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MSNBC:Minute Clinics Better Than MD Offices

Discussion in 'General Residency Issues' started by exPCM, 09.13.09.

  1. exPCM

    exPCM Removed

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    Study: Retail health clinics as good as doc office
    Not only is care cheaper, but in some cases, better than ERs, research finds


    There is no evidence to back up doctors' warnings that low-cost retail health clinics in hundreds of pharmacies and other stores across the country could expose customers to substandard medical care, researchers said this week.

    The clinics, which operate under names like MinuteClinic, TakeCare and MediMinute, have become increasingly popular as convenient options for Americans seeking routine care without the expense of visits to doctors' offices or hospital emergency departments.

    More than 1,200 such clinics now dot the country since the first ones opened in pharmacies under the QuickMedX name (now MinuteClinic) in 2000, according to the Convenient Care Association, the industry's trade group. A company called AeroClinic has even opened retail locations in two airports — Hartsfield-Jackson Atlanta and Philadelphia International — with plans to expand as early as this fall.

    Some physicians' groups, such as the American Academy of Pediatrics and the American Academy of Family Physicians, have raised concerns about potential conflicts of interest and the quality of care at retail clinics, where immunizations and treatment for routine illnesses like middle ear infections and sore throats are generally offered by nurse practitioners rather than doctors.

    But the new research, the first large-scale study of the care provided in U.S. retail clinics, found "no difference in the quality offered to patients visiting retail clinics, physician offices and urgent care centers." For some services, retail clinics even did slightly better than hospital emergency rooms, said the researchers, who published their findings in two papers this week in the Annals of Internal Medicine.

    The studies are likely to add to the debate over controlling health care costs as President Barack Obama and Congress seek an agreement on a new health care system. The research, which was organized by the nonprofit Rand Corp., found that retail clinics charged significantly less for services commonly offered for several hundreds of dollars by doctors in private settings.

    "These findings provide more evidence that retail clinics are an innovative new way of delivering health care," said the lead author, Ateev Mehrotra, a physician and professor at the University of Pittsburgh School of Medicine. "Retail clinics are more convenient for patients, less costly and provide care that is of equal quality as received in other medical settings."

    Clinics not available to everyone
    If anything, the authors said, the biggest concern about retail clinics — more than 400 of which are operated by Wal-Mart Stores Inc. alone — is that there aren't enough of them.

    Nearly half of all retail clinics are concentrated in just five states — Florida, California, Texas, Minnesota and Illinois — while 18 states have none at all. As a result, less than a third of Americans live within a 10-minute driving distance from one, the studies found.

    For patients who can get to one, a retail clinic offers several advantages over visits to traditional doctors' offices or urgent care centers.

    Nearly all of them accept major insurance plans, and because they are usually attached to pharmacies, patients can fill their prescriptions immediately. Meanwhile, the costs for routine procedures like flu shots, sore throat exams and cholesterol screenings are significantly lower — an average of $110, compared with $166 for doctors' offices, $156 for urgent care centers and $570 for hospital emergency departments.

    To track the quality of care, the researchers studied outcomes for three routine illnesses — middle ear infections; pharyngitis, or a sore throat caused by inflammation of the pharynx; and urinary tract infections — for hundreds of patients each at doctors' offices, urgent care centers, hospital emergency rooms and MinuteClinic retail clinics in Minnesota.

    They recorded no significant differences in patient outcomes except in emergency departments, where prescription costs were higher and quality scores were significantly lower than in the other settings.

    Researchers say doctors' fears unfounded
    As a result, the researchers found "no evidence to support the concerns" of physicians groups that retail clinics might be likely to overprescribe antibiotics or overlook some conditions because doctors are not conducting examinations.

    In 2007, the American Academy of Family Physicians issued a statement raising those and other questions — including concerns about disrupting the traditional doctor-client relationship — and stressing that "the Academy does not endorse these clinics."

    Three years ago, the American Academy of Pediatrics raised similar objections in a policy statement in which it said it "strongly discourages their use."

    Mehrotra, the studies' lead author, acknowledged doctors' concerns and said "we need to continue to examine retail medical clinics as they grow in number." But he said "the results we have seen thus far" suggest that retail clinics do "provide high-quality care in a convenient and cost-effective fashion."

    Co-author Marcus Thygeson, medical director of HealthPartners Inc., a Minnesota health maintenance organization unaffiliated with MinuteClinic, agreed, saying the research should be "reassuring to consumers."

    While retail clinics offer a limited set of services, "the price is affordable and the quality — at least at MinuteClinic — seems to be as good as you would get in the average doctor's office," he said.


    http://www.msnbc.msn.com/id/32681973/ns/health-health_care/

    Comment: These Minute clinics are staffed by PAs/NPs and not physicians. MSNBC is effectively telling the public that NPs/PAs do as good a job as physicians at a lower cost. What do you think this will do to primary care offices as these clinics siphon off the most profitable patients (insured patients with quick and simple problems) and offer the convenience of an onsite pharmacy?
    Last edited: 09.13.09
  2. yaah

    yaah Boring Administrator

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    Who funded the study? Says the lead author is a professor at UPitt but was the study funded by one of these groups? Didn't see that in there.

    Are these clinics required, like emergency rooms are, to see anyone who walks through the door? If not, how do they get around it? The point about siphoning off the insured patients is a good one, and problematic. Part of the reason they get better results probably is that they don't have to deal with uninsured patients.
  3. exPCM

    exPCM Removed

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    Good points.

    Since they are not ERs they are not subject to EMTALA and therefore they will not see you for free. Of course many private physician offices won't see patients for free either.

    Anyhow it is sad to think of the millions of Americans who are now being taught that PA/NP=MD/DO.

    The study was reportedly organized by the Rand Corporation however I am not sure what that means -did Rand fund the study? The lead doc quoted in the article is an Assistant Professor at Pittsburgh and board certified in IM and Peds ( http://www.rand.org/about/people/m/mehrotra_ateev.html ). His contact info is on the webpage and I thought about emailing him to ask about the funding of the study but then I decided not to bother about it.

    P.S. There are now 145 accredited PA programs with 11 of these being new over the last 2 years.
    http://www.arc-pa.org/Acc_Programs/acc_programs.html
    There are over 800 NP programs: http://www.rntomsn.com/programs/nurse-practitioner/
    Last edited: 09.13.09
  4. chartero

    chartero

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  5. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    What was the point in including EDs for measuring cost and outcomes of things like cholesterol screening, Flu shots, etc.? Is anyone suprised that routine health care maintenance and prevention costs more in an ED than their PCP's office?
  6. exPCM

    exPCM Removed

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    As a student of history I am afraid that the primary care docs are the Romans and their empire is now being overrun by the Visigoths/barbarians (the NPs/PAs). The production of NPs/PAs now exceeds that of primary care docs and I am afraid there is nothing to stem the tide.

    "The Roman empire in the end was overrun by millions of barbarians from the north and east of Europe. It is believed to have happened two or three times in history that huge migrations took place across Europe, where peoples moved to settle in new territories. The great migration proved too much for the Romans to stem. Their armies were designed to defeat other armies, not entire folks and peoples flooding toward them. The collapse was completed when Rome itself was conquered by the Visigoth Odoacer and his men in the year AD 476."

    http://www.roman-empire.net/children/history.html
  7. medsRus

    medsRus

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    What a shame! Excellent comparison... Something must be done to stop this.
  8. Tired

    Tired Still winning.

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    Like Primary Care docs stepping up their customer service and adherence to standards of care?
  9. peppy

    peppy Senior Member

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    I think it may be too late to stop it. That's one of the reasons I have avoided specializing in primary care even though I think it actually is an enjoyable and worthwhile field of medicine.

    Personally, I think the medical profession should start talking about redefining the role of Family Med docs now that their role is being taken over (whether it's fair or not) by NPs and PAs. Even if PCPs are better, it seems that NPs and PAs are doing an adequate enough job handling the routine minor issues like UTIs and sinus infections for the general public to accept them for primary care.
    Maybe it would be better to start talking about things like making IM subspecialty fellowships open to Family Medicine docs, or putting a greater emphasis on public health or administrative training in FM residencies so they could use their broad based understanding of illness in those roles. There have to be other avenues for Family Medicine docs where their flexible training can be put to real use.
    Last edited: 09.13.09
  10. Gastrapathy

    Gastrapathy no longer apathetic

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    Come on now. Spoken like someone who's never worked in a real primary care environment. Your current practice is not so different from these minute clinics.

    The problem with these clinics is that they cherry pick off the easy patients and address a single problem at a time. Anything serious gets punted to an ED and the patient gets seen twice. Further, this leaves only the 10 problem octogenarians for the real primary care clinics.
  11. Rendar5

    Rendar5

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    first thing i thought when reading the initial paragraphs was "duh" of course these provide more cost-effective care and sometimes more appropriate care than EDs :). At least from the ED perspective these clinics are great because they help take the edge off our overcrowding issues going on righ tnow. Just hope they're trained well enough to know when to deal with soemthing there and when to refer out.
  12. Tired

    Tired Still winning.

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    So what? Are you suggesting that we should force everyone with a simple acute care problem back to their primary care physician, where they can't get an appointment for a week, spend 2hrs in the waiting room, and then get exactly the same treatment that an NP in Wal-Mart could have given them for half the cost in under 10 minutes?

    Seriously, these clinics are better than Primary Care physicians and ERs for the things they treat. Instead of arguing about who funded the study, how about we wake up ad ackowledge the truth: Primary Care docs don't do a particularly good job with customer service. If they did, people wouldn't go to these minute clinics in the first place.

    And you're right, my clinic works a lot like these places do: I'll see walk-ins any time, I don't keep people waiting, and when they walk out they're generally satisfied with the care and service that they got.
  13. mig26x

    mig26x Senior Member

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    do this nurses pay the same exact malpractice/insurance premium that a physician does??
  14. michaelrack

    michaelrack All In at the wrong time SDN Advisor

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    The eastern half of the empire prospered for severall hundred years and survived for near a millenium after the fall of the west. Most specialists will continue to do ok long after the collapse of primary care.
  15. smq123

    smq123 John Singer Sargent Administrator SDN Senior Moderator SDN Advisor

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    I do think that sometimes people with a simple acute care problem need to be seen by the same PCP over and over again.

    - If the "simple acute care" problem is a symptom of a longer chronic problem (ex: a male with a UTI due to BPH)

    - If the "simple acute care" problem is one of a string of repeated episodes (ex: a little kid with several episodes of OM - at some point, he'll need tubes)

    etc.

    I think it's unfair to compare a PCP, who needs to worry about continuity of care (which takes longer) to minute clinics, who can just focus on one problem and not worry too much about the long term consequences. I mean, it'd be great if PCPs could do that too - just give out birth control and not worry or care that the patient has never had a pap (despite being sexually active for >3 years), and has had multiple STDs? That'd save a lot of time. Not have to worry about tracking down charts? Great! Not have to spend time arguing with long-term problematic patients? ("What do you mean, you won't give me more percocet?") That'd be fantastic. Not have to update your charts when patients come back to you after an eventful 5 years? ("Well, for starters, I got a kidney transplant. What do you mean, the urologist never told you?")

    That's a lot of the stuff that slows things down. EMR would help, a lot, but sometimes things just take longer than they should.
  16. aProgDirector

    aProgDirector Pastafarians Unite! Moderator SDN Advisor

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    Maybe the care at these minute clinics are actually equivalent?

    Perhaps that's because patients recognize when they have a minor illness, and hence self triage to these urgent care clinics.

    Many primary care offices have hired NP/PA's to see urgent minor visits. Maybe a better model is centralizing this in minute clinics.

    I could imagine a world where I only see octogenarians with 10+ problems. Such a world would have a different compensation system such that a long visit to deal with these issues would be paid the same as multiple short visits.

    Would NP/PA's miss things? Probably, but most could get picked up by MD/DO's a bit later without any major problem. Will NP/PA's send complex cases to the ED? Probably, but so will many MD/DO offices.

    Will NP/PA's miss some things that will not be picked up in time to avoid harm? Probably. Do docs miss some things that are not picked up in time to avoid harm? Certainly. How much more often will it happen with NP/PA's? No idea, unclear if it's worth any potential cost savings / increased customer satisfaction.

    In fact, I could imagine a bunch of "specialty clinics" like urgent care clinics. In my academic office, we have a warfarin clinic run by nurses. They do a much better job than I do -- keep a database, know whom has missed an INR check, much higher in-range rate, etc. Although each PCP office could try to recreate this, it makes much more sense for someone to open a "warfarin clinic" and let PCP's refer in.
  17. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    Not by a long shot.

    While rate calculations will vary by state, length of employment, and type of employment (ie, CRNAs and Midwifes typically have higher rates), in my state, an RN with greater than 1 year of experience since graduation who wants the same coverage that MDs/DOs are required to have (1 mil/3 mil) pays an annual rate of approximately $102.00.

    Yes. You read that correctly. That is about 100 times less than I paid in my first year of practice (or over a 1000 times less than I would have paid in Pennsylvania) and 500 times less than I pay now. Of course, surgeons are sued more often than nurses, but in general, they pay much much less than physicians do for the same coverage.
  18. Tired

    Tired Still winning.

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    So, to be clear, you are suggesting that all these clinics should be shut down, and all their patients forced to go back to their primary care physicians?
  19. mig26x

    mig26x Senior Member

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    YOu have very good points. Is very easy to treat someone when you only are thinking about problem A and nothing else. I think this minute clinics are going to bring communication problems between a PCP and a patient in terms that we dont know what they have done for them in those clinics. I think I read somewhere that they give the patient a summary of what the did or that they sent to the PCP what they did at the minute care clinic, in other words they treat the problem, wash their hands from the problem and now is the PCP problem if any complications because they wont see the complications ( It might not be in the menu of things they can treat).

    And then for my surprise they premium they pay for insurance/malpractice is a joke and the PCP is the one stuck with the complication if any.
  20. Tired

    Tired Still winning.

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    I think you guys are really overstating the worries. Most of the people who go into these clinics are getting flu shots, have strep throat, or a viral URI. In fact, anything much more complicated than that, and they won't see them. It's algorithmic medical care (literally, they have a book with flow charts) for minor concerns, done on a cash basis. The "complications" from these kinds of illnesses are about as likely as complications from self-treating with tylenol. It's a good business, and definitely one that larger primary care groups should think about getting in to.
  21. Farmer Jane

    Farmer Jane Anti-ANA RN

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    I must say, as a patient I would love to see a minute-clinic-type option within my primary care physicians office system. This spring I had strep so went to see my physician. My cost was over $100. I could have walked down the street to Walgreen's and paid a fraction of that. It's unfortunate that to stay within my clinic, which I prefer to do, there is no quick and easy option.
  22. McGillGrad

    McGillGrad Building Mind and Body

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    The best option is to have physician businessmen buy and operate them as a second revenue stream. Always a silver lining.
  23. dotdash

    dotdash

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    I was on vacation with my daughter, who got a sore throat. Since our PCPs were in a different state, I brought my daughter to a minute clinic for a strep test. It was quick, but I got a bill for $135. So not necessarily cheaper.
  24. dragonfly99

    dragonfly99

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    I disagree that these clinics are necessarily cheaper. Sometimes they are not.

    Many primary care offices do keep open walk-in slots for urgent care patients, and/or they have an associated urgent care clinic. I personally usually wait far longer at specialists' offices than I ever have in a primary care office (waiting >1.5 hours to see an orthopedist for a foot injury and got no explanation nor apology for why I had to wait that long).

    I do agree that we should try to provide quick and convenient care whenever possible. I also think that we (all physicians, not just primary care) have a duty to protect patients and not act like providing medical care is like serving fast food at Mcdonald's, because it isn't. It isn't simple and it isn't that easy, and maybe we need to have more dialogue with the general public about that.

    I don't think these urgent care/NP clinics are necessarily a totally bad thing. However, I do share smp and gastrapathy's concerns. These clinics are basically a way for people to skim off the easy, less sick patients and bill for them, leaving traditional primary care with all the sick little old ladies and little old guys or younger people with multiple chronic illnesses. As such, one could see these in-store clinics as just another nail in the coffin of primary care.

    If the only people who went to these clinics were healthy 20-40 year olds with minor illnesses, they'd probably be O.K. However, human nature being what it is, I am afraid that there will be a number of patients who don't belong in these clinics who end up there, and are not triaged appropriately. It doesn't affect me any more b/c I'm not doing primary care, but I wouldn't want to be the primary doc that tries to clean up these clinics' messes. However, I don't think they are much worse than a lot of the physician-run, free standing doc in the box places that do the same type of cherry picking and don't follow up on the patients they saw either...

    I also see an inherent conflict of interest in having these clinics located inside the same stores or pharmacies where antibiotics and other meds are being sold. I think if this is going to be allowed, then it's silly to try to say that physicians shouldn't be able to start their own hospitals or free-standing surgical centers, etc. It's all the same type of conflict of interest, in my book.

    Lastly, I don't think the research study shown above really proves much that is of value. Bayes Theorem applies here...what is the pretest probability of serious badness in most of the patients who walk into these types of places? Not high, because they come in there with mostly minor illnesses...a lot of which could probably be treated at home with self care. Also, it doesn't seem like the study can measure some important things...such as if I'm an IM resident in primary care resident clinic and a patient walks in c/o a sore back and I see that he's also obese and doesn't exercise and is 39 with a Fhx of diabetes, I'll screen him for HTN and suggest we check his cholesterol and also suggest that he should lose weight and be followed up periodically/get yearly physicals. You can't really measure long term outcomes with these types of studies...you can only prove that the retail clinics don't seem to be killing a lot of people quickly...LOL.
  25. Hernandez

    Hernandez Paranoid and Crotchety...

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    I moonlight at an urgent care frequently, and to get just a rapid strep, it's $35, but if you see me the doc, it's $100 for me to tell you it's viral or allergy.

    I can assure you that you would be surprised what walks through the doors of urgent cares. In the last 2 months, I've had 2-3 peritonsilar abscess, an MI, 2 joints that were very concerning for being septic, an appy, a few nasty looking pneumonias that were in the severity index of class 3, erythema multiforme. And it never ceases to amaze me the people who have horrible medical diseases who think it's ok to go to an urgent care, I've seen people with Inflam bowel dz, EE, severe COPD, uncontrolled asthma, malignant HTN, ESRD, and other dz's who just walk in because we see them faster. I'm pretty sure I diagnosed a case of relapsing polychondritis after this guy had shown up to this UC 3-4 times with auriculitis, the UC I worked at had just bought another UC that was staffed primarily by NPs who keep giving him steroid injections and PO pred and sending him on his way.
  26. Rendar5

    Rendar5

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    as an aside, i'm not sure if i'm that convinced anymore that strep even needs to be treated since rheumatogenic strains don't seem to be around much anymore. course, if the general public ever thought that, then there would go half of a minute clinic's revenue, lol.
  27. nolagas

    nolagas Member

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    ? Wouldn't most of the outcomes for these clinics be just as good if the patients seek no care at all? It is hardly meaningful to compare 2 sources of unnecessary, minimally beneficial treatments. Of course there is no difference! When people who are seriously ill show up where are they better taken care of?
  28. dragonfly99

    dragonfly99

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    I agree.
  29. Long Dong

    Long Dong My middle name is Duc.

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    Cool, then we can stop all this talk about the mayo clinic model, and reform health care to look more like the minute clinic model. Who needs MD/DOs anymore NPs for the win.
  30. meister

    meister Senior Member

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    I'm shocked, just shocked, that practitioners with much less training can correctly diagnose viral illness, otitis media, or sinusitis and treat accordingly. This is shocking.

    Asthma as well?!
  31. Long Dong

    Long Dong My middle name is Duc.

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    Yeah how dare they diagnose viral illnesses like EBV and CMV infection and miss things like hemophagocytic syndrome/hemophagocytic lymphohistiocytosis.
  32. mig26x

    mig26x Senior Member

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    hey, I been saying it= nursing school is the new med school!!!! According to Mundinger they are equal or better than physicians!!! LOL.
  33. Rendar5

    Rendar5

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    hey let em. Put them one to one with physicians. if they can do something equivalent, let them, if they fail to provide something equivalent, let them get sued up the wazoo. the more minute clinics the better.
  34. Long Dong

    Long Dong My middle name is Duc.

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    qft
  35. mig26x

    mig26x Senior Member

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    that's the problem, have you seen their insurance/malpractice rate?? its a freaking joke and also doc's are still responsible if they make any mistake that's why the practice so happily= its never going to be their fault!!!
  36. meister

    meister Senior Member

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    I'm criticizing the study, where the only measures they used were really dumb diagnoses.

    So they just use the easiest diseases and ignore everything else. Selection bias? Never heard of it.
  37. Long Dong

    Long Dong My middle name is Duc.

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    Oh snap, I thought obama said NP=MD/DO in the other thread, let them take on the fault and malpratice then they'll be equal all they want. :thumbdown:
  38. Rendar5

    Rendar5

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    Attending Physician
    SDN 10+ Year Member
    Well in my mind that means one of 2 things. Either minute clinics are not making enough clinically significant mistakes to warrant higher malpractice rates (since malpractice insurance is a business designed to make money and won't set rates that lose them money in the long-run), or FPs are getting ****ed over by the malpractice companies and need to unite to change that. Either way, this beef against minute clinics is misplaced and needs to be redirected to other issues: malpractice companies and scope of practice (the idea that an FP's/internist's major practice is directed towards minor acute issues) There are a few solutions to this latter one that I can think of, but who knows how practical they are.
  39. Baller MD

    Baller MD

    Joined:
    07.21.08
    Messages:
    439
    SDN 5+ Year Member
    Yeah, total BS.

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