Retail store NPs: good or bad idea?

[joy09]

I just read an article in about NPs running the urgent-type care in retail stores solo. What do you think? I worked in Urgent Care in a hospital satellite. I would not be interested in doing registration to discharge, lab work for health screening, physicals and medical billing (these were all specifically mentioned as well rounding the experience). Most of the promotion in the article was done by the marketing staffer. It may be a good one if it is NP owned and operated but it sounds like it is more profits for the retail drug stores and the hospital. Also, the article quoted the NP as "turning away patients who have chest pain or stroke symptoms" and sending them to the ER. Again, working in Urgent Care, we couldn't turn anyone away until they saw a practitioner. Is there is an obligation to see the "customer" through to the ambulance once they walk in and announce life threatening symptoms? Does anyone have any details? I am very curious and I don't have one close to me yet. What's the reality? Does anyone know what the salary range is for these positions? Finally, the article referred to a woman who couldn't wait 2 hours in an urgent care and was in and out in 15 minutes. Seems like this would be less likely as it catches on. It's too bad we can't just get an appointment in our own doctor's office in the first place.

[core0]

I think that working in this type of environment might be good for NPs who wish to work in a place with limited liability, set hours, good salary, etc. I do not see it as damaging to the image of nurse practitioners. There are PTs, SLPs, pharmacists and many other providers practicing in a wide variety of settings. For instance, some pharmacists are highly specialized transplant pharmacists in tertiary care hospitals, while others work the night shift at Walgreens. Both play an important role in providing care to patients where they need it most, whether it be in the community or in a more complex setting.

I would question the limited liability part. I can't comment on NP liability but in the PA world the liability is actually considered fairly high. The most common insurer groups the risk into three tiers. Tier 1 is most PAs. Tier 2 is surgery, anesthesia, no delivery OB and EM 10 hours per week, and OB with delivery. The retail clinics are considered tier 2 (ie with risk on par with surgery). The representative that I spoke with said they consider them on par with urgent care which is also tier 2.

If you consider the elements that define liability the element that influences whether a provider gets sued or not is the relationship with the patient. Also depending on the state you can incur liability for the patient not following up on recommended tests. Overall you have a lot of elements that worsen liability including lack of relationship with the patient, limited medical history, lack of ancillary testing. All of the issues that make EM high risk with the addition of lack of ancillary testing.

Here is a nice article from AAFP on this:

http://www.aafp.org/fpm/20030300/29seve.html

Look at the lawsuit issues. Some such as OB issues are not germane but others such as missed fracture are more difficult to deal with in a retail setting. Also if you look at their three ways to avoid lawsuits, 2 of them are fairly difficult in a retail environment.

David Carpenter, PA-C

[n_g]

That's why these outlets try to practice CYA by limiting it to just 33 or so diagnoses and having people follow templates step-by-step. These templates have no doubt been reviewed by the company's doctors as another way of CYA.

[core0]

That's why these outlets try to practice CYA by limiting it to just 33 or so diagnoses and having people follow templates step-by-step. These templates have no doubt been reviewed by the company's doctors as another way of CYA.

Two problems here. Templates don't always represent the patient. What if the patient has a atypical presentation that exactly mimics an item that is on the template. This is why we practice a lot of defensive medicine and why a good clinician uses clinical guidelines along with their own clinical experience (in my opinion). Good clinicians do not use templates (in my opinion). I used templates as an Army medic. Knowing what I know now the Army gets away with it because they a) can't be sued, and b) have a young healthy population. This is not what you are necessarily seeing in a retail clinic.

The other problem is what if they don't follow up. What if you say, this is outside my practice parameters and you have to go to an ER. Are you going to call an ambulance for all of them? In a practice where I know my patients I call an ambulance if there is an doubt and allow them to go by car if I trust them. There is adequate case law about follow up tests and ER referrals where the provider took the hit when the patient didn't go. The same applies for referrals for chronic conditions or specialty referrals. Most primary care offices spend a fair amount of time and money certifying specialty referrals. I don't see a retail clinic doing this for their patients. Without precertification its pretty unlikely that the patient is going to get to a specialist if they need one.

I think that the liability by some providers is being underestimated. It sounds like some of the insurance companies are looking at this and right now putting the job in a medium risk category.

David Carpenter, PA-C

[n_g]

I'm sure that the retail chain emphasizes to NP's working there that "if you have the tiniest doubt, tell the patient to go see their doctor". It's preferable for the chain to treat patients who neatly fit the templates and send them on their way if they don't. I know if I were the manager of one these chains I would want to minimize my risks.