AFCM Interviews Take Care Health's Co-Founder and President Peter K. Miller
Peter K. Miller is one of the founders of Take Care Health Systems, one of the nation's top medical clinic businesses and a wholly owned subsidiary of America's largest drugstore company, Walgreens. Mr. Miller, who recently spoke with Americans for Free Choice in Medicine (AFCM) about Take Care's clinics in an exclusive interview, is the company's president and chief executive officer (CEO).
With a purpose to provide convenient and affordable quality health care, Take Care's clinics are staffed by nurse practitioners (NPs) and physician assistants (PAs), with some degree of medical doctor (MD) oversight. Rather than solely concentrating on quick treatment, Take Care adopts what it describes as an integrated approach to the patient's health. Take Care Health Clinics are located at Walgreens drugstores nationwide.
The clinics' staff diagnoses and treats common illnesses and provides vaccinations, physical examinations, and screenings. Take Care uses clinical guidelines and standards adopted by the Convenient Care Association, and maintains electronic records and physician review to ensure quality care. Conshohocken, Pennsylvania-based Take Care, founded in 2004 with initial clinic operation in 2005, reports that its clinics have treated over 280,000 patients.
During his 15 years with Johnson & Johnson, Peter K. Miller led multi-billion dollar global health care companies. Building such brands as Tylenol, Motrin, Pepcid, and Imodium, Mr. Miller has a track record of simplifying complex issues through marketing and earning a profit in the business of medicine.
AFCM: Please explain how Take Care's clinics operate.
Peter K. Miller:: Take Care's system is built around the patient—providing a patient experience unlike any other experience-and that's our driving philosophy. My partner [Take Care Co-Founder and Chairman] Hal Rosenbluth wrote a New York Times bestseller called The Customer Comes Second, so our system is also built around the provider [i.e., those who produce, distribute and practice medicine]. We met with individual physicians and others and we were strongly influenced by the American Academy of Family Physicians (AAFP). We knew that more than 40 percent of patients do not have a consistent health care provider, so, when we open a clinic, we build a network around that center with a goal to take care of the patient. We do refer between 10 and 20 percent of [patients] out [to doctors], though now we're getting referrals to our clinics—between five and 15 percent.
AFCM: Take Care touts an integrated approach to medical treatment. Please provide an example of this idea in practice.
Peter K. Miller:: The reality is that, sometimes, people end up with more complex health problems. As part of our commitment, we do a full personal and family medical history. We take vital signs, regardless of the conditions. We see a substantial number of cases in which we call ambulances or refer patients to the emergency room (ER). For example, we had a guy come in who came for sinusitis. The nurse practitioner noted a significant blood pressure level and he was complaining of chest tightness. He was referred to an emergency room and, within 24 hours, he had three stents put in and he had open heart surgery—this was in Chicago—and the patient's family sent flowers to our nurse practitioners. He felt that he would have probably just waited it out and nto done anything which could have been tragic for him—that we really saved his life.
AFCM: Are there other examples?
Peter K. Miller:: Yes. In Milwaukee, Wisconsin, a 58-year-old male approached the nurse practitioner asking for a recommendation on an over-the-counter medication for Athlete's Foot. After encouraging him to come to the exam room to be seen, she realized that for months he'd been self-treating a typical melanoma. He thought it was a blood blister and then Athlete's Foot, and for months he ignored what he thought was a callous. The NP discussed signs of melanoma, showing him pictures and educational information. She called at least five dermatology offices to get him an immediate appointment. That day he was seen and in the following three days he underwent surgery. He came back to the clinic thanking the NP for saving his life. In another Chicago case, a 76-year-old patient was brought to a clinic by his wife with the complaint of a cough. As the NP started the exam, she noted a heart gallop and edema in the lower legs. He said he was becoming tired as the day went by, not sleeping well, and urinating often. His color was very pale. He had not been to a medical office in 40 years. Due to his symptoms, the NP immediately sent him to the ER where they found a [gastrointestinal] bleed and gave him three blood transfusions in two days. This man might have died.
AFCM: How does Walgreens, with its pharmaceutical history, improve Take Care?
Peter K. Miller:: First off, they're just good people. Their ethical standards are high and they really are committed to improving people's lives. They just possess good Midwestern values. They own some of the best real estate in the United States and they do that well. They have very strong operational excellence. Having Walgreens as our partner enables us to think more broadly.
AFCM: According to Take Care, clinics treat patients 18 months and older, typically for strep throat, pink eye, ear and sinus infections, and poison ivy and Take Care patients can fill prescriptions at any pharmacy. What percentage use Walgreens?
Peter K. Miller:: We give every patient a choice of pharmacy. Having said that, a very high percentage goes to Walgreens. To the patient, it's part of the value proposition.
AFCM: Patient care is provided by Take Care Health Services, an operating entity in each local market. How do you assure quality of care in such a franchise system?
Peter K. Miller:: We have a robust quality control management system. Ten percent of all patients we see have their records reviewed by physicians, making sure they're inside our guidelines and protocols. A lieutenant in the [United States] Air Force developed our peer review system—Sandy Ryan, our chief nurse practitioner officer—and it's great. In 10 percent of cases, the NPs are evaluated and they each have to understand what we're doing in our clinics. In some cases, the NPs don't work out. We've spent over $ 1 million in our protocols for patient use in clinic settings with NPs. Also, every Take Care patient receives a nurse practitioner callback within 24 hours of their visit, asking how they're feeling and how their experience was. Also, if a recommendation was made to follow up with another provider, that NP will confirm with the patient that they made the appointment. If they haven't, we'll call back up to three more times to make sure they do. It's very important. This is just another way we help the patient navigate the health care system.
AFCM: Take Care relies on nurse practitioners and physician assistants (PAs) with review by medical doctors. What is the doctor's role in Take Care's treatment?
Peter K. Miller:: We largely use NPs—government regulations are tighter for PAs, so we're predominantly NP-oriented—and, in our clinics, if an NP thinks the patient's condition is too complex for our setting, she will refer to [what Take Care designates] a collaborating physician, who [is contracted] to be available for our call. Doctors develop good relationships with the NPs, who call every few days or so. It's great for our NPs to have the comfort to call a physician. Physicians primarily do quality management and records review. Collaborating physicians stop by [clinics] from time to time. They can also call our headquarters or a chief NP.
AFCM: How is the doctor paid?
Peter K. Miller:: On a fee for service basis.
AFCM: What is the worst example of government intervention in Take Care's business?
Peter K. Miller:: There haven't been regulations that are phenomenally negative [yet]. Regulations exist and some have proposed regulations to "compete" [by taking advantage of government intervention] with our low cost delivery system. For us to be beneficial, we have to be both high quality and low cost. In the majority of states, the regulations are satisfactory. There are states with onerous regulations. Down in Texas, there's a requirement that collaborating physicians be on site 20 percent of the time. In an age of electronics records, we have physicians that literally sit around and do nothing [to comply with that regulation]. It's not providing any value to the patient. Also, [low] reimbursement rates on Medicaid mean we have to be low cost.
AFCM: Take Care clinics in Nashville, Tennessee, recently opened with extended evening and weekend hours. What are a clinic's typical hours for service?
Peter K. Miller:: Generally, it's 76 hours per week. 12 hours from Monday through Friday and eight hours on the weekend—both days of the weekend. We want to unclog these huge backlogs in ERs—and we work closely with hospitals to alleviate that problem.
AFCM: Your firm has 109 clinics in 14 American cities, with more than 400 planned for opening by the end of 2008. Does each market reflect acceptance of the clinic idea, or does it usually ignite government intervention?
Peter K. Miller:: We're opening almost one clinic a day. For us, success is less about government regulation than access to care. Many states restrict the number of NPs we can have but we [already] want reasonable ratios. When we entered Kansas City, there was a small vocal group that opposed us—largely physicians that were worried we'd impact their business. Now that they've seen how Take Care works, they know that we are committed to quality care. In mid-2008, Take Care plans to open clinics in northern and southern California.
AFCM: Is Take Care profitable?
Peter K. Miller:: We are near or above profitability in markets open more than a year.
AFCM: Please explain Take Care's relationships with Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), the federal government's Medicare program, and the government-mandated state Medicaid programs.
Peter K. Miller:: In every market we've been in for at least a couple of months, we contract with major national providers. The national providers bring 40 to 50 percent of patients, depending on the market, so we are an entry point into the health care system.
AFCM: Have you personally used a Take Care clinic for medical diagnosis and treatment?
Peter K. Miller:: I'm probably one of our best customers. I get my flu shot there every year—and I try to get into one of our clinics very often. All the executives work in our clinics for 12 hours and it's hard to work for 12 hours a day—our busier clinics are seeing 20 to 30 patients a day. It really sensitizes us to understanding what it's like to be a provider. We are a walk-in model, so executives spend a lot of time out in the market. There's nothing like working there for 12 hours.
AFCM: Clinics are open seven days a week with no appointment necessary. How do you guard against patient overutilization or unnecessary health care treatment?
Peter K. Miller:: Flags in our system. If someone is what we call a frequent flyer, there's a patient that needs to be counseled. We haven't had the need to shut someone off [from service]. In fact, we'll soon be publishing data with Dartmouth [College] and with Thomas Jefferson University in terms of patient wait times, protocols, access to care, safety, affordability—and we measure and track all those factors. For example, our appropriate use of antibiotics is significantly better than other primary care providers. So, it's all about education. People come in and say, "how can I get this?" and we actually take the time to say, "you really don't need this". We do the same thing with frequent flyers.
AFCM: The average cost for a visit is under $75. Does the relatively lower cost encourage Take Care to depend upon higher patient volume?
Peter K. Miller:: It is part of our economic model because we need [to budget for] relatively predictable 20-minute examinations. The NP operates with complete autonomy, but when volume reaches 12 patients, we add a patient concierge. Those economics allow us to keep our costs low and our quality high.
AFCM: What percentage of Take Care's patients are repeat customers?
Peter K. Miller:: 11 percent.
AFCM: What percentage of Take Care's patients pay in cash?
Peter K. Miller:: 20 percent.
AFCM: Do you see patients who own Health Savings Accounts (HSAs)?
Peter K. Miller:: Though there is a fair amount of complexity with regard to HSAs, we are starting to see more.
Scott Holleran, Editorial Director
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