Healthy Skepticism Library item: 16853

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Publication type: news

Pratt S
Doctors and druggists under one roof
The Edmonton Journal 2009 Dec 6
http://web.archive.org/web/20100207225832/http://www.edmontonjournal.com/health/Doctors+druggists+under+roof/2309019/story.html

Abstract:

Drugstore giant Rexall is forging a new and closer relationship with doctors in Alberta. It’s part of an expanded role for pharmacies and pharmacists, but some observers fear the changes may compromise doctors’ independence

Full text:

Canada’s biggest drugstore owner, Daryl Katz, is getting into the business of buying doctors’offices as well as building them into his new Rexall stores in Alberta. The move is described as a good corporate business strategy, but it is also raising questions among professionals and consumers in the health-care community.

Earlier this year, a string of walk-in clinics founded by two Edmonton doctors 30 years ago became part of Medicentres Canada Inc.

Through a series of intervening companies, Katz holds a majority shareholder interest in Medicentres Holding Corp., the sole voting shareholder in one or more of three amalgamating entitites that ulimately formed Medicentres Canada Inc. This information is based on public records filed with Alberta Corporate Registry.

The Katz Group in Edmonton declined to comment.

Dr. Lloyd Reddington, a co-founder of Medicentres in 1979 and now retired to Kelowna, also declined to comment, citing possible confidentiality issues. He noted, however, that he still sits on the two-person board of directors of Medicentres Canada Inc. with his former partner Dr. Andrew Johnston.

As part of its “rapid pace of expansion in Edmonton,” Katz’s Rexall company this year opened two new Rexall pharmacies with Medicentre doctors’ offices attached “to offer a one-stop health solution” for consumers, says a company news release.

The new 11,000-square-foot store on Ellerslie Road with its drive-thru pharmacy is one of six new stores the company plans to open in Alberta. A second was recently opened in Sherwood Park with a Medicentre clinic. Another combined store and doctors’ clinic has opened on Jasper Avenue at 118 Street.

A closer working relationship between doctors and pharmacists is a key aspect of the “community-based health care” the province is rolling out to alleviate the doctor shortage and improve people’s access to health services outside hospitals and crowded doctors’ offices.

But while the Rexall model— putting doctors’ offices in a retail drugstore—offers convenience to patients, it also raises conflict-of-interest issues that the public should be aware of, say the Alberta College of Physicians and Surgeons and the College of Pharmacists, the regulatory bodies overseeing the conduct of doctors and pharmacists.

Moreover, what makes good business sense for the pharmacy and its corporate owner also raises issues for consumers who are faced with increased marketing of health services and products in a retail setting, say consumer advocates.

Trevor Theman, registrar of the College of Physician and Surgeons, says it can be a good business decision to have a doctors’ office in a drugstore, but the rules around conflict of interest and independent practice of medicine

must be adhered to strictly. A doctor, for instance, cannot allow an outside party to influence how he or she practises medicine, including the prescribing of drugs, says Theman.

So, hypothetically, if a landlord offers financial incentives for changing prescribing patterns or for directing patients to a certain pharmacy, the doctor should not accept, he says.

It’s up to a doctor not to enter into any business arrangement that “would prevent them from giving safe, ethical care,” he says.

Doctors should know the identity of their landlord and guard against any lease arrangement or business contract that would compromise their independence, he says.

“Are we cognizant of the potential for influence on doctors? Sure we are,” says Theman.

“The potential for problems is greater (in these combined situations). You

have to have your eyes wide open.” Theman says the college could,

for instance, monitor lease arrangements or business contracts to make sure doctors’ independence is not compromised. It has not done so to

date, he added. It’s also unclear whether that information would be released publicly.

About 100 city doctors work in Edmonton’s 15 Medicentres, with 65 full-time and the rest part-time and casual, says Dr. Arif Bhimji, president

of Medicentres Canada Inc. There are nine clinics in Calgary and a handful in Ontario.

Most doctors are attracted by the “turn-key” arrangement—they can concentrate on treating patients while Medicentre builds the office space and runs the business side, says Bhimji.

The company is fully aware of the college’s conflict-of-interest guidelines and expects the doctors who work in the company’s clinics to follow those rules, as they have for the past 30 years, says Bhimji.

“Our job is to abide by the practice standards, otherwise we won’t have any doctors working for us, and no business,” he says.

Doctors are in charge of treating their patients, while Medicentres Inc. — for a set management fee— provides office space, nursing staff and administrative staff to handle the appointments and billing for doctors’ services, he says. It’s called “practice management” and it has been around for years, he adds.

Under those arrangements, doctors carry their own liability insurance and report to the college, says Bhimji, adding “we would not get involved in the medical side.”

“All the doctors are independent practitioners.”

Bhimji said Medicentres had been cleared of one complaint by the College of Physicians last summer. He declined to give further details.

Medicentres were pioneers in offering walk-in, “no-appointment-necessary” family medicine and after-hours care, a major change in traditional family medicine. The company continues to innovate.

About 18 months ago, for instance, Medicentres started a ‘‘fast-track system’‘ in its clinics to handle simpler health problems such as earaches or contraceptive counselling. A patient first sees a triage nurse who inquires about history and symptoms before the patient sees the doctor. While the time with the doctor is much shorter, a patient gets more time with the nurse. About 900 patients have been treated that way, says Bhimji.

As for the locating doctors offices in Rexall drugstores, Bhimji says that partnership is no different than doctors’ offices located close to medical services such as X-ray, physiotherapy, and diagnostic labs.

Although Katz ultimately owns both sides— the drugstore and the doctors’office—Bhimji says as the company’s medical director, he reports to the two-person board of directors of Medicentre Canada Inc, who are both medical doctors.

The Alberta College of Pharmacists, which regulates the professional conduct of pharmacists, keeps a close eye on the independence of pharmacists in chain stores and combination drugstores and doctors’ offices, says registrar Greg Eberhart.

Having doctors and pharmacists work closer together as part of “community-based” health care is the right approach and will result in better patient care, says Eberhart.

But having doctors’offices in retail drugstores creates new challenges, especially considering many drug stores are not owned by the local pharmacist, but by a chain or corporate entity, says Eberhart.

In the old days, doctors and druggists were independent business people with their own offices. These days, there can be three players in the relationship—the doctor, the pharmacist and a corporate entity, he says.

“At the root of it, the question is, where a business relationship exists, we have to be careful to make sure ethical considerations are met. We are encouraging professions to work together, but it brings new challenges.

“We have to make sure health decisions are made objectively and not in the interests of the purse of the pharmacy or the doctor. We do that by putting the patient at the centre.

“We’d be concerned if we received confirmation that a patient was directed to go to a certain pharmacy.

“We as the college would also strongly object if there was any corporate direction on pharmacists to dispense certain drugs.

“The bottom line is the patient must be the one who chooses and must not be directed to use certain services.

“Patients have to understand their role in this new community care,’‘ Eberhart adds. “They can question the pharmacists, they have a choice about what services to use and should not make their decision solely on convenience.”

To monitor those ethical considerations, the college relies on feedback from patients, he adds.

“We’d both(the colleges of pharmacists and physicians) be interested in whether that outside influence is affecting the practice of pharmacy and doctors’ care of patients,” he says.

John Church, a political scientist in the School of Public Health at the University of Alberta, says Katz has come up with a smart business strategy by combining doctors’offices with his drugstores, and people will appreciate the convenience.

But the closer business relationship calls for more transparency, he says. Doctors, and the public, have a right to know who owns the doctors’ office in these commercial spaces because those owners directly benefit from a major outlay of public money in doctors’ fees, he says.

“Previously it was entrepreneurial doctors like Reddington who owned the business. Katz is the first big business guy and there’s a market opportunity with the government talking health reforms,” says Church.

But just how independent are the doctors, he wonders, if they don’t control their own business environment?

Trudo Lemmens, a University of Toronto law professor and expert in medical law and ethics, agrees that closer monitoring is necessary with in-store doctors’ offices.

“It’s not so much to say people will act badly, but it is the creation of risk that people will do something that will affect their practice,” he said. “I raise the question: Could they be influenced in their prescription patterns?”

Lemmens also worries about the subtle ways patients can be pushed to buy more health services in these commercial settings. “It’s not a new concern, but it’s bound to be at a higher level when everyone is in the same building.”

At the U of A, professor and pharmacist Ross Tsuyuki teaches in the medical school and runs the Community Pharmacy Research and Interdisciplinary Strategies (COMPRIS), a research institute dedicated to promoting “ new and renewed roles for pharmacists within the interdisciplinary health-care team,” says its mission statement. The sponsors are drug companies.

In April 2007, Alberta pharmacists were given the broadest scope of practice in Canada and the U.S.—new powers to manage chronic disease, prescribe drugs, modify prescriptions, give injections and offer counselling. Just recently, they were also given the power to order lab tests.

Tsuyuki is excited about the expanded role for pharmacists as key health providers in “community-based health care.” Having doctors’ offices located in pharmacies provides “a great opportunity for better collaboration,” says Tsuyuki, who also holds the pharmacy school’s Merck Frosst research chair.

“These are both professional groups with strict codes of conduct, he says, adding that “it’s pretty far-fetched to think anyone would act unethically.”

Wendy Armstrong, Edmonton-based health policy researcher and longtime board member of the Consumers Association of Canada (Alberta)cautions that in-store doctors’office have some hidden costs for consumers along with all the convenience.

For instance, U.S. industry studies reported in Drugstore News, an online trade magazine, show 70 per cent of people using in-store clinics become new drug customers, Armstrong points out. And 95 per cent of them fill their prescription on the spot without checking prices. Yet there can be major differences in prices of prescription drugs if you shop around, she says.

Just as pharmacists are emerging as the key players in Health Minister Ron Liepert’s new model of “community-based health care,” so retail drugstores are emerging as a major new site for many of these services—services historically provided in doctors’ offices, clinics, labs and public health centres.

Retail drugstores are marketing themselves as wellness centres and offering a range of instore screening tests for high blood pressure, osteoporosois, high cholesterol and diabetes. While this new trend provides people with more access to certain health services, it raises other concerns, she says.

“It’s often difficult for people to tell the difference between clever marketing and legitimate health promotion” she says. People can’t always judge whether those tests are necessary, she says. There is also growing controversy over using these tests in isolation, she adds.

Yet industry studies show these additional screening tests lead to more prescriptions and over the counter sales, she adds.

This kind of marketing can make people unnecessarily anxious about their health care, says Armstrong. It may also cause them to divert more of their spending to pharmaceutical products rather than looking at non-drug therapies, she adds.

The provincial government is still working out how pharmacists will be paid for their new duties and for spending more time managing patient care.

“People assume the government will cover the cost of paying pharmacists to provide those new clinical services, but that’s not necessarily the case,” she says. “So people may have to pay for some of the services at the drugstore as well as the cost of the drugs.”

Tsuyuki says the issue of how to pay pharmacists for their new responsibilities is currently under discussion with Alberta Health and Wellness. It won’t be an “add-on” to the system because new care for pharmacists should reduce the number to the doctors and hospitals, he says.

COMPRIS is currently studying options such as performance-based payment—a pharmacist would be compensated for meeting a certain health outcome, like lowering someone’s blood pressure rather than payment per prescription, he adds.

In October, the province said in a release that “new practice and reimbursement models” for pharmacists are under study. The plan is to use some of the $100 million in savings it expects to realize by reducing what it pays drugstores for generic drugs under legislation passed this fall.

The Katz Group also owns a chain of drugstores in the U.S. where there is a rapid expansion of health clinics in big retail stores like Walmart, though in the U.S. these are staffed by a nurse or physician assistant, not a doctor. The drugstore and drug company trade literature in the U.S. promotes these arrangements as an opportunity for the pharmacy business and drug manufacturers to “grow the pharmaceutical pie,” notes Armstrong.

“Yet there is already concern in medical circles and among health advocacy groups that people are over medicated,” says Armstrong.

Lemmens agrees: “Overconsumption of drugs is one of the biggest challenges of health practice these days. The elderly are a particularly vulnerable population affected by this.

“This kind of setting won’t necessarily contribute to it, but it is possible to see doctors prescribing more. There is certainly a perception of a joint interest,” he adds.

Tsuyuki looks at it differently. A lot of people have health problems that go untreated, perhaps because symptoms aren’t obvious, such as high cholesterol, he says. A pharmacist can be proactive at finding those “under-medicated” people and provide treatment, he says.

For instance, in 2007, a COMPRIS research project at the U of A worked with 14 Medicine Shoppe Pharmacies (also owned by Katz) in Edmonton, says Tsuyuki, who led the study. The pharmacists went through their own instore records to identify 227 diabetic patients with high blood pressure.

Some of that group were given “enhanced care” by pharmacists and they saw their blood pressure go down, more so than those with routine doctors’ care, said Tsuyuki, the senior author of the research paper.

Tsuyuki said he didn’t see a privacy issue in having pharmacists go through their own in-store records to recruit people for the study, especially as it led to better care.

But Armstrong disagrees. The consumers association dealt with those privacy issues at hearings in the Alberta legislature in 2004 and 2006 into the then proposed privacy legislation.

The Consumers Association of Canada objected to a proposal from a drugstore chain to allow retail pharmacists to use their customers records and new electronic health records to “monitor therapy adherence” and identify possible “under-diagnosed” and “under-treated patients”—without the customer’s consent or knowledge.

Such “surveillance” of patients by a pharmacy goes against Albertans’ view of medical confidentiality and patient autonomy, says Armstrong, and should be opposed.

“No one wants Big Brother in their medicine cabinet,” she says.

Tsuyuki sees if differently: If you are aware a person might have a health problem, “as a health-care provider, you have an obligation to intervene and help.

“People don’t know they need to be found,” he adds.

“We’re not talking about telemarketing, we’re talking about people who have signed on for care with a professional,” says Tsuyuki, adding patients can always turn down the call.

There is no question that pharmacists need access to more detailed patient information to safely carry out their new duties, such as making changes to prescriptions and managing chronic diseases, says Tsuyuki.

In 2003, with thousands of Albertans unable to find a family doctor, the province set up a policy to encourage the formation of primary-care networks. Family doctors would form teams with pharmacists, dietitians and physiotherapists to offer a full range of care and after-hours services. PCNs would be owned and run by a group of doctors in conjunction with the regional health authority.

To get started, doctors were paid a$50 bonus for every patient they enrolled in their PCN location, with the funds to be used to help cover the cost of hiring other health professionals for the team.

The U of A’s John Church, whose research for two decades has focused on primary-care issues, says in recent years it has been very difficult to get information from government on the success rate of PCNs and how many patients or doctors are enrolled.

Interestingly, the partnership between Medicentres Inc. and Rexall drugstores is beginning to look like a parallel version of PCNs “in a private-sector setting,” says Church. “So this may fit the government’s policy objectives.”

Also, once a company owns a number of clinics, it is easier to implement standardized care across the system.

Though this may make it easier to make a doctor’s office run more efficiently, it raises questions about physicians’ independence, says Church.

“If that becomes the dominant model, that will be bad news for physicians. The Alberta Medical Association should be concerned.”

Yet among family doctors at least, there is a growing trend to move into retail outlets because of the high cost of running a practice in a traditional doctor’s office, according to the president of the Alberta Primary Care Physician Association.

“More and more community physicians are shifting to managed care settings in offices supported by commercial interests such as Walmart, Superstore and London drugs,” wrote Dr. Blythe Brown in April 2008 in a letter to the Calgary Herald, “to escape the expense and hassle and traditional family practice office.”

Bhimji says Medicentres are different than PCNs in that they do not get additional funding to hire other team members such as dietitians or physiotherapists. Also, their doctors do not get extra pay for working night shifts, as that’s all part of the contract.

Medicentres, however, is currently negotiating with the province to find a funding mechanism for hiring other health professionals and hopes to hire dietitians and psychologists soon. At this point, “it’s primary care network-lite,” says Bhimji.

The AMA, the doctors’ lobby group, had no comment on these issues, referring queries to the College of Physicians.