Erik L. Goldman

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Senator Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the applecart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an equation he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures and costly acute care will more than adequately cover the costs of insuring all uninsured Americans. And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

“Under my plan, if you lose your job, you do not lose your coverage. Your subsidy would go up, so you'd be able to continue to pay for coverage, and you will still have to pay the portion for which you are responsible. But through the magic of electronic transfers, you will be guaranteed continuous coverage,” he said.

By introducing the Healthy Americans Act, Sen. Wyden has beaten the Democratic presidential hopefuls to the battlefield. Does it have a chance of passing, given a split government and a major election in the offing?

Many observers think not, but Sen. Wyden believes the split Congress and election campaign pressures are an asset. “We want to work together [with Republicans in accordance with] the principles of the Healthy Americans Act. Ten Senators have joined me—five Democrats and five Republicans—in a letter to the President. We're trying to leverage the conditions of a divided government. Remember, welfare legislation got passed in a divided government. Health care is a top issue, and both parties have to go to the voters in 2008.”

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Senator Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the applecart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an equation he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures and costly acute care will more than adequately cover the costs of insuring all uninsured Americans. And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

“Under my plan, if you lose your job, you do not lose your coverage. Your subsidy would go up, so you'd be able to continue to pay for coverage, and you will still have to pay the portion for which you are responsible. But through the magic of electronic transfers, you will be guaranteed continuous coverage,” he said.

By introducing the Healthy Americans Act, Sen. Wyden has beaten the Democratic presidential hopefuls to the battlefield. Does it have a chance of passing, given a split government and a major election in the offing?

Many observers think not, but Sen. Wyden believes the split Congress and election campaign pressures are an asset. “We want to work together [with Republicans in accordance with] the principles of the Healthy Americans Act. Ten Senators have joined me—five Democrats and five Republicans—in a letter to the President. We're trying to leverage the conditions of a divided government. Remember, welfare legislation got passed in a divided government. Health care is a top issue, and both parties have to go to the voters in 2008.”

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Senator Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the applecart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an equation he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures and costly acute care will more than adequately cover the costs of insuring all uninsured Americans. And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

“Under my plan, if you lose your job, you do not lose your coverage. Your subsidy would go up, so you'd be able to continue to pay for coverage, and you will still have to pay the portion for which you are responsible. But through the magic of electronic transfers, you will be guaranteed continuous coverage,” he said.

By introducing the Healthy Americans Act, Sen. Wyden has beaten the Democratic presidential hopefuls to the battlefield. Does it have a chance of passing, given a split government and a major election in the offing?

Many observers think not, but Sen. Wyden believes the split Congress and election campaign pressures are an asset. “We want to work together [with Republicans in accordance with] the principles of the Healthy Americans Act. Ten Senators have joined me—five Democrats and five Republicans—in a letter to the President. We're trying to leverage the conditions of a divided government. Remember, welfare legislation got passed in a divided government. Health care is a top issue, and both parties have to go to the voters in 2008.”

WASHINGTON — Wal-Mart's CEO Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable accessible and high-quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart store a locus of affordable basic health care for millions of Americans.

“We now have 76 independently owned clinics in our stores in the U.S. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient,” Mr. Scott said. “We can drive effectiveness in these settings.”

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse-practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into health care services. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies, such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices. That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” Mr. Scott said.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals.

“People trust their hospitals, especially their local hospitals,” Mr. Scott said. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief. Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” Mr. Scott said. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries, who cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care. “Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, improves the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders!”

He seems baffled by the discrepancy between medicine's 21st-century therapeutic technology and its early 20th-century paper-based information systems.

The criticism is fair enough, but unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

From RediClinics and the $4 prescriptions to the call for universal coverage and a shift away from employer-financed health care, nearly everything Mr. Scott has done thus far has attracted its share of ire. But the Wal-Mart CEO seems to have little time for critics.

“It is easier to sit on the sidelines and criticize what others are doing,” he said. “Those who do so are either stuck in an old debate or protecting their own parochial interests.”

RediClinics, which are housed inside Wal-Mart stores, are typically staffed by nurse-practitioners who have physician and hospital backup. ©Wal-Mart Inc.

WASHINGTON — Wal-Mart's CEO Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable accessible and high-quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart store a locus of affordable basic health care for millions of Americans.

“We now have 76 independently owned clinics in our stores in the U.S. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient,” Mr. Scott said. “We can drive effectiveness in these settings.”

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse-practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into health care services. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies, such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices. That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” Mr. Scott said.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals.

“People trust their hospitals, especially their local hospitals,” Mr. Scott said. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief. Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” Mr. Scott said. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries, who cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care. “Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, improves the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders!”

He seems baffled by the discrepancy between medicine's 21st-century therapeutic technology and its early 20th-century paper-based information systems.

The criticism is fair enough, but unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

From RediClinics and the $4 prescriptions to the call for universal coverage and a shift away from employer-financed health care, nearly everything Mr. Scott has done thus far has attracted its share of ire. But the Wal-Mart CEO seems to have little time for critics.

“It is easier to sit on the sidelines and criticize what others are doing,” he said. “Those who do so are either stuck in an old debate or protecting their own parochial interests.”

RediClinics, which are housed inside Wal-Mart stores, are typically staffed by nurse-practitioners who have physician and hospital backup. ©Wal-Mart Inc.

WASHINGTON — Wal-Mart's CEO Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable accessible and high-quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart store a locus of affordable basic health care for millions of Americans.

“We now have 76 independently owned clinics in our stores in the U.S. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient,” Mr. Scott said. “We can drive effectiveness in these settings.”

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse-practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into health care services. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies, such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices. That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” Mr. Scott said.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals.

“People trust their hospitals, especially their local hospitals,” Mr. Scott said. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief. Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” Mr. Scott said. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries, who cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care. “Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, improves the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders!”

He seems baffled by the discrepancy between medicine's 21st-century therapeutic technology and its early 20th-century paper-based information systems.

The criticism is fair enough, but unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

From RediClinics and the $4 prescriptions to the call for universal coverage and a shift away from employer-financed health care, nearly everything Mr. Scott has done thus far has attracted its share of ire. But the Wal-Mart CEO seems to have little time for critics.

“It is easier to sit on the sidelines and criticize what others are doing,” he said. “Those who do so are either stuck in an old debate or protecting their own parochial interests.”

RediClinics, which are housed inside Wal-Mart stores, are typically staffed by nurse-practitioners who have physician and hospital backup. ©Wal-Mart Inc.

WASHINGTON — Wal-Mart's Chief Executive Officer Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable accessible and high quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart stores a locus of affordable basic health care for millions of Americans. It's an idea that certainly redefines “retail therapy.”

“We now have 76 independently owned clinics in our stores in the U.S. We have a great model. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient. We can drive effectiveness in these settings,” said Mr. Scott.

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into the health care services game. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices.

That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals. “People trust their hospitals, especially their local hospitals,” said Mr. Scott. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief.

Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a medical reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in Information Technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries, who simply cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care.

“Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, improves the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders! Wal-Mart uses [radio-frequency identification] on everything, but today only 5% of hospitals are using bar codes to track medications and patient samples. That's unacceptable.”

He seems baffled by the discrepancy between medicine's 21st century therapeutic technology, and it's early 20th century paper-based information systems.

The criticism is fair enough, provided one overlooks the fact that unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

Though willing to acknowledge the push-back, he's not willing to settle for it. “We need to challenge ourselves and move forward,” he said. To this end, Wal-Mart is partnering with Pitney-Bowes and other major corporations to launch Dossier, an independent, not-for-profit company that will provide secure personal electronic medical records to employees and retirees who own and control their own records.

“It is safe, secure, always up to date, and doctors can have easy access to up-to-date information on their patients,” promised Mr. Scott. “If we commit to health care IT we can improve the quality of life for all 300 million Americans.”

Echoing what's become something of a mantra among corporate leaders concerned with health care, Mr. Scott argued that better information about health care pricing and quality will lead to more intelligent consumer choices.

“People don't have the tools they need. They're prevented from being good consumers of health care. There's a big disconnect between providers, patients, and the cost-value proposition. People can't compare quality. They don't know if one surgeon or hospital or medication is better than another. Imagine if Wal-Mart ran like U.S. health care, where there were no obvious differences in the products we sold, no pricing information, and the customers only saw a very small fraction of the cost of the items they bought.”

Arguably, Mr. Scott's most audacious move in the health care arena was his call, in February, for federally funded universal health insurance coverage. The call, issued jointly by Mr. Scott and Andy Stern, president of the Service Employees International Union, took place in the context of a new coalition called “Better Health Care Together.”

In addition to Wal-Mart and SEIU, the coalition's founding organizations include AT&T; the Howard H. Baker Jr. Center for Public Policy; the Center for American Progress; the Committee for Economic Development; the Communications Workers of America; Intel; and Kelly Services. Its four “common sense” principles are:

▸ We believe every person in America must have quality, affordable health insurance coverage.

▸ We believe individuals have a responsibility to maintain and protect their health.

▸ We believe that America must dramatically improve the value it receives for every health care dollar.

▸ We believe that businesses, governments, and individuals all should contribute to managing and financing a new American health care system.

WASHINGTON — Wal-Mart's Chief Executive Officer Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable accessible and high quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart stores a locus of affordable basic health care for millions of Americans. It's an idea that certainly redefines “retail therapy.”

“We now have 76 independently owned clinics in our stores in the U.S. We have a great model. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient. We can drive effectiveness in these settings,” said Mr. Scott.

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into the health care services game. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices.

That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals. “People trust their hospitals, especially their local hospitals,” said Mr. Scott. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief.

Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a medical reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in Information Technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries, who simply cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care.

“Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, improves the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders! Wal-Mart uses [radio-frequency identification] on everything, but today only 5% of hospitals are using bar codes to track medications and patient samples. That's unacceptable.”

He seems baffled by the discrepancy between medicine's 21st century therapeutic technology, and it's early 20th century paper-based information systems.

The criticism is fair enough, provided one overlooks the fact that unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

Though willing to acknowledge the push-back, he's not willing to settle for it. “We need to challenge ourselves and move forward,” he said. To this end, Wal-Mart is partnering with Pitney-Bowes and other major corporations to launch Dossier, an independent, not-for-profit company that will provide secure personal electronic medical records to employees and retirees who own and control their own records.

“It is safe, secure, always up to date, and doctors can have easy access to up-to-date information on their patients,” promised Mr. Scott. “If we commit to health care IT we can improve the quality of life for all 300 million Americans.”

Echoing what's become something of a mantra among corporate leaders concerned with health care, Mr. Scott argued that better information about health care pricing and quality will lead to more intelligent consumer choices.

“People don't have the tools they need. They're prevented from being good consumers of health care. There's a big disconnect between providers, patients, and the cost-value proposition. People can't compare quality. They don't know if one surgeon or hospital or medication is better than another. Imagine if Wal-Mart ran like U.S. health care, where there were no obvious differences in the products we sold, no pricing information, and the customers only saw a very small fraction of the cost of the items they bought.”

Arguably, Mr. Scott's most audacious move in the health care arena was his call, in February, for federally funded universal health insurance coverage. The call, issued jointly by Mr. Scott and Andy Stern, president of the Service Employees International Union, took place in the context of a new coalition called “Better Health Care Together.”

In addition to Wal-Mart and SEIU, the coalition's founding organizations include AT&T; the Howard H. Baker Jr. Center for Public Policy; the Center for American Progress; the Committee for Economic Development; the Communications Workers of America; Intel; and Kelly Services. Its four “common sense” principles are:

▸ We believe every person in America must have quality, affordable health insurance coverage.

▸ We believe individuals have a responsibility to maintain and protect their health.

▸ We believe that America must dramatically improve the value it receives for every health care dollar.

▸ We believe that businesses, governments, and individuals all should contribute to managing and financing a new American health care system.

WASHINGTON — Wal-Mart's Chief Executive Officer Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable accessible and high quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart stores a locus of affordable basic health care for millions of Americans. It's an idea that certainly redefines “retail therapy.”

“We now have 76 independently owned clinics in our stores in the U.S. We have a great model. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient. We can drive effectiveness in these settings,” said Mr. Scott.

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into the health care services game. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices.

That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals. “People trust their hospitals, especially their local hospitals,” said Mr. Scott. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief.

Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a medical reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in Information Technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries, who simply cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care.

“Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, improves the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders! Wal-Mart uses [radio-frequency identification] on everything, but today only 5% of hospitals are using bar codes to track medications and patient samples. That's unacceptable.”

He seems baffled by the discrepancy between medicine's 21st century therapeutic technology, and it's early 20th century paper-based information systems.

The criticism is fair enough, provided one overlooks the fact that unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

Though willing to acknowledge the push-back, he's not willing to settle for it. “We need to challenge ourselves and move forward,” he said. To this end, Wal-Mart is partnering with Pitney-Bowes and other major corporations to launch Dossier, an independent, not-for-profit company that will provide secure personal electronic medical records to employees and retirees who own and control their own records.

“It is safe, secure, always up to date, and doctors can have easy access to up-to-date information on their patients,” promised Mr. Scott. “If we commit to health care IT we can improve the quality of life for all 300 million Americans.”

Echoing what's become something of a mantra among corporate leaders concerned with health care, Mr. Scott argued that better information about health care pricing and quality will lead to more intelligent consumer choices.

“People don't have the tools they need. They're prevented from being good consumers of health care. There's a big disconnect between providers, patients, and the cost-value proposition. People can't compare quality. They don't know if one surgeon or hospital or medication is better than another. Imagine if Wal-Mart ran like U.S. health care, where there were no obvious differences in the products we sold, no pricing information, and the customers only saw a very small fraction of the cost of the items they bought.”

Arguably, Mr. Scott's most audacious move in the health care arena was his call, in February, for federally funded universal health insurance coverage. The call, issued jointly by Mr. Scott and Andy Stern, president of the Service Employees International Union, took place in the context of a new coalition called “Better Health Care Together.”

In addition to Wal-Mart and SEIU, the coalition's founding organizations include AT&T; the Howard H. Baker Jr. Center for Public Policy; the Center for American Progress; the Committee for Economic Development; the Communications Workers of America; Intel; and Kelly Services. Its four “common sense” principles are:

▸ We believe every person in America must have quality, affordable health insurance coverage.

▸ We believe individuals have a responsibility to maintain and protect their health.

▸ We believe that America must dramatically improve the value it receives for every health care dollar.

▸ We believe that businesses, governments, and individuals all should contribute to managing and financing a new American health care system.

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Senator Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the heady days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the apple cart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHAs) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an equation he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures and costly acute care will more than adequately cover the costs of insuring all uninsured Americans. And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

“Under my plan, if you lose your job, you do not lose your coverage. Your subsidy would go up, so you'd be able to continue to pay for coverage, and you will still have to pay the portion for which you are responsible. But through the magic of electronic transfers, you will be guaranteed continuous coverage,” he said.

By introducing the Healthy Americans Act, Sen. Wyden has beaten the Democratic presidential hopefuls to the battlefield. Does it have a chance of passing, given a split government and a major election in the offing?

Many observers think not, but Sen. Wyden believes the split Congress and election campaign pressures are an asset. “We want to work together [with Republicans in accordance with] the principles of the Healthy Americans Act. Ten Senators have joined me—five Democrats and five Republicans—in a letter to the President. We're trying to leverage the conditions of a divided government. Remember, welfare legislation got passed in a divided government. Health care is a top issue, and both parties have to go to the voters in 2008.”

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Senator Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the heady days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the apple cart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHAs) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an equation he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures and costly acute care will more than adequately cover the costs of insuring all uninsured Americans. And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

“Under my plan, if you lose your job, you do not lose your coverage. Your subsidy would go up, so you'd be able to continue to pay for coverage, and you will still have to pay the portion for which you are responsible. But through the magic of electronic transfers, you will be guaranteed continuous coverage,” he said.

By introducing the Healthy Americans Act, Sen. Wyden has beaten the Democratic presidential hopefuls to the battlefield. Does it have a chance of passing, given a split government and a major election in the offing?

Many observers think not, but Sen. Wyden believes the split Congress and election campaign pressures are an asset. “We want to work together [with Republicans in accordance with] the principles of the Healthy Americans Act. Ten Senators have joined me—five Democrats and five Republicans—in a letter to the President. We're trying to leverage the conditions of a divided government. Remember, welfare legislation got passed in a divided government. Health care is a top issue, and both parties have to go to the voters in 2008.”

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Senator Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the heady days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the apple cart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHAs) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an equation he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures and costly acute care will more than adequately cover the costs of insuring all uninsured Americans. And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

“Under my plan, if you lose your job, you do not lose your coverage. Your subsidy would go up, so you'd be able to continue to pay for coverage, and you will still have to pay the portion for which you are responsible. But through the magic of electronic transfers, you will be guaranteed continuous coverage,” he said.

By introducing the Healthy Americans Act, Sen. Wyden has beaten the Democratic presidential hopefuls to the battlefield. Does it have a chance of passing, given a split government and a major election in the offing?

Many observers think not, but Sen. Wyden believes the split Congress and election campaign pressures are an asset. “We want to work together [with Republicans in accordance with] the principles of the Healthy Americans Act. Ten Senators have joined me—five Democrats and five Republicans—in a letter to the President. We're trying to leverage the conditions of a divided government. Remember, welfare legislation got passed in a divided government. Health care is a top issue, and both parties have to go to the voters in 2008.”

WASHINGTON — Wal-Mart Chief Executive Officer Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open thousands more of the clinics in the near future. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans but scorned by others as a marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style. “The time for politics in health care is over. We need action to create affordable accessible and high-quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart stores a locus of affordable basic health care for millions of Americans. It's an idea that certainly redefines “retail therapy.”

“We now have 76 independently owned clinics in our stores in the U.S. We have a great model. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient. We can drive effectiveness in these settings,” said Mr. Scott.

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into the health care services game. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices.

That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals. “People trust their hospitals, especially their local hospitals,” said Mr. Scott. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief. Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a medical reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries, who simply cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care.

“Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, improves the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders! Wal-Mart uses [radio-frequency identification] on everything, but today only 5% of hospitals are using bar codes to track medications and patient samples. That's unacceptable.”

He seems baffled by the discrepancy between medicine's 21st-century therapeutic technology, and it's early 20th century paper-based information systems.

The criticism is fair enough, provided one overlooks the fact that unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

Though willing to acknowledge the pushback, he's not willing to settle for it. “We need to challenge ourselves and move forward,” he said. To this end, Wal-Mart is partnering with Pitney-Bowes and other major corporations to launch Dossier, an independent, not-for-profit company that will provide secure personal electronic medical records to employees and retirees who own and control their own records.

“It is safe, secure, always up to date, and doctors can have easy access to up-to-date information on their patients,” promised Mr. Scott. “If we commit to health care IT we can improve the quality of life for all 300 million Americans.”

Echoing what's become something of a mantra among corporate leaders concerned with health care, Mr. Scott argued that better information about health care pricing and quality will lead to more intelligent consumer choices.

“People don't have the tools they need. They're prevented from being good consumers of health care. There's a big disconnect between providers, patients, and the cost-value proposition. People can't compare quality. They don't know if one surgeon or hospital or medication is better than another. Imagine if Wal-Mart ran like U.S. health care, where there were no obvious differences in the products we sold, no pricing information, and the customers only saw a very small fraction of the cost of the items they bought.”

Arguably, Mr. Scott's most audacious move in the health care arena was his recent call for federally funded universal health insurance coverage. The call, issued jointly by Mr. Scott and Andy Stern, president of the Service Employees International Union, was in the context of a new coalition called “Better Health Care Together.”

In addition to Wal-Mart and SEIU, the coalition's founding organizations include AT&T; the Howard H. Baker Jr. Center for Public Policy; the Center for American Progress; the Committee for Economic Development; the Communications Workers of America; Intel; and Kelly Services. Its four “common sense” principles are:

▸ We believe every person in America must have quality, affordable health insurance coverage.

▸ We believe individuals have a responsibility to maintain and protect their health.

▸ We believe that America must dramatically improve the value it receives for every health care dollar.

▸ We believe that businesses, governments, and individuals all should contribute to managing and financing a new American health care system.

Mr. Scott said coalition members have set a deadline of 2012 for “major improvements in the health care system.”

“Ninety percent of patients going to these clinics are satisfied or very satisfied with the service,” says Wal-Mart CEOLee Scott, who plans at least 2,000 such clinics. ©Wal-Mart, Inc.

WASHINGTON — Wal-Mart Chief Executive Officer Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open thousands more of the clinics in the near future. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans but scorned by others as a marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style. “The time for politics in health care is over. We need action to create affordable accessible and high-quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart stores a locus of affordable basic health care for millions of Americans. It's an idea that certainly redefines “retail therapy.”

“We now have 76 independently owned clinics in our stores in the U.S. We have a great model. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient. We can drive effectiveness in these settings,” said Mr. Scott.

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into the health care services game. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices.

That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals. “People trust their hospitals, especially their local hospitals,” said Mr. Scott. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief. Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a medical reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries, who simply cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care.

“Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, improves the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders! Wal-Mart uses [radio-frequency identification] on everything, but today only 5% of hospitals are using bar codes to track medications and patient samples. That's unacceptable.”

He seems baffled by the discrepancy between medicine's 21st-century therapeutic technology, and it's early 20th century paper-based information systems.

The criticism is fair enough, provided one overlooks the fact that unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

Though willing to acknowledge the pushback, he's not willing to settle for it. “We need to challenge ourselves and move forward,” he said. To this end, Wal-Mart is partnering with Pitney-Bowes and other major corporations to launch Dossier, an independent, not-for-profit company that will provide secure personal electronic medical records to employees and retirees who own and control their own records.

“It is safe, secure, always up to date, and doctors can have easy access to up-to-date information on their patients,” promised Mr. Scott. “If we commit to health care IT we can improve the quality of life for all 300 million Americans.”

Echoing what's become something of a mantra among corporate leaders concerned with health care, Mr. Scott argued that better information about health care pricing and quality will lead to more intelligent consumer choices.

“People don't have the tools they need. They're prevented from being good consumers of health care. There's a big disconnect between providers, patients, and the cost-value proposition. People can't compare quality. They don't know if one surgeon or hospital or medication is better than another. Imagine if Wal-Mart ran like U.S. health care, where there were no obvious differences in the products we sold, no pricing information, and the customers only saw a very small fraction of the cost of the items they bought.”

Arguably, Mr. Scott's most audacious move in the health care arena was his recent call for federally funded universal health insurance coverage. The call, issued jointly by Mr. Scott and Andy Stern, president of the Service Employees International Union, was in the context of a new coalition called “Better Health Care Together.”

In addition to Wal-Mart and SEIU, the coalition's founding organizations include AT&T; the Howard H. Baker Jr. Center for Public Policy; the Center for American Progress; the Committee for Economic Development; the Communications Workers of America; Intel; and Kelly Services. Its four “common sense” principles are:

▸ We believe every person in America must have quality, affordable health insurance coverage.

▸ We believe individuals have a responsibility to maintain and protect their health.

▸ We believe that America must dramatically improve the value it receives for every health care dollar.

▸ We believe that businesses, governments, and individuals all should contribute to managing and financing a new American health care system.

Mr. Scott said coalition members have set a deadline of 2012 for “major improvements in the health care system.”

“Ninety percent of patients going to these clinics are satisfied or very satisfied with the service,” says Wal-Mart CEOLee Scott, who plans at least 2,000 such clinics. ©Wal-Mart, Inc.

WASHINGTON — Wal-Mart Chief Executive Officer Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open thousands more of the clinics in the near future. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans but scorned by others as a marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style. “The time for politics in health care is over. We need action to create affordable accessible and high-quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart stores a locus of affordable basic health care for millions of Americans. It's an idea that certainly redefines “retail therapy.”

“We now have 76 independently owned clinics in our stores in the U.S. We have a great model. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient. We can drive effectiveness in these settings,” said Mr. Scott.

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into the health care services game. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices.

That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals. “People trust their hospitals, especially their local hospitals,” said Mr. Scott. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief. Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a medical reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries, who simply cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care.

“Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, improves the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders! Wal-Mart uses [radio-frequency identification] on everything, but today only 5% of hospitals are using bar codes to track medications and patient samples. That's unacceptable.”

He seems baffled by the discrepancy between medicine's 21st-century therapeutic technology, and it's early 20th century paper-based information systems.

The criticism is fair enough, provided one overlooks the fact that unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

Though willing to acknowledge the pushback, he's not willing to settle for it. “We need to challenge ourselves and move forward,” he said. To this end, Wal-Mart is partnering with Pitney-Bowes and other major corporations to launch Dossier, an independent, not-for-profit company that will provide secure personal electronic medical records to employees and retirees who own and control their own records.

“It is safe, secure, always up to date, and doctors can have easy access to up-to-date information on their patients,” promised Mr. Scott. “If we commit to health care IT we can improve the quality of life for all 300 million Americans.”

Echoing what's become something of a mantra among corporate leaders concerned with health care, Mr. Scott argued that better information about health care pricing and quality will lead to more intelligent consumer choices.

“People don't have the tools they need. They're prevented from being good consumers of health care. There's a big disconnect between providers, patients, and the cost-value proposition. People can't compare quality. They don't know if one surgeon or hospital or medication is better than another. Imagine if Wal-Mart ran like U.S. health care, where there were no obvious differences in the products we sold, no pricing information, and the customers only saw a very small fraction of the cost of the items they bought.”

Arguably, Mr. Scott's most audacious move in the health care arena was his recent call for federally funded universal health insurance coverage. The call, issued jointly by Mr. Scott and Andy Stern, president of the Service Employees International Union, was in the context of a new coalition called “Better Health Care Together.”

In addition to Wal-Mart and SEIU, the coalition's founding organizations include AT&T; the Howard H. Baker Jr. Center for Public Policy; the Center for American Progress; the Committee for Economic Development; the Communications Workers of America; Intel; and Kelly Services. Its four “common sense” principles are:

▸ We believe every person in America must have quality, affordable health insurance coverage.

▸ We believe individuals have a responsibility to maintain and protect their health.

▸ We believe that America must dramatically improve the value it receives for every health care dollar.

▸ We believe that businesses, governments, and individuals all should contribute to managing and financing a new American health care system.

Mr. Scott said coalition members have set a deadline of 2012 for “major improvements in the health care system.”

“Ninety percent of patients going to these clinics are satisfied or very satisfied with the service,” says Wal-Mart CEOLee Scott, who plans at least 2,000 such clinics. ©Wal-Mart, Inc.

WASHINGTON — Wal-Mart's CEO Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable, accessible, and high-quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart store a locus of affordable basic health care for millions of Americans. It's an idea that certainly redefines “retail therapy.”

“We now have 76 independently owned clinics in our stores in the [United States]. We have a great model. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient. We can drive effectiveness in these settings,” said Mr. Scott.

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies, such as MinuteClinic and Take Care Health, competing for the contracts.

The retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments, and at affordable and clearly visible prices.

That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model is based on building partnerships between the store-based clinics and local hospitals. “People trust their hospitals, especially their local hospitals,” said Mr. Scott. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief.

Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers. “If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a medical reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said. If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries who simply cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care.

“Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, [improving] the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders! Wal-Mart uses [radio-frequency identification] on everything, but today only 5% of hospitals are using bar codes to track medications and patient samples. That's unacceptable.”

He seems baffled by the discrepancy between medicine's 21st century therapeutic technology and its early 20th century paper-based information systems.

Though willing to acknowledge the push-back, he's not willing to settle for it. “We need to challenge ourselves and move forward,” he said. To this end, Wal-Mart is partnering with Pitney-Bowes and other major corporations to launch Dossier, an independent, not-for-profit company that will provide secure personal electronic medical records to employees and retirees who own and control their own records.

“It is safe, secure, [and] always up to date, and doctors can have easy access to up-to-date information on their patients,” promised Mr. Scott. “If we commit to health care IT we can improve the quality of life for all 300 million Americans.”

Echoing what's become something of a mantra among corporate leaders concerned with health care, Mr. Scott argued that better information about health care pricing and quality will lead to more intelligent consumer choices.

“People don't have the tools they need. They're prevented from being good consumers of health care. There's a big disconnect between providers, patients, and the cost-value proposition. People can't compare quality. They don't know if one surgeon or hospital or medication is better than another. Imagine if Wal-Mart ran like U.S. health care, where there were no obvious differences in the products we sold, no pricing information, and the customers only saw a very small fraction of the cost of the items they bought.”

Arguably, Mr. Scott's most audacious move in the health care arena was his call, in February, for federally funded universal health insurance coverage. The call, issued jointly by Mr. Scott and Andy Stern, president of the Service Employees International Union, took place in the context of a new coalition called “Better Health Care Together.”

In addition to Wal-Mart and SEIU, the coalition's founding organizations include AT&T; the Howard H. Baker Jr. Center for Public Policy; the Center for American Progress; the Committee for Economic Development; the Communications Workers of America; Intel; and Kelly Services. Its four “common sense” principles are:

▸ We believe every person in America must have quality, affordable health insurance coverage.

▸ We believe individuals have a responsibility to maintain and protect their health.

▸ We believe that America must dramatically improve the value it receives for every health care dollar.

▸ We believe that businesses, governments, and individuals all should contribute to managing and financing a new American health care system.

Mr. Scott said coalition members have set a deadline of 2012 for “major improvements in the health care system.

From RediClinics and the $4 prescriptions to the call for universal coverage and a shift away from employer-financed health care, nearly everything Mr. Scott has done thus far has attracted its share of ire. But the Wal-Mart CEO seems to have little time for critics.

“It is easier to sit on the sidelines and criticize what others are doing. Those who do so are either stuck in an old debate, or protecting their own parochial interests,” he said.

The RediClinics that operate inside Wal-Mart stores are owned and operated by an independent company. Nurse practitioners with an MD on-call staff the clinics. ©Wal-Mart, Inc.

WASHINGTON — Wal-Mart's CEO Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable, accessible, and high-quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart store a locus of affordable basic health care for millions of Americans. It's an idea that certainly redefines “retail therapy.”

“We now have 76 independently owned clinics in our stores in the [United States]. We have a great model. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient. We can drive effectiveness in these settings,” said Mr. Scott.

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies, such as MinuteClinic and Take Care Health, competing for the contracts.

The retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments, and at affordable and clearly visible prices.

That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model is based on building partnerships between the store-based clinics and local hospitals. “People trust their hospitals, especially their local hospitals,” said Mr. Scott. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief.

Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers. “If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a medical reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said. If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries who simply cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care.

“Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, [improving] the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders! Wal-Mart uses [radio-frequency identification] on everything, but today only 5% of hospitals are using bar codes to track medications and patient samples. That's unacceptable.”

He seems baffled by the discrepancy between medicine's 21st century therapeutic technology and its early 20th century paper-based information systems.

Though willing to acknowledge the push-back, he's not willing to settle for it. “We need to challenge ourselves and move forward,” he said. To this end, Wal-Mart is partnering with Pitney-Bowes and other major corporations to launch Dossier, an independent, not-for-profit company that will provide secure personal electronic medical records to employees and retirees who own and control their own records.

“It is safe, secure, [and] always up to date, and doctors can have easy access to up-to-date information on their patients,” promised Mr. Scott. “If we commit to health care IT we can improve the quality of life for all 300 million Americans.”

Echoing what's become something of a mantra among corporate leaders concerned with health care, Mr. Scott argued that better information about health care pricing and quality will lead to more intelligent consumer choices.

“People don't have the tools they need. They're prevented from being good consumers of health care. There's a big disconnect between providers, patients, and the cost-value proposition. People can't compare quality. They don't know if one surgeon or hospital or medication is better than another. Imagine if Wal-Mart ran like U.S. health care, where there were no obvious differences in the products we sold, no pricing information, and the customers only saw a very small fraction of the cost of the items they bought.”

Arguably, Mr. Scott's most audacious move in the health care arena was his call, in February, for federally funded universal health insurance coverage. The call, issued jointly by Mr. Scott and Andy Stern, president of the Service Employees International Union, took place in the context of a new coalition called “Better Health Care Together.”

In addition to Wal-Mart and SEIU, the coalition's founding organizations include AT&T; the Howard H. Baker Jr. Center for Public Policy; the Center for American Progress; the Committee for Economic Development; the Communications Workers of America; Intel; and Kelly Services. Its four “common sense” principles are:

▸ We believe every person in America must have quality, affordable health insurance coverage.

▸ We believe individuals have a responsibility to maintain and protect their health.

▸ We believe that America must dramatically improve the value it receives for every health care dollar.

▸ We believe that businesses, governments, and individuals all should contribute to managing and financing a new American health care system.

Mr. Scott said coalition members have set a deadline of 2012 for “major improvements in the health care system.

From RediClinics and the $4 prescriptions to the call for universal coverage and a shift away from employer-financed health care, nearly everything Mr. Scott has done thus far has attracted its share of ire. But the Wal-Mart CEO seems to have little time for critics.

“It is easier to sit on the sidelines and criticize what others are doing. Those who do so are either stuck in an old debate, or protecting their own parochial interests,” he said.

The RediClinics that operate inside Wal-Mart stores are owned and operated by an independent company. Nurse practitioners with an MD on-call staff the clinics. ©Wal-Mart, Inc.

WASHINGTON — Wal-Mart's CEO Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable, accessible, and high-quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart store a locus of affordable basic health care for millions of Americans. It's an idea that certainly redefines “retail therapy.”

“We now have 76 independently owned clinics in our stores in the [United States]. We have a great model. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient. We can drive effectiveness in these settings,” said Mr. Scott.

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies, such as MinuteClinic and Take Care Health, competing for the contracts.

The retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments, and at affordable and clearly visible prices.

That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

For those families that have health insurance and their own physicians, it's still pretty hard to argue with the store-based clinic's convenience.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model is based on building partnerships between the store-based clinics and local hospitals. “People trust their hospitals, especially their local hospitals,” said Mr. Scott. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief.

Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription. No doubt, this has traction with consumers. “If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a medical reporter for the Wall Street Journal, who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said. If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, is like many corporate leaders in nonmedical industries who simply cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care.

“Wal-Mart applies technology very intensively. We can track stuff all over the world. This lowers cost and streamlines operations, [improving] the quality of life for employers and customers. Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders! Wal-Mart uses [radio-frequency identification] on everything, but today only 5% of hospitals are using bar codes to track medications and patient samples. That's unacceptable.”

He seems baffled by the discrepancy between medicine's 21st century therapeutic technology and its early 20th century paper-based information systems.

Though willing to acknowledge the push-back, he's not willing to settle for it. “We need to challenge ourselves and move forward,” he said. To this end, Wal-Mart is partnering with Pitney-Bowes and other major corporations to launch Dossier, an independent, not-for-profit company that will provide secure personal electronic medical records to employees and retirees who own and control their own records.

“It is safe, secure, [and] always up to date, and doctors can have easy access to up-to-date information on their patients,” promised Mr. Scott. “If we commit to health care IT we can improve the quality of life for all 300 million Americans.”

Echoing what's become something of a mantra among corporate leaders concerned with health care, Mr. Scott argued that better information about health care pricing and quality will lead to more intelligent consumer choices.

“People don't have the tools they need. They're prevented from being good consumers of health care. There's a big disconnect between providers, patients, and the cost-value proposition. People can't compare quality. They don't know if one surgeon or hospital or medication is better than another. Imagine if Wal-Mart ran like U.S. health care, where there were no obvious differences in the products we sold, no pricing information, and the customers only saw a very small fraction of the cost of the items they bought.”

Arguably, Mr. Scott's most audacious move in the health care arena was his call, in February, for federally funded universal health insurance coverage. The call, issued jointly by Mr. Scott and Andy Stern, president of the Service Employees International Union, took place in the context of a new coalition called “Better Health Care Together.”

In addition to Wal-Mart and SEIU, the coalition's founding organizations include AT&T; the Howard H. Baker Jr. Center for Public Policy; the Center for American Progress; the Committee for Economic Development; the Communications Workers of America; Intel; and Kelly Services. Its four “common sense” principles are:

▸ We believe every person in America must have quality, affordable health insurance coverage.

▸ We believe individuals have a responsibility to maintain and protect their health.

▸ We believe that America must dramatically improve the value it receives for every health care dollar.

▸ We believe that businesses, governments, and individuals all should contribute to managing and financing a new American health care system.

Mr. Scott said coalition members have set a deadline of 2012 for “major improvements in the health care system.

From RediClinics and the $4 prescriptions to the call for universal coverage and a shift away from employer-financed health care, nearly everything Mr. Scott has done thus far has attracted its share of ire. But the Wal-Mart CEO seems to have little time for critics.

“It is easier to sit on the sidelines and criticize what others are doing. Those who do so are either stuck in an old debate, or protecting their own parochial interests,” he said.

The RediClinics that operate inside Wal-Mart stores are owned and operated by an independent company. Nurse practitioners with an MD on-call staff the clinics. ©Wal-Mart, Inc.

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Senator Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the apple cart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting.

He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” he said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an equation he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures and costly acute care will more than adequately cover the costs of insuring all uninsured Americans.

And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

“Under my plan, if you lose your job, you do not lose your coverage. Your subsidy would go up, so you'd be able to continue to pay for coverage, and you will still have to pay the portion for which you are responsible. But through the magic of electronic transfers, you will be guaranteed continuous coverage,” he said.

By introducing the Healthy Americans Act, Sen. Wyden has beaten the Democratic presidential hopefuls to the battlefield. Does it have a chance of passing, given a split government and a major election in the offing?

Many observers think not, but Sen. Wyden believes the split Congress and election campaign pressures are an asset. “We want to work together [with Republicans in accordance with] the principles of the Healthy Americans Act. Ten Senators have joined me—five Democrats and five Republicans—in a letter to the President. We're trying to leverage the conditions of a divided government. Remember, welfare legislation got passed in a divided government. Health care is a top issue, and both parties have to go to the voters in 2008.”

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Senator Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the apple cart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting.

He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” he said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an equation he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures and costly acute care will more than adequately cover the costs of insuring all uninsured Americans.

And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

“Under my plan, if you lose your job, you do not lose your coverage. Your subsidy would go up, so you'd be able to continue to pay for coverage, and you will still have to pay the portion for which you are responsible. But through the magic of electronic transfers, you will be guaranteed continuous coverage,” he said.

By introducing the Healthy Americans Act, Sen. Wyden has beaten the Democratic presidential hopefuls to the battlefield. Does it have a chance of passing, given a split government and a major election in the offing?

Many observers think not, but Sen. Wyden believes the split Congress and election campaign pressures are an asset. “We want to work together [with Republicans in accordance with] the principles of the Healthy Americans Act. Ten Senators have joined me—five Democrats and five Republicans—in a letter to the President. We're trying to leverage the conditions of a divided government. Remember, welfare legislation got passed in a divided government. Health care is a top issue, and both parties have to go to the voters in 2008.”

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Senator Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the apple cart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting.

He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” he said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an equation he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures and costly acute care will more than adequately cover the costs of insuring all uninsured Americans.

And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

“Under my plan, if you lose your job, you do not lose your coverage. Your subsidy would go up, so you'd be able to continue to pay for coverage, and you will still have to pay the portion for which you are responsible. But through the magic of electronic transfers, you will be guaranteed continuous coverage,” he said.

By introducing the Healthy Americans Act, Sen. Wyden has beaten the Democratic presidential hopefuls to the battlefield. Does it have a chance of passing, given a split government and a major election in the offing?

Many observers think not, but Sen. Wyden believes the split Congress and election campaign pressures are an asset. “We want to work together [with Republicans in accordance with] the principles of the Healthy Americans Act. Ten Senators have joined me—five Democrats and five Republicans—in a letter to the President. We're trying to leverage the conditions of a divided government. Remember, welfare legislation got passed in a divided government. Health care is a top issue, and both parties have to go to the voters in 2008.”

WASHINGTON – Wal-Mart's CEO Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable accessible and high quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart store a locus of affordable basic health care for millions of Americans.

“We now have 76 independently owned clinics in our stores in the U.S. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient,” Mr. Scott said. “We can drive effectiveness in these settings.”

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into health care services. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices. That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals.

“People trust their hospitals, especially their local hospitals,” Mr. Scott said. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief. Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a reporter for the Wall Street Journal who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care. “Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders!”

He seems baffled by the discrepancy between medicine's 21st-century therapeutic technology, and its early 20th-century paper-based information systems.

The criticism is fair enough, but unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

From RediClinics and the $4 prescriptions to the call for universal coverage and a shift away from employer-financed health care, nearly everything Mr. Scott has done thus far has attracted its share of ire. But the Wal-Mart CEO seems to have little time for critics.

“It is easier to sit on the sidelines and criticize what others are doing,” he said. “Those who do so are either stuck in an old debate, or protecting their own parochial interests.”

RediClinics, housed inside Wal-Mart stores, are typically staffed by nurse practitioners with access to physician backup. ©Wal-Mart Inc.

WASHINGTON – Wal-Mart's CEO Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable accessible and high quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart store a locus of affordable basic health care for millions of Americans.

“We now have 76 independently owned clinics in our stores in the U.S. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient,” Mr. Scott said. “We can drive effectiveness in these settings.”

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into health care services. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices. That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals.

“People trust their hospitals, especially their local hospitals,” Mr. Scott said. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief. Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a reporter for the Wall Street Journal who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care. “Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders!”

He seems baffled by the discrepancy between medicine's 21st-century therapeutic technology, and its early 20th-century paper-based information systems.

The criticism is fair enough, but unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

From RediClinics and the $4 prescriptions to the call for universal coverage and a shift away from employer-financed health care, nearly everything Mr. Scott has done thus far has attracted its share of ire. But the Wal-Mart CEO seems to have little time for critics.

“It is easier to sit on the sidelines and criticize what others are doing,” he said. “Those who do so are either stuck in an old debate, or protecting their own parochial interests.”

RediClinics, housed inside Wal-Mart stores, are typically staffed by nurse practitioners with access to physician backup. ©Wal-Mart Inc.

WASHINGTON – Wal-Mart's CEO Lee Scott isn't waiting around for Washington's power elite to reform health care. He's taking on the job himself, one gigantic retail store at a time.

In the past 2 years, Wal-Mart has established on-site medical clinics in 76 of its stores, and plans to open several thousand more clinics over the next 5 years. Last year, the company began offering $4 generic prescriptions, a move hailed by some as a major step forward in reducing drug costs for millions of Americans, but scorned by others as a low-brow marketing ploy.

Under Mr. Scott's leadership, Wal-Mart is forming alliances with other major corporations to push the federal government to establish universal health insurance coverage and transportable, patient-owned electronic medical records.

Welcome to health reform, Wal-Mart style.

“The time for politics in health care is over. We need action to create affordable accessible and high quality health care. I believe American business can lead and we should lead. We must be a catalyst for positive change,” said Mr. Scott, speaking at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

Revered by some, reviled by others, Mr. Scott is unquestionably one of the most active corporate leaders on health care issues. He seems determined to make the Wal-Mart store a locus of affordable basic health care for millions of Americans.

“We now have 76 independently owned clinics in our stores in the U.S. In the next 4 years, we plan 2,000 such clinics. We know customers like and want them. Ninety percent of patients going to these clinics are satisfied or very satisfied with the service. It's fast, easy, and convenient,” Mr. Scott said. “We can drive effectiveness in these settings.”

Wal-Mart's “RediClinics” are owned and operated by an independent company, not by Wal-Mart itself. They are typically staffed by nurse practitioners who have ready access to physician and hospital backup if needed.

Wal-Mart is not the only retail chain to get into health care services. Walgreen's, CVS, Target, and Kroger all have or are exploring some form of quickie clinic, and there are a number of independent companies such as MinuteClinic and Take Care Health, competing for the contracts.

Though they are no replacement for comprehensive physician or hospital services, the retail-floor quickie clinics can provide what even many well-run physician offices cannot: instant access walk-in service, without appointments or waiting time, and at affordable and clearly visible prices. That's an awfully enticing combination for many Americans, and the retail clinic model is clearly filling a need. Surveys of customers using the Wal-Mart RediClinics indicate that more than half are uninsured, suggesting that the clinics may be serving as a vital primary care center for many.

“Fifteen percent said they would have had to go to the emergency room for care if the store clinic was not there. Twenty percent were parents bringing children in for treatment,” said Mr. Scott.

That latter fact has not exactly endeared Mr. Scott to the leadership of the American Academy of Pediatrics, which has been outspoken in its criticism of Wal-Mart's clinics and retail-based medicine. But Mr. Scott believes that store-based care is better than no care at all.

Other medical organizations, including the American Medical Association and the American Academy of Family Physicians, have taken a softer stance toward the retail clinic trend, acknowledging that the clinics are a reality, while at the same time pushing for standardized operating principles that limit the scope of services provided, and establishing guidelines for referrals to physicians and hospitals.

Mr. Scott stressed that Wal-Mart is not positioning the RediClinics as replacements for mainstream health care facilities. The future evolution of Wal-Mart's model centers on building partnerships between the store-based clinics and local hospitals.

“People trust their hospitals, especially their local hospitals,” Mr. Scott said. With the right partnerships, the clinic in Aisle No. 3 can become an entry point to more comprehensive care.

If the RediClinics raised eyebrows among health care pundits, Mr. Scott's $4 generic prescription move has them shaking their heads in disbelief. Wal-Mart is now offering shoppers the opportunity to obtain generic forms of many popular medications for $4 per prescription.

“If you have cardiovascular disease, you will be able to get a regimen of drugs for between $12 and $16 per month as opposed to $300 for the branded drugs,” said Ron Winslow, a reporter for the Wall Street Journal who moderated the session at which Mr. Scott spoke. “This has significant implications for health care costs, for drug development, and for drug marketing.”

“Response to this has been nothing short of spectacular. We've generated $290 million in cost savings on drugs for our customers,” said Mr. Scott. In the last year, “35% of all orders we fill are for $4 prescriptions, and nearly 30% of these are filled without insurance.”

Mr. Scott pulled no punches about Wal-Mart's intention to push generics.

“It's about pharmacists and doctors working in new ways. The pharmacists will work with the doctors to determine if generics might be better choices. And we educate consumers about the efficacy of generics. We post full price disclosures. We encourage them to talk to doctors and to learn about generics,” he said.

If his belief in generic drugs is firm, his faith in information technology is nigh on evangelical.

Mr. Scott, who began his Wal-Mart career nearly 30 years ago in the trucking logistics department, cannot understand why the bar-code tracking systems and standardized consumer databases that revolutionized retail and manufacturing several decades ago have not become the norm in health care. “Wal-Mart can pinpoint a pallet of laundry detergent anywhere in our supply chain. I wish it were as easy for doctors to pull a patient's electronic files. They're still using manila folders!”

He seems baffled by the discrepancy between medicine's 21st-century therapeutic technology, and its early 20th-century paper-based information systems.

The criticism is fair enough, but unlike retailers, physicians and other health care givers have little to gain financially from updating their information systems, and unlike pallets of laundry detergent, human beings have concerns about what sorts of information are recorded about them, how that information is used, and by whom it might be seen.

From RediClinics and the $4 prescriptions to the call for universal coverage and a shift away from employer-financed health care, nearly everything Mr. Scott has done thus far has attracted its share of ire. But the Wal-Mart CEO seems to have little time for critics.

“It is easier to sit on the sidelines and criticize what others are doing,” he said. “Those who do so are either stuck in an old debate, or protecting their own parochial interests.”

RediClinics, housed inside Wal-Mart stores, are typically staffed by nurse practitioners with access to physician backup. ©Wal-Mart Inc.

NEW YORK — Researchers at Columbia University and the New York State Psychiatric Institute are using the tools of neuroimaging to modernize electroconvulsive therapy for severe depression and other psychiatric disorders.

By applying principles similar to those used in rational drug design, they are endeavoring to design highly targeted ECT protocols that focus electrical current to those brain regions involved in generating the debilitating symptoms of depression, while minimizing the distribution of charge through uninvolved areas of the brain.

“We're trying to develop new forms of focal brain stimulation. We're learning a lot about the anatomy and the circuitry of mood regulation and dysregulation in the brain,” Dr. Robert Berman said at a symposium sponsored by NARSAD, the Mental Health Research Association.

Dr. Berman, a recipient of NARSAD's 2006 young investigator award, has been working with Harold Sackeim, Ph.D., on a new protocol called focal electrically applied seizure therapy (FEAST), a still experimental approach that directs the electrical charges to discrete areas of the frontal lobes.

For many patients with severe, crippling depression, ECT is still a reasonable treatment option. In many studies, only one-third of patients with the most severe forms of depression obtain meaningful relief with antidepressant medications, and among those who do, side effects can be a long-term problem. For some, ECT is the only treatment that can provide symptom control.

Right unilateral ECT has largely replaced bilateral ECT, with a corresponding decrease in cognitive side effects, but Dr. Berman and Dr. Sackeim believe that ECT can be made even more focal.

Electricity applied to the cranium generally spreads through all areas of the brain, including regions thought to contribute to the cognitive side effects of ECT, thus compromising the risk-benefit ratio. Dr. Berman's work is focused on minimizing this problem.

He believes that the evolution of drug design can provide a meaningful framework for the future development of ECT and other forms of brain stimulation, such as transcranial magnetic stimulation (TMS). “Medications go all over the brain and all over the body. Many of the side effects of medications are systemic,” Dr. Berman said. Targeted modulation of specific neurocircuitry may be a much more focused and favorable way to treat.”

“Rational drug design” is based on the idea that if the particular anatomical and neurochemical pathways that are involved in producing a set of symptoms are known, then molecular structures to fit those pathways can be designed. “Our idea is to develop 'rational brain-stimulation design,'” he said.

The first step in this direction is the identification of specific brain regions involved in mood regulation. Dr. Berman and his colleagues have reviewed neuroimaging studies comparing responders versus nonresponders to a host of antidepressant therapies, including medication, conventional ECT, and transcranial magnetic stimulation. “The scans show that some of the parts of the brain that light up in responders are common to all these different therapies, so this is helping us to define the relevant targets,” he said.

This identification—coupled with general improvements in ECT technology over the last 20 years—has made rational, targeted delivery of current a reality. Dr. Sackeim and his colleagues have developed a system that can focus the electrical pulses only to specific areas in the frontal cortex, while sparing parts of the brain that may not be involved in the antidepressant response but may give rise to side effects. The FEAST approach works, at least in principle.

They recently tested the system in monkeys, after implanting each animal with three recording electrodes containing 10 leads each. These were placed, under MRI guidance, at 30 specific sites all over the brain, providing 30 recording sites spaces throughout the brain. This allowed the researchers to track exactly where the FEAST current traveled, as well as the local neuronal response—including intracerebral EEG, compared with conventional ECT and magnetic stimulation.

The experiment suggested that FEAST is capable of inducing seizures, including EEG-only seizures, without convulsions originating primarily in the frontal portion of the brain, with decreased spread of the electrical impulse to the temporal lobes. “The FEAST protocol single-pulse electrical voltage is high in front and low in the back, which is exactly what we want to see. The topography of the induced voltage is controllable; FEAST induces seizures safely and reliably, and these seizures are more focal than those induced by conventional ECT,” Dr. Berman said. The next step is a pilot clinical trial, to test the efficacy and safety of this approach in human subjects with severe depression who do not respond to drug therapies.

Commenting on the presentation, Dr. J. John Mann, chief of the department of neuroscience at the New York State Psychiatric Institute, said this approach holds tremendous potential for improving the treatment of severe depression because it can potentially spare patients from the adverse effects—especially memory loss—that infrequently accompany conventional ECT.

“Over the past 10–15 years, we've been able to map in detail the parts of the brain affected by depression, and identify the [anatomical sites] responsible for the specific components of what we call depression,” Dr. Mann said. “The parts of the brain adversely affected by ECT and responsible for memory loss are not essentially involved in the depression syndrome, and therefore, they should be spared.”

If focally induced seizures that do not result in generalized motor convulsions are shown to be clinically effective, there would be other benefits as well. In routine ECT, muscle blocking agents are used to dampen the motor convulsion, protecting patients from injury. The greatest risk to ECT patients actually comes from the anesthetic agents used than from the ECT treatment itself, and any reduction in anesthetic would make ECT considerably safer. According to Dr. Berman, there's also a possibility that a protocol like FEAST might be used to induce focal neurogenesis, an objective that's been something of a Holy Grail for generations of research neurologists.

“We don't really know how neurons are induced to divide. But we know that ECT stimulates robust neurogenesis in the hippocampus and there is now some evidence for neurogenesis in other parts of the cortex as well,” he said.

Dr. Berman acknowledged, however, that routine clinical applications of FEAST—or any of the other new, experimental forms of brain stimulation—are still several years in the offing.

“Before patients will be able to have access to this, it will have to be presented to and approved by the [Food and Drug Administration]. We need to demonstrate that it really is an improvement over standard ECT.”

NEW YORK — Researchers at Columbia University and the New York State Psychiatric Institute are using the tools of neuroimaging to modernize electroconvulsive therapy for severe depression and other psychiatric disorders.

By applying principles similar to those used in rational drug design, they are endeavoring to design highly targeted ECT protocols that focus electrical current to those brain regions involved in generating the debilitating symptoms of depression, while minimizing the distribution of charge through uninvolved areas of the brain.

“We're trying to develop new forms of focal brain stimulation. We're learning a lot about the anatomy and the circuitry of mood regulation and dysregulation in the brain,” Dr. Robert Berman said at a symposium sponsored by NARSAD, the Mental Health Research Association.

Dr. Berman, a recipient of NARSAD's 2006 young investigator award, has been working with Harold Sackeim, Ph.D., on a new protocol called focal electrically applied seizure therapy (FEAST), a still experimental approach that directs the electrical charges to discrete areas of the frontal lobes.

For many patients with severe, crippling depression, ECT is still a reasonable treatment option. In many studies, only one-third of patients with the most severe forms of depression obtain meaningful relief with antidepressant medications, and among those who do, side effects can be a long-term problem. For some, ECT is the only treatment that can provide symptom control.

Right unilateral ECT has largely replaced bilateral ECT, with a corresponding decrease in cognitive side effects, but Dr. Berman and Dr. Sackeim believe that ECT can be made even more focal.

Electricity applied to the cranium generally spreads through all areas of the brain, including regions thought to contribute to the cognitive side effects of ECT, thus compromising the risk-benefit ratio. Dr. Berman's work is focused on minimizing this problem.

He believes that the evolution of drug design can provide a meaningful framework for the future development of ECT and other forms of brain stimulation, such as transcranial magnetic stimulation (TMS). “Medications go all over the brain and all over the body. Many of the side effects of medications are systemic,” Dr. Berman said. Targeted modulation of specific neurocircuitry may be a much more focused and favorable way to treat.”

“Rational drug design” is based on the idea that if the particular anatomical and neurochemical pathways that are involved in producing a set of symptoms are known, then molecular structures to fit those pathways can be designed. “Our idea is to develop 'rational brain-stimulation design,'” he said.

The first step in this direction is the identification of specific brain regions involved in mood regulation. Dr. Berman and his colleagues have reviewed neuroimaging studies comparing responders versus nonresponders to a host of antidepressant therapies, including medication, conventional ECT, and transcranial magnetic stimulation. “The scans show that some of the parts of the brain that light up in responders are common to all these different therapies, so this is helping us to define the relevant targets,” he said.

This identification—coupled with general improvements in ECT technology over the last 20 years—has made rational, targeted delivery of current a reality. Dr. Sackeim and his colleagues have developed a system that can focus the electrical pulses only to specific areas in the frontal cortex, while sparing parts of the brain that may not be involved in the antidepressant response but may give rise to side effects. The FEAST approach works, at least in principle.

They recently tested the system in monkeys, after implanting each animal with three recording electrodes containing 10 leads each. These were placed, under MRI guidance, at 30 specific sites all over the brain, providing 30 recording sites spaces throughout the brain. This allowed the researchers to track exactly where the FEAST current traveled, as well as the local neuronal response—including intracerebral EEG, compared with conventional ECT and magnetic stimulation.

The experiment suggested that FEAST is capable of inducing seizures, including EEG-only seizures, without convulsions originating primarily in the frontal portion of the brain, with decreased spread of the electrical impulse to the temporal lobes. “The FEAST protocol single-pulse electrical voltage is high in front and low in the back, which is exactly what we want to see. The topography of the induced voltage is controllable; FEAST induces seizures safely and reliably, and these seizures are more focal than those induced by conventional ECT,” Dr. Berman said. The next step is a pilot clinical trial, to test the efficacy and safety of this approach in human subjects with severe depression who do not respond to drug therapies.

Commenting on the presentation, Dr. J. John Mann, chief of the department of neuroscience at the New York State Psychiatric Institute, said this approach holds tremendous potential for improving the treatment of severe depression because it can potentially spare patients from the adverse effects—especially memory loss—that infrequently accompany conventional ECT.

“Over the past 10–15 years, we've been able to map in detail the parts of the brain affected by depression, and identify the [anatomical sites] responsible for the specific components of what we call depression,” Dr. Mann said. “The parts of the brain adversely affected by ECT and responsible for memory loss are not essentially involved in the depression syndrome, and therefore, they should be spared.”

If focally induced seizures that do not result in generalized motor convulsions are shown to be clinically effective, there would be other benefits as well. In routine ECT, muscle blocking agents are used to dampen the motor convulsion, protecting patients from injury. The greatest risk to ECT patients actually comes from the anesthetic agents used than from the ECT treatment itself, and any reduction in anesthetic would make ECT considerably safer. According to Dr. Berman, there's also a possibility that a protocol like FEAST might be used to induce focal neurogenesis, an objective that's been something of a Holy Grail for generations of research neurologists.

“We don't really know how neurons are induced to divide. But we know that ECT stimulates robust neurogenesis in the hippocampus and there is now some evidence for neurogenesis in other parts of the cortex as well,” he said.

Dr. Berman acknowledged, however, that routine clinical applications of FEAST—or any of the other new, experimental forms of brain stimulation—are still several years in the offing.

“Before patients will be able to have access to this, it will have to be presented to and approved by the [Food and Drug Administration]. We need to demonstrate that it really is an improvement over standard ECT.”

NEW YORK — Researchers at Columbia University and the New York State Psychiatric Institute are using the tools of neuroimaging to modernize electroconvulsive therapy for severe depression and other psychiatric disorders.

By applying principles similar to those used in rational drug design, they are endeavoring to design highly targeted ECT protocols that focus electrical current to those brain regions involved in generating the debilitating symptoms of depression, while minimizing the distribution of charge through uninvolved areas of the brain.

“We're trying to develop new forms of focal brain stimulation. We're learning a lot about the anatomy and the circuitry of mood regulation and dysregulation in the brain,” Dr. Robert Berman said at a symposium sponsored by NARSAD, the Mental Health Research Association.

Dr. Berman, a recipient of NARSAD's 2006 young investigator award, has been working with Harold Sackeim, Ph.D., on a new protocol called focal electrically applied seizure therapy (FEAST), a still experimental approach that directs the electrical charges to discrete areas of the frontal lobes.

For many patients with severe, crippling depression, ECT is still a reasonable treatment option. In many studies, only one-third of patients with the most severe forms of depression obtain meaningful relief with antidepressant medications, and among those who do, side effects can be a long-term problem. For some, ECT is the only treatment that can provide symptom control.

Right unilateral ECT has largely replaced bilateral ECT, with a corresponding decrease in cognitive side effects, but Dr. Berman and Dr. Sackeim believe that ECT can be made even more focal.

Electricity applied to the cranium generally spreads through all areas of the brain, including regions thought to contribute to the cognitive side effects of ECT, thus compromising the risk-benefit ratio. Dr. Berman's work is focused on minimizing this problem.

He believes that the evolution of drug design can provide a meaningful framework for the future development of ECT and other forms of brain stimulation, such as transcranial magnetic stimulation (TMS). “Medications go all over the brain and all over the body. Many of the side effects of medications are systemic,” Dr. Berman said. Targeted modulation of specific neurocircuitry may be a much more focused and favorable way to treat.”

“Rational drug design” is based on the idea that if the particular anatomical and neurochemical pathways that are involved in producing a set of symptoms are known, then molecular structures to fit those pathways can be designed. “Our idea is to develop 'rational brain-stimulation design,'” he said.

The first step in this direction is the identification of specific brain regions involved in mood regulation. Dr. Berman and his colleagues have reviewed neuroimaging studies comparing responders versus nonresponders to a host of antidepressant therapies, including medication, conventional ECT, and transcranial magnetic stimulation. “The scans show that some of the parts of the brain that light up in responders are common to all these different therapies, so this is helping us to define the relevant targets,” he said.

This identification—coupled with general improvements in ECT technology over the last 20 years—has made rational, targeted delivery of current a reality. Dr. Sackeim and his colleagues have developed a system that can focus the electrical pulses only to specific areas in the frontal cortex, while sparing parts of the brain that may not be involved in the antidepressant response but may give rise to side effects. The FEAST approach works, at least in principle.

They recently tested the system in monkeys, after implanting each animal with three recording electrodes containing 10 leads each. These were placed, under MRI guidance, at 30 specific sites all over the brain, providing 30 recording sites spaces throughout the brain. This allowed the researchers to track exactly where the FEAST current traveled, as well as the local neuronal response—including intracerebral EEG, compared with conventional ECT and magnetic stimulation.

The experiment suggested that FEAST is capable of inducing seizures, including EEG-only seizures, without convulsions originating primarily in the frontal portion of the brain, with decreased spread of the electrical impulse to the temporal lobes. “The FEAST protocol single-pulse electrical voltage is high in front and low in the back, which is exactly what we want to see. The topography of the induced voltage is controllable; FEAST induces seizures safely and reliably, and these seizures are more focal than those induced by conventional ECT,” Dr. Berman said. The next step is a pilot clinical trial, to test the efficacy and safety of this approach in human subjects with severe depression who do not respond to drug therapies.

Commenting on the presentation, Dr. J. John Mann, chief of the department of neuroscience at the New York State Psychiatric Institute, said this approach holds tremendous potential for improving the treatment of severe depression because it can potentially spare patients from the adverse effects—especially memory loss—that infrequently accompany conventional ECT.

“Over the past 10–15 years, we've been able to map in detail the parts of the brain affected by depression, and identify the [anatomical sites] responsible for the specific components of what we call depression,” Dr. Mann said. “The parts of the brain adversely affected by ECT and responsible for memory loss are not essentially involved in the depression syndrome, and therefore, they should be spared.”

If focally induced seizures that do not result in generalized motor convulsions are shown to be clinically effective, there would be other benefits as well. In routine ECT, muscle blocking agents are used to dampen the motor convulsion, protecting patients from injury. The greatest risk to ECT patients actually comes from the anesthetic agents used than from the ECT treatment itself, and any reduction in anesthetic would make ECT considerably safer. According to Dr. Berman, there's also a possibility that a protocol like FEAST might be used to induce focal neurogenesis, an objective that's been something of a Holy Grail for generations of research neurologists.

“We don't really know how neurons are induced to divide. But we know that ECT stimulates robust neurogenesis in the hippocampus and there is now some evidence for neurogenesis in other parts of the cortex as well,” he said.

Dr. Berman acknowledged, however, that routine clinical applications of FEAST—or any of the other new, experimental forms of brain stimulation—are still several years in the offing.

“Before patients will be able to have access to this, it will have to be presented to and approved by the [Food and Drug Administration]. We need to demonstrate that it really is an improvement over standard ECT.”

NEW YORK – Riluzole, a drug for amyotrophic lateral sclerosis that targets glutamate cycling in the brain, can markedly improve depression in some patients who remain highly symptomatic despite treatment with other antidepressants, Dr. Steven F. Kendell reported at a symposium sponsored by NARSAD, the Mental Health Research Association.

Though the findings are still preliminary, they are in accord with a growing body of data indicating that the glutaminergic and GABAergic neuron systems may be as important in the etiology of depression as are the more commonly targeted serotonergic and dopaminergic systems, he said.

“Of the currently available antidepressants, almost all of them target the monoamine neurotransmitters: epinephrine, serotonin, and dopamine. But despite treatment with these medications, almost half of all patients are stuck with residual symptoms, and some get very little benefit at all. There's a tremendous need to develop novel medications with novel mechanisms of action,” said Dr. Kendell of the department of psychiatry at Yale University in New Haven, Conn.

The glutamate system is a very promising target. Dr. Gerard Sanacora, who heads Yale University's depression research programs, has identified clear abnormalities in both glutamate and cortical γ-aminobutyric acid (GABA) in depressed versus nondepressed individuals.

Roughly half of all severely depressed patients will show markedly lower levels of GABA but markedly increased levels of glutamate (Arch. Gen. Psychiatry 2004;61:705–13).

Glutamate is normally taken up either by glutaminergic neurons and turned into glutamine, or by GABAergic neurons and turned into GABA.

This process is regulated in large measure by the glial cells.

Other research teams have shown that many patients with severe depression have reduced numbers of glial cells in many parts of their brains, including the anterior cingulate cortex and the prefrontal cortex (Arch. Gen. Psychiatry 2001;58:545–53).

The result is that in some depressed patients, there is a lot of glutamate, which can be toxic at high concentrations, hanging around in the synaptic spaces. This inhibits normal presynaptic glutamate release, reduces glutamate cycling, and inhibits GABA synthesis.

“The excess glutamate feeds back presynaptically and inhibits normal release of glutamate, leading to memory problems and impairment in the ability to think clearly,” Dr. Kendell said.

Riluzole is a fairly unknown medication approved by the Food and Drug Administration for treatment of amyotrophic lateral sclerosis (Lou Gehrig's disease). It is one of the few available drugs that affect glutamate cycling.

It actually increases uptake of glutamate by the glial cells, thus reducing the buildup of synaptic glutamate and normalizing GABA synthesis.

Dr. Kendell and his colleagues tested riluzole as an add-on to other antidepressant medications in a cohort of 10 severely depressed individuals.

These patients were already on an average of three antidepressants and still had Hamilton depression (HAM-D) scores of more than 25 at the start of the study, he said.

Addition of riluzole produced a significant decrease in HAM-D scores in the cohort as a whole, knocking the mean score down from a baseline of 27 to 21 at the end of 12 weeks.

Four of the 10 patients showed a particularly strong response to riluzole, with HAM-D scores dropping from a mean of 26 at baseline to 7 by the close of the 3-month study. In these cases, the response was very rapid; the HAM-D scores took a fast nosedive within the first 2 weeks of treatment.

“We know that about 50% of individuals with depression have abnormal GABA and glutamine levels compared with controls. Are the individuals who had rapid responses to riluzole the same as those who have low GABA and high glutamate? We really need to study this,” Dr. Kendell said.

The next step in this line of research is to use neuroimaging techniques to compare GABA and glutamate levels before and after treatment with riluzole. Then, of course, comes the placebo-controlled clinical trial.

Dr. Kendell said that the Yale team became interested in glutamate cycling in the context of depression in response to reports that ketamine could have profound and long-lasting positive effects in some patients with severe depression.

Ketamine, which is known as “Special K” on the streets, affects GABAergic and glutaminergic neurons.

Some do not think this drug is a good candidate for routine treatment of depression, because it can also induce psychosis, he said.

This line of research also raises the question of whether over-the-counter GABA supplements can improve depression. Dr. Sanacora, who was present at the NARSAD symposium, said that so far there is no evidence to suggest that GABA, when taken orally, “can get into the brain compartments that we're interested in.”

NEW YORK – Riluzole, a drug for amyotrophic lateral sclerosis that targets glutamate cycling in the brain, can markedly improve depression in some patients who remain highly symptomatic despite treatment with other antidepressants, Dr. Steven F. Kendell reported at a symposium sponsored by NARSAD, the Mental Health Research Association.

Though the findings are still preliminary, they are in accord with a growing body of data indicating that the glutaminergic and GABAergic neuron systems may be as important in the etiology of depression as are the more commonly targeted serotonergic and dopaminergic systems, he said.

“Of the currently available antidepressants, almost all of them target the monoamine neurotransmitters: epinephrine, serotonin, and dopamine. But despite treatment with these medications, almost half of all patients are stuck with residual symptoms, and some get very little benefit at all. There's a tremendous need to develop novel medications with novel mechanisms of action,” said Dr. Kendell of the department of psychiatry at Yale University in New Haven, Conn.

The glutamate system is a very promising target. Dr. Gerard Sanacora, who heads Yale University's depression research programs, has identified clear abnormalities in both glutamate and cortical γ-aminobutyric acid (GABA) in depressed versus nondepressed individuals.

Roughly half of all severely depressed patients will show markedly lower levels of GABA but markedly increased levels of glutamate (Arch. Gen. Psychiatry 2004;61:705–13).

Glutamate is normally taken up either by glutaminergic neurons and turned into glutamine, or by GABAergic neurons and turned into GABA.

This process is regulated in large measure by the glial cells.

Other research teams have shown that many patients with severe depression have reduced numbers of glial cells in many parts of their brains, including the anterior cingulate cortex and the prefrontal cortex (Arch. Gen. Psychiatry 2001;58:545–53).

The result is that in some depressed patients, there is a lot of glutamate, which can be toxic at high concentrations, hanging around in the synaptic spaces. This inhibits normal presynaptic glutamate release, reduces glutamate cycling, and inhibits GABA synthesis.

“The excess glutamate feeds back presynaptically and inhibits normal release of glutamate, leading to memory problems and impairment in the ability to think clearly,” Dr. Kendell said.

Riluzole is a fairly unknown medication approved by the Food and Drug Administration for treatment of amyotrophic lateral sclerosis (Lou Gehrig's disease). It is one of the few available drugs that affect glutamate cycling.

It actually increases uptake of glutamate by the glial cells, thus reducing the buildup of synaptic glutamate and normalizing GABA synthesis.

Dr. Kendell and his colleagues tested riluzole as an add-on to other antidepressant medications in a cohort of 10 severely depressed individuals.

These patients were already on an average of three antidepressants and still had Hamilton depression (HAM-D) scores of more than 25 at the start of the study, he said.

Addition of riluzole produced a significant decrease in HAM-D scores in the cohort as a whole, knocking the mean score down from a baseline of 27 to 21 at the end of 12 weeks.

Four of the 10 patients showed a particularly strong response to riluzole, with HAM-D scores dropping from a mean of 26 at baseline to 7 by the close of the 3-month study. In these cases, the response was very rapid; the HAM-D scores took a fast nosedive within the first 2 weeks of treatment.

“We know that about 50% of individuals with depression have abnormal GABA and glutamine levels compared with controls. Are the individuals who had rapid responses to riluzole the same as those who have low GABA and high glutamate? We really need to study this,” Dr. Kendell said.

The next step in this line of research is to use neuroimaging techniques to compare GABA and glutamate levels before and after treatment with riluzole. Then, of course, comes the placebo-controlled clinical trial.

Dr. Kendell said that the Yale team became interested in glutamate cycling in the context of depression in response to reports that ketamine could have profound and long-lasting positive effects in some patients with severe depression.

Ketamine, which is known as “Special K” on the streets, affects GABAergic and glutaminergic neurons.

Some do not think this drug is a good candidate for routine treatment of depression, because it can also induce psychosis, he said.

This line of research also raises the question of whether over-the-counter GABA supplements can improve depression. Dr. Sanacora, who was present at the NARSAD symposium, said that so far there is no evidence to suggest that GABA, when taken orally, “can get into the brain compartments that we're interested in.”

NEW YORK – Riluzole, a drug for amyotrophic lateral sclerosis that targets glutamate cycling in the brain, can markedly improve depression in some patients who remain highly symptomatic despite treatment with other antidepressants, Dr. Steven F. Kendell reported at a symposium sponsored by NARSAD, the Mental Health Research Association.

Though the findings are still preliminary, they are in accord with a growing body of data indicating that the glutaminergic and GABAergic neuron systems may be as important in the etiology of depression as are the more commonly targeted serotonergic and dopaminergic systems, he said.

“Of the currently available antidepressants, almost all of them target the monoamine neurotransmitters: epinephrine, serotonin, and dopamine. But despite treatment with these medications, almost half of all patients are stuck with residual symptoms, and some get very little benefit at all. There's a tremendous need to develop novel medications with novel mechanisms of action,” said Dr. Kendell of the department of psychiatry at Yale University in New Haven, Conn.

The glutamate system is a very promising target. Dr. Gerard Sanacora, who heads Yale University's depression research programs, has identified clear abnormalities in both glutamate and cortical γ-aminobutyric acid (GABA) in depressed versus nondepressed individuals.

Roughly half of all severely depressed patients will show markedly lower levels of GABA but markedly increased levels of glutamate (Arch. Gen. Psychiatry 2004;61:705–13).

Glutamate is normally taken up either by glutaminergic neurons and turned into glutamine, or by GABAergic neurons and turned into GABA.

This process is regulated in large measure by the glial cells.

Other research teams have shown that many patients with severe depression have reduced numbers of glial cells in many parts of their brains, including the anterior cingulate cortex and the prefrontal cortex (Arch. Gen. Psychiatry 2001;58:545–53).

The result is that in some depressed patients, there is a lot of glutamate, which can be toxic at high concentrations, hanging around in the synaptic spaces. This inhibits normal presynaptic glutamate release, reduces glutamate cycling, and inhibits GABA synthesis.

“The excess glutamate feeds back presynaptically and inhibits normal release of glutamate, leading to memory problems and impairment in the ability to think clearly,” Dr. Kendell said.

Riluzole is a fairly unknown medication approved by the Food and Drug Administration for treatment of amyotrophic lateral sclerosis (Lou Gehrig's disease). It is one of the few available drugs that affect glutamate cycling.

It actually increases uptake of glutamate by the glial cells, thus reducing the buildup of synaptic glutamate and normalizing GABA synthesis.

Dr. Kendell and his colleagues tested riluzole as an add-on to other antidepressant medications in a cohort of 10 severely depressed individuals.

These patients were already on an average of three antidepressants and still had Hamilton depression (HAM-D) scores of more than 25 at the start of the study, he said.

Addition of riluzole produced a significant decrease in HAM-D scores in the cohort as a whole, knocking the mean score down from a baseline of 27 to 21 at the end of 12 weeks.

Four of the 10 patients showed a particularly strong response to riluzole, with HAM-D scores dropping from a mean of 26 at baseline to 7 by the close of the 3-month study. In these cases, the response was very rapid; the HAM-D scores took a fast nosedive within the first 2 weeks of treatment.

“We know that about 50% of individuals with depression have abnormal GABA and glutamine levels compared with controls. Are the individuals who had rapid responses to riluzole the same as those who have low GABA and high glutamate? We really need to study this,” Dr. Kendell said.

The next step in this line of research is to use neuroimaging techniques to compare GABA and glutamate levels before and after treatment with riluzole. Then, of course, comes the placebo-controlled clinical trial.

Dr. Kendell said that the Yale team became interested in glutamate cycling in the context of depression in response to reports that ketamine could have profound and long-lasting positive effects in some patients with severe depression.

Ketamine, which is known as “Special K” on the streets, affects GABAergic and glutaminergic neurons.

Some do not think this drug is a good candidate for routine treatment of depression, because it can also induce psychosis, he said.

This line of research also raises the question of whether over-the-counter GABA supplements can improve depression. Dr. Sanacora, who was present at the NARSAD symposium, said that so far there is no evidence to suggest that GABA, when taken orally, “can get into the brain compartments that we're interested in.”