"Retail" walk-in clinics, located in supermarkets and stores like CVS and Target, are already competing with physicians in many communities. Now Blue Cross and Blue Shield of Minnesota has added a new twist: It's waiving copayments for patients who go to these in-store clinics. So far, this option applies only to employees of Blue Cross and half a dozen self-insured companies, but the plan is offering it to employers all over Minnesota.

Copayments for office visits are on the rise everywhere; 49 percent of workers in employer-sponsored plans now have copays of $20 or more. So if there were no copays in retail clinics, an increasing number of patients would have an incentive to go there. Blue Cross sees this as a matter of saving money for its customers and for itself, since the average cost of a retail clinic visit (around $50) is about half that of a trip to the doctor's office.

FP Michael J. Morris of Willmar, MN, thinks the insurer's approach to this issue works against its efforts (and those of other plans) to encourage primary care doctors to manage patients' overall health. A nurse at a walk-in clinic, he says, isn't likely to check patients' cholesterol, make sure they're up on their immunizations, and talk to them about their weight or their smoking habit. "Those are things that people usually don't come in for," Morris says. "You catch them at the same time they're in for an acute illness, and try to include their healthcare maintenance simultaneously. So one of the main problems with retail clinics is that they fragment the care."

Rick Kellerman, president-elect of the AAFP, says the Blue Cross initiative is "a bit shortsighted. If they're going to waive copays on visits to retail clinics, why don't they waive them for a similar service in a physician's office? They should try to encourage people to have a personal medical home, where cost can be better controlled and quality better assured."

During a routine office visit, notes Kellerman, the typical family physician takes care of an average of three problems, including the acute problem that may have prompted the visit and a range of preventive and chronic care services. So if Blue Cross thinks it's going to save money by steering patients to retail clinics, he suggests, it may not be including the whole cost of care in its calculations.

The insurer, on the other hand, believes that physicians are making too much of the fact that they might have fewer opportunities to provide health maintenance services if patients use retail clinics. "It's a trivial risk," says internist David W. Plocher, senior vice president and medical director of Blue Cross and Blue Shield of Michigan. Preventive and chronic care, he stresses, are indeed the responsibility of the primary care physician, and retail clinics shouldn't venture into that area.

So why not give patients the same incentive to visit primary care physicians for minor problems that the plan gives them to go to retail clinics? It's mainly a matter of price, replies Plocher. If a nurse practitioner can provide the same service at half the cost, Blue Cross wants patients to use the NP. And that would be true, he adds, even if more medical practices had extended hours, as most retail clinics do. "For minor symptoms and nonserious conditions, delivery systems that rely on nurse practitioners are a better buy."