In Ontario, do walk-in clinics complement—or compete with—primary care?
Megan Diaz* started visiting the walk-in clinic at the mall near her apartment in Toronto after moving to the city for university a few years ago. She goes about twice a year, whenever she feels something is “off” with her body—a bad headache or diarrhea, or when she has a yeast infection. A couple of years ago, she went into the walk-in with what she thought was an anxiety attack; the physician who saw her thought differently, and referred her to a neurologist. “It turned out to be a seizure,” says Diaz, who now sees a specialist every six months for follow-up.
Walk-in clinics started cropping up in the U.S. in the mid-1970s as commercial “free-standing emergency centers,” but soon morphed mainly into an alternative to primary care. By 1979, they had migrated into Canada, with the first opening in 1979 in Edmonton. In 1986, Ontario had 12, and by 1988, there were more than 100 in the province. Today, the number is unknown; the province doesn’t track them. Many family practices offer walk-in services during regular business hours both to their own patients and to the public, and there are also after-hours clinics that are both attached and unattached to rostered practices (in which patients have signed an enrolment form and are assigned to a specific family doctor). And then there are urgent care clinics, which do not keep a roster of patients, are typically open outside business hours, and have the additional feature of being able to provide diagnostic services such as blood work and imaging on site.
Early literature on walk-in clinics in Ontario suggests that they were used by patients who considered their symptoms too serious to wait for an appointment with their GP but felt uncomfortable presenting in the emergency department. In the late ’90s and early 2000s, when there was a shortage of family doctors, walk-in clinics helped fill gaps in service. But what is their role today? Are they a critical complement to primary care or are they a duplication of service? Are they a symptom of “McMedicine,” a drive within the health care system to favour convenience over connection between patients and doctors? There is a dearth of data on walk-in clinics in Canada; the most recent study on quality of care and patient satisfaction is a decade-and-a-half old. A 2017 Cochrane Review seeking to compare quality of care and patient satisfaction in walk-in clinics against physician’s offices and emergency departments found no studies on which to base their research.
Still, walk-in clinics are looking more and more like a permanent fixture in Ontario’s health care system, with an ever-evolving role. Here’s a look at some of what we do know about them.
How walk-in clinics work
A “true” walk-in clinic sees patients with whom they (typically) have no ongoing relationship and without requiring an appointment. On the whole, they deal with acute and episodic issues such as urinary tract infections or pink eye, rather than preventive (such as cancer screening) or chronic (such as managing diabetes) ones. Many are owned by private businesses that provide physicians with physical and administrative infrastructure; doctors are paid by OHIP on a fee-for-service basis and direct a percentage of their payments to the clinic, which employs reception and nursing staff as it considers necessary. Some walk-in clinics, such as those owned by MCI The Doctors Office, which has more than 20 locations in the Greater Toronto Area, also have family practices on site, though Geena Sakellaris, a regional manager at MCI, estimates that about 70 percent of the business is comprised of walk-in services. Sakellaris describes the physicians who work at MCI walk-in clinics as running the gamut from new graduates trying to decide where and how they want to practise to veteran family physicians who have closed their own practices but want to keep working.
When patients enrol with a family practice, they sign a form agreeing not to visit walk-in clinics, though nothing prevents them from doing so, and they do not pay for these visits. However, if a patient is enrolled with a practice that is funded on the capitation model—in which their doctor receives a flat fee for a “basket” of services the patient is considered likely to need—the doctor is penalized for that walk-in clinic visit. A walk-in clinic visit about a cold, for example, for which the fee is $33, will cost their family doctor $33. There is a ceiling on how much a doctor can be penalized for each patient, but the system does create competition between family practices and walk-in clinics.
Why do people use walk-in clinics?
Rick Glazier, family physician at St. Michael’s Hospital and researcher at the Institute for Clinical Evaluative Sciences in Toronto, suggests there are four main reasons patients go to walk-in clinics: 1) They don’t have their own family doctor (about 800,000 Ontarians do not, according to the Ontario Medical Association); 2) they commute long distances between work and home and cannot get to their family practice within the hours that it’s open; 3) they aren’t able to get an appointment soon enough with their own doctor; 4) they choose to for reasons of convenience, frequently without calling their own family doctor first. A review of OHIP data from 2011-12 found that patients enrolled in rostered practices made 1.7 million visits to “outside” physicians. About 93 percent of these visits happened on weekdays, and in at least half of cases, the patients’ own practices had appointment times available when the outside visits took place.
The primary inefficiency with walk-in clinics, says Glazier, is that people often turn up at their family doctor’s office the next day. “They’ll say: ‘I got these orange-and-red capsules; I brought them with me. Do you think I should take them?’” says Glazier. “That happens very frequently.”
Glazier sees walk-in clinics as having a legitimate role in Ontario’s health care system, especially given that they are primarily used by younger people for minor problems. “It’s appropriate at that age and stage of life,” he says. It would be nice if walk-in clinics were affiliated with specific primary care groups, he says, and “it would be even nicer if they were linked to the whole system.” In the absence of electronic medical records that patients can access themselves and also provide access to, Glazier says it would be helpful if walk-in clinics even just sent him a fax. “A simple one-pager, ‘I saw the patient for a sore throat, took a swab, and prescribed this antibiotic,’” he says. “In my experience, that’s extremely rare.”
Do walk-in clinics increase access?
Leo Liao thinks walk-in clinics can significantly increase access, and in a very specific way: through the use of telemedicine. Over the past two years, Liao’s company, Good Doctors, has opened more than 20 walk-in clinics in Ontario. Patients come into a small bricks-and-mortar facility—perhaps two rooms adjacent to a pharmacy—without an appointment, and are assessed by an RN or RPN who then emails the assessment to one of five or six doctors (often in Toronto or Ottawa) on shift. The doctor “sees” the patient through the Ontario Telemedicine Network, a secure technology that is free to physicians. The presenting symptoms are typically “simple things,” says Nicole Anderson, the RPN who runs the Good Doctors clinic in Thunder Bay—rashes, UTIs, prescription refills.
Anderson sees between 10 and 20 people a day, most of whom, she says, don’t have a family doctor. And in the very small communities Good Doctors is hoping to enter—right now they are speaking to several north of Thunder Bay, and already have a clinic in Aamjiwnaang, a First Nation community of about 2,300 outside Sarnia —primary care isn’t even available. Clinicians—often nurses—fly in every few weeks, but, as Liao points out, it might be a different person each time. “It’s much harder to build a relationship,” he says. “If you have someone local to guide you through the system, it makes the whole encounter a lot easier.”
So is walk-in telemedicine a potential solution to reaching underserved, isolated settings? Not a long-term one, according to Sarah Newbery, a family physician in Marathon, Ont. “Some access is better than no access,” she says. “But we should be working to ensure that people have equitable access to the kinds of primary care services that we know actually create an effective health care system.”
First and foremost, for Newbery, this is about continuity. “It’s important for us to be aware of the importance of convenience for people,” she says. “[And] you don’t need a relationship with a patient to treat their UTI or their pink eye. But the value of treating those things in the primary care setting is that it builds the relationship so that when the problem is a cancer diagnosis, or a child who’s committed suicide, or a partner who’s got a terminal illness, [then] you can see someone with whom you’ve built your relationship over time.”
Megan Diaz has never told the walk-in clinic she visits about her follow-up with the neurologist. The doctor who made the original referral has since left the clinic, and “it just hasn’t come up in regards to what I’ve gone there for,” she says. Diaz still has a family doctor in her home town—the same one since childhood—and she still sees him once in a while. She’s no longer in school and plans to stay in Toronto. On the question of whether she will look for a family doctor there, she is on the fence. The familiarity of seeing the same person “is really comforting,” she says, “but it’s just the inconvenience.”
*Name has been changed to protect privacy