diagnosis, exams, and sealants, but this could change as laws evolve or new workforce models emerge.
A core service would be referrals to dentists for further treatment if necessary. Retail dental clinics would not become “dental homes” and replace dentists. Rather, their services would complement those of dentists and help patients establish a dental home, thus ensuring they receive more complex treatment if and when they need it. Importantly, all providers – clinics, hygienists, and dentists – must educate patients about, and motivate them to maintain, oral health.
Findings from two of three consumer surveys for this report suggest that retail dental clinics could complement dental homes. Of respondents who expressed interest in using such clinics, the vast majority agreed or strongly agreed with these statements:
1. “I like that the results of the exam and x-rays can be sent to my dentist” (87 percent).
[As if eDRs are the only way to accomplish this]
2. “The option to send a copy of my visit record to a dental home is important to me” (84 percent).
[This is a duplicate question for number 1. Who knows why there is a difference of 3%]
3. “The option to get a referral to a dentist I can afford is important to me” (83 percent).
[That sounds like a sales promise that has no possible provision for being delivered. I wonder if the California HealthCare Foundation officials bought it.]
Depending on clinicians’ scope of practice, services they might provide include adult and/or pediatric exams, x-ray images, adult and/or pediatric cleaning, fluoride application, sealants (mostly pediatric), and referrals to dentists for further treatment or to establish a dental home.
[How does one establish a “dental home” by getting the easy stuff done by a hygienist in the mall and the harder stuff done by a real dentist? Ms. Scott isn’t the first to use “dental home” as a buzzword. BCBSTX shops the phrase in a strategic, bastardized manner as well.]
Cleaning
Teeth cleaning can also be straightforward or complex and more time-consuming. The three levels of cleaning are basic (hand scaling), medium (ultrasonic and hand scaling) and high (ultrasonic scaling, hand scaling, and polish). The level of complexity is related to the amount and type of work performed and the patient’s overall oral health.
[I’ll be disappointed if at least one hygienist doesn’t find problems with Ms. Scott’s “levels of cleaning.”]
X-Ray Images
X-ray exams, an essential diagnostic tool, would be a key service at retail dental clinics. Digital x-ray images, which are captured by sensors rather than photographic film, can be delivered to a patient’s dental home easily and cost-effectively, assuming the dentist has the necessary electronic communication technology. Given the small footprint of a typical retail clinic (200 to 500 square feet), it would not be feasible or cost-effective to install traditional x-ray technology. (Such technology necessitates lead-lined walls, and retailers would likely reject it due to safety concerns.) Many states, including California, require dentists to submit x-ray images with reimbursement claims.
Integrating with a Dental Home
Many elements of the retail dental clinic model are dictated by space constraints and the need to integrate with patients’ dental homes. Electronic dental records and digital x-ray technology would better enable clinics to streamline transfers of patient information to dental homes. Digital intraoral cameras can greatly facilitate such transfers. They yield high-quality images that can be sent to a dentist’s office along with x-ray images and the hygienist’s findings, and would reduce the time it takes a dentist to examine a patient who has already been seen at a retail clinic.
[Does that sound reasonable to you?]
Personal Dental Records
Consumers could populate and manage their own personalized dental records if retail clinics were to share the digital information with them, perhaps for use in publicly available personal health record software available from Google or Microsoft. This would help patients stay abreast of their routine and preventive dental care.
[Computers will never solve the problem of motivating patients to brush their teeth and see the dentist regularly. That is pure fantasy and it scares me that a Foundation of any kind would pay attention to this rubbish.]
The Business Model
To better assess feasibility, the author constructed a hypothetical retail dental clinic operating at full capacity. The clinic would occupy 500 square feet in a retail outlet; employ an unspecified number of registered dental hygienists; use standard dental equipment, including digital x-ray and an electronic dental record; be open from 8 a.m. to 8 p.m. on weekdays and for 12 hours on weekends; and engage in limited marketing.
Building out and equipping the clinic would cost about $220,000, including plumbing. Fixed operating costs – labor and rent – and variable operating expenses would be approximately $195,000 and $48,000 a year, respectively. About three-quarters of expenses would be for dental hygienists to staff the clinic.
[From those figures, I assume Ms. Scott means that two (?) hygienist would make about $30,000 each out of a 500 square foot office.]
Early proponents of retail dental clinics thought the cost structure might be very similar to that of retail health care clinics. However, dental supplies cost more than medical supplies do, and capital expenses, such as those for digital x-ray equipment and dental chairs, are higher. In addition, hourly prices for dental services are lower than prices for medical services, which means lower hourly revenues.
[“digital x-rays and chairs.” I understand her fascination with digital x-rays because if the x-rays are digital because as the MBA says, the office walls don’t have to be lined with lead and there isn’t the “safety” issue that worries landlords. If you recall, it was when she noted that digital x-rays don’t leave a large “footprint” compared to conventional x-rays. However, why she thought it was important to mention “chairs” I don’t know.]
Clinic Size and Configuration
A retailer’s available space would dictate a dental clinic’s size in most cases. At mass merchandise locations, health care clinics are typically about 500 square feet and often located at the front of the store. Clinics in drugstores and elsewhere are much smaller – about 200 square feet. Retailers would require that dental clinics retrofit and occupy all of the space they lease, with a three-room configuration most likely. Clinics would have to accommodate both adults and children, although booster seats enable children to use the adult chairs. In-store construction can be challenging, given the small space, after-hours work, and the need to complete construction quickly and without disrupting the pleasant shopping atmosphere.
[Booster seats? How does a paper concerning retail dental clinics become distilled down to a discussion about booster seats?]
Services Beyond Diagnostic and Preventive Care
A clinic could extend its service mix to include optional services, depending on the potential patient and payer mixes, demand, and management prerogatives. Cosmetic dentistry, in particular, could increase revenues. Such services might include a 15-minute or 90-minute whitening and a 15-minute bleaching, and/or orthodontic teeth straightening, any of which professionals other than dentists may perform. Among the financial considerations are additional capital costs for equipment and training, and additional operating costs for marketing, ongoing training, and supplies.
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I think the fact that Mary Kate Scott, M.B.A. went into far more detail discussing cosmetic procedures, digital x-rays and booster seats than the kinds of care poor people really need reveals that she is just another clueless stakeholder. The most accurate thing she said was: “However, it is unclear if retail dental clinics would substantially improve access to services and the oral health of the underserved, since the model could evolve in various directions.”
No kidding. It already has.
D. Kellus Pruitt; DDS
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Large Doctor’s Offices Are Paid $14/Visit More Than Small Offices
Health Affairs recently published a study on reimbursement differences between small and large insurers and doctor’s offices. Here are some key findings from the report:
• Small insurers (5%- market share) are billed $86 for a routine doctor’s office visit.
• Medium insurers are billed $70 for a routine doctor’s office visit.
• Large insurers (15%+ market share) are billed $68 for a routine visit.
• Small doctor’s offices are paid $72 average for a routine visit.
• Medium doctor’s offices are paid $77 average for a routine visit.
• Large doctor’s offices are paid $86 average for a routine visit.
Source: The Washington Post, January 9, 2017
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