MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Medical clinics inside drug stores, urgent care facilities with office space in the mall. Many consumers are increasingly turning to the convenience of retail health clinics. Joining me to talk about the trend and what it means for patients, doctors and the healthcare industry, Susan Dentzer of The Robert Wood Johnson Foundation, Dr. Robert Wergin, a family physician.

MS. DIANE REHMHe's president elect of The American Academy of Family Physicians. Joining us from a studio at WCPN in Cleveland, Vaughn Kauffman of PW Health Industries. And by phone from Providence, Rhode Island, Dr. Nancy Gagliano. She's chief medical officer at the CVS MinuteClinic. If you'd like to ask your questions, comments, feel free to call us at 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or send us a tweet.

MS. DIANE REHMWelcome to all of you. Thanks for joining us.

DR. ROBERT WERGINGlad to be here, Diane.

MS. SUSAN DENTZERGreat to be with you, Diane.

DR. NANCY GAGLIANOThank you very much for the opportunity.

MR. VAUGHN KAUFFMANThank you, Diane.

REHMGood to have you all with us. Dr. Gagliano, describe for us the CVS push to open health clinics within drug stores. Why has that come about and how much progress are you making?

GAGLIANOThank you, Diane. We currently have about 800 healthcare clinics in CVSs across the country. We're in 28 states and the District of Columbia and we've grown quite extensively over the last couple of years. One of the things we have found is that about half of the patients who come to a retail clinic report that they do not have a primary care physician so that we know that access to affordable convenient healthcare is really a challenge in the country, particularly with the shortage of primary care.

GAGLIANOPredominantly, the kind of care that we provide is for acute minor illnesses, things like coughs, colds, sore throats, but more so as healthcare is evolving and more and more folks are paying attention to population health, we're finding ourselves being asked by affiliate health systems to actually do blood pressure screenings and diabetes screenings to really help be a community resource right within CVS and accessible to patients.

REHMSo from your point of view, you feel that these kind of clinics can play a role in monitoring chronic ailments?

GAGLIANOYes, we do. One of the things that we have focused on in the last couple of years is a affiliations with health systems across the country. MinuteClinic has affiliations with over 30 health systems, such as Cleveland Clinic, (word?) UCLA and they're all aware of the fact that there's a shortage of primary care and that it's inconvenient for patients sometimes to take off from work.

GAGLIANOSo we can be that nurse practitioner down the hall, but actually in the community. We focus on integrating our electronic medical records so that any time a patient sees us, our records goes right back to their primary care provider.

REHMSuppose they don’t have a primary care provider, then where does that information go? Is it simply kept within CVS records?

GAGLIANOSo that's a great point because about 50 percent of the patients come to us don’t have a primary care provider, one of the things that we are absolutely committed to is the importance of the primary care medical home. And any patient who doesn't have a PCP, we give them a list of local primary care providers right within their community who are accepting new patients and encourage them very strongly to set up a relationship.

GAGLIANOThe patient also gets a copy of their visit so that they always have it. We have it. And if they do develop a relationship with a PCP, then we can sent it to them.

REHMDr. Nancy Gagliano, she's chief medical officer for CVS MinuteClinic. Susan Dentzer, how does what CVS and other clinics like that are offering, how does that differ from ordinary care that you'd get elsewhere?

DENTZERWell, as Dr. Gagliano said, most of the care provided at retail clinics is, as she said, sort of minor acute. We know a huge volume of visits to primary care physicians in the country today are for the common cold. Of course, you can't do too much about the common cold, but a lot of people are worried when they develop a cold. They think it might be something, you know, another bacterial infection or something.

DENTZERSo people will often use a retail clinic for that kind of a situation. I've got a cold. I've got a minor sinus infection, et cetera. We also know a great volume of the care provided at retail clinics are for immunizations, just vaccinations. If you have to get your kids vaccinated or get an annual flu shot, people will often do that at a retail clinic. So they basically come into, initially, to take up a part of the care that people need to access on a very rapid basis, often, because a physician's office might be closed on a weekend or they are providing some care that is easy to provide, that it can be administered by a nurse practitioner.

DENTZERMost retail clinics are staffed by nurse practitioners, not physicians.

REHMI'd be a little concerned, for example, about people bringing a child in for a vaccination or a flu shot or something of that sort without having a physician and record-keeping in the background watching that child, whether that child needs that vaccination at that time.

DENTZERWell, clearly, a preferable situation is to have a kind of pediatric medical home type practice that your child can be a part of for immunizations that are administered in childhood. Because as you say, you want to track all of that and make sure they're delivered over time.

REHMYou bet.

DENTZERHowever, I mean, I am among the many mothers in the country who've taken my kids to a retail clinic for an annual flu shot. Convenience is a big factor here for retail clinics.

REHMDo you see these retail clinics in any way substituting for emergency rooms in the hospitals?

DENTZERNo. And in fact, again, just speaking from personal experience, I've gone to a MinuteClinic and had the nurse practitioner immediately redirect me to an emergency room for a condition she clearly recognized was beyond her scope of practice...

REHMInteresting.

DENTZER...and needed to be dealt with with somebody with more experience and more expertise and more capacity to deliver more urgent care.

REHMSusan Dentzer, she's with The Robert Wood Johnson Foundation. She's on-air analyst on health issues at the PBS News Hour. Turning to you, Dr. Wergin, you're a physician in private practice in Milford, Nebraska. What kinds of trends are you seeing in terms of these kinds of on-the-street clinics, CVS, Walgreens, others? How are they affecting what you're doing as a private family physician?

WERGINWell, as a practicing family physician, there may be a role for the retail health clinic as part of my patients that are -- may go home when I'm not available. But the scope or the types of visits they have needs to be limited. And I would draw the line at the chronic care model of care, further fragmentation of our healthcare system would result in what we get now, which is higher cost and lower quality.

WERGINBut a personal story in my own office, I realize that access is an issue. We focus on that. I have, in my office in Milford, Nebraska, a fast track. If you call in, Diane, with your daughter with an earache, they're told to come in. And orange flag's placed over that. When I look down the hallway, I know that that's an acute limited visit. I stick my head in there.

WERGINRelationships are important. We know they're important for ultimate outcome. Many of those children are people I've delivered. They're not afraid of me. I look in their ear. I comment, set up a treatment plan. If there's a follow-up, that is important and many times get many thank yous, I can tell you. Before I leave the room, the patient will grab me and say, thank you, Dr. Wergin. I was so worried about my daughter.

WERGINAnd it's very rewarding to do that.

REHMSo that relationship and that trust that you build up over time, you regard as an important part of the healthcare providing, that you're giving.

WERGINYes. And I think there's evidence-based studies that show that outcomes are there, that are improved knowing your doctor, them knowing you is important. The second issue, I'd say, is many times, Diane, there's an opportunity there and that's what I would say there may be a lost opportunity. Diane comes to my office for her sore throat and as I look at your record, I say, Diane, do you realize you haven't had a mammogram in four years?

WERGINLet's address this problem. As we leave, I'll have my nurse set that visit. Or do you realize your blood pressure's a little high. We should follow that up. And when you come back, you won't see another shift-working person, you'll see me again.

REHMAt the same time, you won't be working on Sundays. You won't be working, say, in the middle of the night when a 24-hour MinuteClinic might be open.

WERGINAnd that may be the role I see for the MinuteClinics or the retail health clinics as part of my medical community. But the key part of that, again, Diane, you addressed earlier, it has to be communicated. What did they see? What did they do? In our survey of our members, and I'll change hats for my private practice to the president-elect of the academy, about 71 percent of our members have same-day appointments and another 40 percent have weekend or after hour care.

REHMDr. Robert Wergin, a family physician in Milford, Nebraska. Short break here. When we come back, we'll talk with Vaughn Kauffman of PWC Health Industries.

REHMAnd welcome back. We're talking about the increasingly popular retail health clinics, not only here in Washington but certainly around the country. Here in the studio with me, Susan Dentzer of the Robert Wood Johnson Foundation and the PBS News Hour and Dr. Robert Wergin, president-elect of the American Academy of Family Physicians. On the line with us is Dr. Nancy Gagliano, chief medical officer for CVS MinuteClinic and Vaughn Kauffman. He's principal for PwC Health Industries.

REHMWe will open the phones soon but first to you, Vaughn Kauffman. Let's talk about how the industry itself is poised for changes in large part, you say, because consumers are now having to pay for so many services out of their own pocket. Talk about that trend.

KAUFFMANFirst Diane, let me thank you for having me on your show. It's a pleasure.

REHMThank you.

KAUFFMANAnd yes, we're looking at a lot of changes that are occurring in our industry from the view of the consumer. And we survey consumers to understand sort of what they feel they need in terms of convenience, choice, access. And one of those changes that we're seeing is the increasing amount of expenditure that's falling on the consumer to pay for their own healthcare. And when we look at other industries that have experienced a similar model, putting the consumer at the center of that industry change is driven by the consumer. And so healthcare's not immune to that.

KAUFFMANAnd I think this is really an exciting time for industry in healthcare because not only are the traditional organizations talking more about the consumer at the center of the health system, but the nontraditional companies such as the retailers and other technology organizations that specialize in the consumer sitting at their -- the middle of their industry. And because of that we're seeing some major disruption, or we believe there's going to be some major disruption in our industry.

REHMSo you're also talking about patient expectation, aren't you, that people, if they feel ill and if they need a flu shot or if they have a cut on the hand they want immediate attention and aren't going any further to emergency rooms in quite the same numbers?

KAUFFMANWell, what I would say is this. In all of our research around the consumer, two things come out very loud and clear. One is convenience and two is price. And I think as we look at sort of what different models that are coming out, whether it be the retail clinic model, the urgent care model or the traditional hospital setting, those factors don't change. And so each of those types of industries and organizations either relook at sort of their business model in those contexts and understand the wants and needs of the consumers because again, expectations of the consumers are frankly -- have been set by other industries.

KAUFFMANI remember not too long ago the day when, you know, I'd still go to a travel agent to book a flight, I'd still go into the bank to deposit a check. Now I can do it in a number of different ways, whether it be online, on my phone or go to see an agent. Those expectations are set by other industries and are going to fall on the healthcare industry to provide similar types of abilities to deliver services to the consumer.

REHMVaughn Kauffman is principal at the PWC Health Industries. I'd be interested, Vaughn Kauffman, in how you respond to the concerns expressed by Dr. Wergin about the relationship between that doctor and patient and how important that is and could and likely will be lost in this kind of retail medical relationship.

KAUFFMANWell, I would say this. I agree with the doctor in that the patient physician relationship is a very important trusted relationship. And a number of things that we've looked at from our consumer survey and research standpoint is we look across the entire healthcare system. There's a trust issue overall. But one thing that does come out is the patient physician relationship is one of the most trusted relationships across the entire system. So that's important.

KAUFFMANAnd as we think about the choices that consumers have today, again whether to go to a retail clinic to get their flu shot or go to their primary care physician to get their flu shot, they're going to need help understanding how to navigate the system because as both doctors highlighted the fact as, there's more choices out there now, not less, for consumers to make.

REHMSusan Dentzer, more choices. I wonder what relationship that might have to the Affordable Care Act. Has that affected these growing retail outlets as well as the doctor patient relationships?

DENTZERVery clearly. And it will be increasingly a driver probably of more use of retail clinics over time. If we look back at the history of Massachusetts, which expanded coverage several years ago, Massachusetts ironically has more primary care physicians per capita than any state in the union, but there was still a perceived quote unquote "shortage" of access to primary care. One of the ways the state dealt with that was to authorize retail clinics to exist for the first time in the state.

DENTZERAnd as a consequence to that plus other changes that have been made in primary care delivery in the state including expansion of community clinics, federally-qualified health centers, that's pretty much alleviated a perceived shortage of primary care in Massachusetts. Again, lots of choices, lots of competing prerogatives here. I mean, consumers are weighing the desire for low cost, as Vaughn Kauffman said. Now consumers are bearing a lot of costs in terms of high deductibles.

DENTZERA lot of the plans created in the health insurance exchanges have very high deductibles, high cost sharing for consumers. Consumers like to be able to go places where they can see prices quoted in advance, which they can often do at retail clinics. You know exactly what it's going to cost you for something that's going to be done.

REHMThat's very interesting.

DENTZERSo these are all sort of, as I say, competing drivers of people's desire for care but they matter and they do -- they will increasingly lead people overtime to more use of retail clinics as an option.

REHMAnd Dr. Wergin, what about the shortage of primary care physicians themselves?

WERGINDiane, we know we need more family physicians in this country but we feel I this interim our organization is pushing for reform of the way graduate medical education has done in this country. We believe the patients at our medical home team-based care can accommodate this increased number of patients that the Affordable Care Act has come about. It's a good thing for our patients to have access to healthcare and enter at an earlier stage in their illnesses. And we believe our team approach -- we say the right provider, the right care at the right time.

WERGINSo we work together in my own office, my physician assistant, me, my -- it goes right up to my receptionist how we get people in and give them access to the care they need and deserve.

REHMDr. Gagliano, what about costs that Susan Dentzer mentioned? Has it become less expensive to visit say a retail clinic than to go to your own doctor?

GAGLIANOThat's a great point because the studies -- excuse me -- show that retail clinics are 40 to 80 percent less than other choices that they might have such as an emergency room. I think an important point is 50 percent of the patients who come to us, come to us in evenings and weekends when their primary care provider is not available. I'm an internist by training. I spent 21 years at Massachusetts General Hospital in a primary care practice. And I certainly 100 percent value the important of the primary care medical home. And the retail health systems are not trying to take over.

GAGLIANOIn fact, we view this as a supportive role, but patients do have higher deductibles, higher healthcare expenses that are falling onto their shoulders. So if it's not feasible for them to see a primary care provider, I think we would all, rather than when appropriate go to something like a retail health clinic where they're going to be seen by the right provider for their condition, a trained family practice, trained nurse practitioner, physician's assistant, and then be referred back to their medical home.

GAGLIANOBut when they arrive, they'll know exactly how much the visit's going to cost and can make the appropriate decision based on their access to resources.

REHMDr. Gagliano, how many CVS retail clinics are opened 24 hours a day?

GAGLIANOSo we are open evenings and weekends and holidays. We're not open 24 hours. One of the things that we have found by looking at the patients who come to us, the type of patients who come to us with coughs and colds or they get out of work and they want to have their blood pressure checked because they couldn't take time off to see their physician, those tend to be in the early evening and during the day. Patients in the middle of the night who need to be seen, tend to be better suited in the emergency room.

GAGLIANOSo we pay careful attention to the hours to make sure we're meeting the needs of the type of patients who's appropriate for a MinuteClinic.

REHMAnd Vaughn Kauffman, is there any sense on the number of emergency room visits that do not happen because individuals have the option of going to a retail health clinic?

KAUFFMANThat's a great question. I don't have the actual data in front of me to answer directly but I will say that it is an important factor when looking at shifting -- or really addressing the overall costs of healthcare. Decisions that you and I make as a consumer of healthcare matter significantly. And if the retail clinic offers an avenue to deflect some of those unneeded emergency department visits, that's when we're really going to start to see the bend of the cost of healthcare.

KAUFFMANBecause again, the decisions are a significant factor in overall -- the overall cost of healthcare.

REHMSusan Dentzer, I had a full physical yesterday. And while doing so my physician was entering everything into her and the larger medical health record. What happens with these retail clinics? Do those records get sort of disseminated in other ways?

DENTZERWell, you heard Dr. Gagliano say that they've made an effort at CVS to connect the electronic health record to other existing -- to patients' other existing electronic health records. But this fundamental question bears on the whole issue of what we call interoperability. It's how much ability there really is in our healthcare system today to exchange records from one place to another. It's a whole other separate tedious question.

DENTZERBut the fact of the matter remains that our system is not as interoperable as we would like it to be...

REHM...yet.

DENTZER...yet, yet. And federal policy is attempting to encourage that. But there are a lot of interests militating against records being able to move freely from one place to another. I think over time we believe there will be more interoperability so that it will be the case. And certainly patients always have the option of taking their records themselves and giving them to other providers and making their providers aware of what happened to them as they got care in another place.

REHMAnd you're listening to "The Diane Rehm Show." Dr. Gagliano, in yesterday's Wall Street Journal there was an article that focused on the particular concerns of pediatricians with regard to continuity of care. I don't know if you've seen that or how you react to that concern.

GAGLIANOYes, I have seen the article and I'm aware of the American Association of Pediatrics' position on the issue. If you look at their writings, a number of concepts that they have are concepts that the Retail Health Association or clinics really follow. First of all, I definitely support the concept that pediatric patients in particular, but adults as well, should have a primary care medical home. And so it's very important that the children are followed in a continuous matter.

GAGLIANOHowever, if a patient does need to be seen for a sore throat on a weekend, we want to make sure that the patient's record gets back to the primary care physicians, the pediatrician. We want to make sure that the patient -- you know, sometimes we see kids who have recently moved into a new area and need a pediatrician. We always make sure that they have a name of a pediatrician in the local area.

REHMBut can you follow up with a child, for example, who may have a really, really bad sore throat? You see that child once. What happens then?

GAGLIANOSo only about 20 percent of the people we see are actually pediatric patients. So I just want to make it clear that we're not seeing huge numbers of pediatric patients. One of the things that we do is if we see a child or an adult who is particularly ill, we will call them at 48 or 72 hours to make sure that they are improving.

REHMI see.

GAGLIANOIf we see somebody very sick, we may send them right back to their PCP or an urgent care center. So one of the things that's really important to us is making sure that we're taking care of the right level of patients and then getting them back to their primary source. So if we saw a kids with a really bad sore throat, we would make sure that they're following up with their pediatrician.

REHMDr. Wergin, I'm sure that would ease your mind somewhat.

WERGINTo some degree. And I want to make a comment about the costs. In my practice personally but I think if you track other practices, it is true that people who aren't better in their 24 to 48 hours often end up back at my office. I don't know if that's a cost factored into the initial cost of the retail health clinic. And it's those individuals that may need other things addressed along the -- in their progress.

WERGINSo I would say that the -- and those aren't insubstantial costs and follow-up. But that is important and I'm glad to hear Dr. Gagliano say that they tell their patients to follow up with their primary care provider.

REHMDr. Robert Wergin. He is president-elect of the American Academy of Family Physicians. When we come back, time to open the phones for your comments and questions. Stay with us.

REHMWelcome back. Time to open the phones. First to Middletown, Conn. Hi there, Jean. You're on the air.

JEANHi, thank you for taking my call.

REHMSurely.

JEANMy question is for Dr. Gagliano and it's in reference to the nurse practitioners. Do -- at the Minute Clinic -- do they have support staff to assist with paperwork or other non-clinical tasks? I know when patients go to a walk-in clinic, for example, there is support staff. Thank you.

REHMAll right. Dr. Gagliano?

GAGLIANOHi there. So that's an interesting question, and there's two pieces to it. The model that we have is a very cost-effective model and that allows us to have very low prices. The nurse practitioner is supported very much electronically. So patients register on an electronic kiosk, as opposed to being signed in by a secretary. The visits are completed entirely by the nurse practitioner at the location, but then we have a whole resource centralized office here, based in Woonsocket, R.I. to support a lot of the other functions, such as billings and follow-up phone calls and paperwork. So it's a bit of a mixed model.

REHMAll right. And here's an email from Royal Oak, Mich. Bob asks Vaughn Kauffman, "You just spoke of consumers rather than patients. And that seems to exemplify the change in relationships that will come as we see more retail healthcare. Subjecting the patient relationship to market forces will likely degrade it, all the while speaking of efficiency. It also raises serious issues of privacy and accessibility for medical records, long-term consistency of care, etcetera. And finally an issue raised by clinics in pharmacies, is whether they'll be more likely to suggest solutions that involve buying something." Vaughn Kauffman, let's start with you.

KAUFFMANGreat question. And, yes, there is a distinction when we talk about consumers and healthcare versus patients. Certainly hospitals, urgent cares, retail clinics play a vital role in patient care. When we think about healthcare in general we just don't think about it in the context of when you need care. But when you start to think about how you make better decisions around health, whether it be food, fitness or when you are in fact needing of some type of care.

KAUFFMANSo the consumer angle that we think about is that notion of the day-to-day decisions that we make that impact our health, whether it be in the case where we're healthy or whether it be in the case when we're not healthy. So it is a distinction that we make. But I do want to make sure we emphasize it doesn't, in no way marginalize the importance of regulation, importance of the quality of care that is administered, whether it is through the retail clinic setting or through the traditional hospital setting, because that's absolutely important.

KAUFFMANBut what we're saying when we talk about the consumer is their wants and needs are changing of the healthcare system in general. And the healthcare system needs to be aware of those changes as they think about their business models going forward.

REHMSusan, do you want to comment?

DENTZERWell, I guess I'm trying to look at this from the standpoint of a person who sometimes thinks of herself as a consumer and sometimes as a patient, right? Or as the mother of patients. Dr. Wergin and I were talking when we were off air. And he mentioned that a third of the AFP, American Academy of Family Practice doctors have weekend hours. That means that two-thirds do not. So on a weekend when my kids are sick and I need to get care, what am I?

DENTZERAm I the mother of patients, am I a consumer who wants that convenience and that access right away?

REHMOh, yes.

DENTZERI don't know. But this is really what I'm trying to drive at. That there is a bigger set of forces at play here. There is, as Vaughn Kauffman said, an expectation, increasingly on the part of consumers, that there be more access to care, more days and hours of the week. And let's point out that America's kind of unique in this entire context. Many industrialized countries, whether it's the Netherlands, whether it's the U.K., etcetera, has specifically told their physicians that they must have after-hours care and weekend care.

DENTZERWe have not done that in the United States. And the consequence is that areas like retail clinics have a reason to meet the…

REHMInteresting.

DENTZER…very clear consumer need or patient need -- whatever you call it -- for that after-hours and weekend care.

REHMAnd, Dr. Gagliano, what about the idea that treating a patient within a Minute Clinic at CVS, for example, might involve suggesting that that patient or consumer purchase something within that drugstore?

GAGLIANOSo one of the important things to know about how Minute Clinic is set up is that we create our own care pathways, our own protocols and guidelines for every single service we provide. And in those guidelines we use the best science to determine what is the appropriate way to evaluate the patient and care for the patient. As I think everybody is aware of, right now in this country there is a tremendous overuse of antibiotics. And one of the things we are very, very careful to monitor is prescribing antibiotics and avoiding unnecessary antibiotics.

GAGLIANOThere was a study in the annals of internal medicine a couple years ago looking at areas of quality and cost at retail compared to urgent cares, physicians' offices and emergency rooms. And it was interesting in it found that quality -- the retail health providers were just as good, if not better, than some locations. And in costs, obviously was lower. But in prescription costs particularly, the retail health was as low, if not lower, than any of the other locations. So the fact that we have guidelines very much focused on what is the right treatment helps us to avoid any misperception that we might be over-prescribing because we're based in a pharmacy.

REHMAll right. Let's go to Drew, in Cape May, N.J. Hi, you're on the air.

DREWHi, Diane. Thank you. When I was growing up in the '60s and '70s we had a neighborhood doctor and a neighborhood pharmacist who kind of knew who we were. And the doctor that you spoke to, seems like that kind of doctor, but nowadays, the hospital in my area, Cape Regional, seems to own all the doctors. And they're managed by managers, not by doctors. They need to see like 80 patients a day sometimes. And recently I had an upper respiratory thing and I just got Affordable Care. So I didn't really have insurance until then.

DREWAnd I couldn't see a doctor because they needed to see me for the full workup. So it was like between four days and a week. I finally got one of my old physicians to squeeze me within two days. But when I did get the appointment, I was diagnosed with COPD and given Symbicort.

DREWBut then when I took the tests -- I had x-rays and a PFT test -- it turns out I had no symptoms. I didn't have PFT. So he diagnosed me with a medication that, by the way, the Affordable Care Act pharmacist didn't cover. It would have been a $200 a month fee to get Symbicort if I did have COPD, which wasn't covered by my prescription plan.

REHMVery complicated stuff. Dr. Wergin?

WERGINYes. And that is the kind of problems we see on a daily basis. But in reference to what he's saying, in our membership about 60 percent of us are employed. And I want to say, going back to relationships, I talk to medical students to generate interest in family medicine. And one of the things I stress is you sit in these meetings with others, with your employer, and there's graphs and bar graphs, those represent people.

WERGINAnd you have to keep that in mind. And you should define who and what you are. And I often tell the med students, look out to see how many family physicians are still practicing at 65, 70 years of age. And I say you know why they do that? It's relationships. They get something other than money. And I'm happy to hear that his '60s and '70s experience was good and I think the glory days of family medicine are on the horizon, they're coming back. And the patient-centered home and team base care will accomplish that.

REHMVaughn Kauffman, would you agree?

KAUFFMANYeah, I think, again, the importance of the relationship between a patient and physician is a very important one. So this notion of sort of the doctor that comes to do the house calls and those kind of things back in the day -- you know it's really interesting. From our perspective, as we look at what I would characterize as the decentralization of healthcare to some degree, where, again, we're seeing these retail clinics come online.

KAUFFMANWe're seeing these urgent cares growing and it provides different choices. Another important trend is what technology enables, consumer-physician relationship and that dialog. We're seeing an increase in the number of E-visits happening within the hospital setting where some hospitals are more advanced than others in terms of patients being able to connect directly with a physician through an electronic channel, if you will.

KAUFFMANAnd I think that helps manage that relationship that a number of people feel like has been missing for a while, but technology is enabling sort of that ability to connect with the physicians.

REHMOf course that cannot take the place of that face-to-face encounter. Dr. Gagliano, did you want to comment?

GAGLIANOSure. You know I think the question highlighted a lot of the challenges that healthcare faces right now, with the shortage of primary care, people becoming insured, not knowing where to go, very expensive medications. And I think what we need to do, as much as possible, try to work together to fill in all the gaps. We know there's a shortage of primary care. As I said, I practiced as an internist for 21 years and I completely loved all of my relationships with patients.

GAGLIANOIt is a very, very special component of providing care. But we have to also remember that for patients sometimes, as the conversation was referring to -- sometimes they just need their sore throat taken care of on a weekend and the doc isn't available. And we need to fix all of the different components, not throw away the relationships, but supplement the healthcare system so that we're filling in the gap, we're providing it in very affordable means, as well as really, really high quality. So as a country I think we have a lot of work to do and I don't think there is one easy answer.

REHMSusan?

DENTZERI'm glad Vaughn Kauffman brought up the issue of technology. Because, as he said, once upon a time nobody thought that people would stop going to bank tellers. Well, that day is gone. And now that we have not only the ability to do virtual visits, E-visits, as he said, we have telemedicine now increasingly being authorized in states. And arrangements even to do it across state lines now forming, which has been an issue in the past. One study suggested that if we just had over-the-counter strep tests available for parents to buy, to give to their children, we could eliminate a huge number of arguably unnecessary visits.

REHMDo you see that coming?

DENTZERWell, you know, you think that things aren't going to happen and then someday they do. And so I think technology is also going to be a factor, shifting these patterns of care delivery in our country.

REHMAnd you're listening to "The Diane Rehm Show." Let's go now to David, in Pittsburgh, Pa. Hi, there.

DAVIDHi, Diane. Thanks for taking my call.

REHMSure.

DAVIDI'm going to follow up on something that two callers ago said, in this relationship between doctors and patients. I'll try to make this real quick. Since my primary care physician took a teaching position three years ago I've been looking for a new doctor. The last doctor my wife and I went to, the doctor never examined us, I never even had my shoes off, took my blood pressure, said that the nurse took my blood pressure wrong, that it was high. Asked me to come back in two weeks. She took my blood pressure again.

DAVIDDidn't let the nurse take my blood pressure and then prescribed me long-term blood pressure medicine. She did the same thing with my wife's cholesterol. Now, I don't see where there's much difference between a retail care facility and a retail doctor's office facility. They're doing the same thing. And as long as the profit motive is the important thing, we've going to get the same outcomes no matter where you go.

REHMYou know, it's interesting when somebody said you see 80 patients a day. Following up on what David just said, this is an email from Shelby, who says, "I have a medical condition and an elderly parent for whom I'm responsible. I visit doctors' offices probably more than many. By far the largest cost of going to the doctor's office, in my opinion, is time. I do not understand why a routine visit with an appointment should take up to two and a half hours, when the actual time spent with the doctor is about 12 minutes.

REHM"Don't misunderstand, I like the doctors I see. They care. My problem is there appears no awareness of the fact that I just spent an hour in the waiting room, another 20 to 30 minutes in the exam room, then more time waiting for the paperwork I need to check out. Heaven forbid I need a test. All for standard treatment at an appointed time." Dr. Wergin?

WERGINWell, first of all, I'd like to say I'm sorry about David's experience. And that's certainly not what we want to have a patient experience. And the patient-centered home is exactly that, patient centered. And I fear that these two patients' experience are the doctor-centered home more than the patient-centered home. And we very much push that running on time -- we realize in our offices we have emergencies, but it sounds like her experience is a routine.

WERGINAnd we very much so that we have an appropriate time scheduled for the patients and the number of problems. And if their problems morph into other things, they can follow up. But we do value patients' time and we need to do better. And we will.

REHMAnd one last tweet along those lines from someone who calls him or herself an entrepreneur, "A Minute Clinic model is needed with a family doctor. The medical field should not drag its feet. Also, kudos for stopping selling tobacco." So there you are, Nancy Gagliano, chief medical officer of CVS Minute Clinic. Vaughn Kauffman, principle for PWC health industries. Dr. Robert Wergin, president-elect of the American Academy of Family Physicians. And Susan Dentzer of the Robert Wood Johnson Foundation. Thank you all.

DENTZERThanks, Diane.

GAGLIANOThank you very much.

WERGINThank you, Diane.

KAUFFMANThanks, Diane.

REHMAnd thanks for listening all. I'm Diane Rehm.