Cost of convenience: Impact of retail clinics on the health care market

In pharmacies, supermarkets and ‘big box’ stores across the country, retail health clinics have experienced exponential growth, stemming largely from patients’ involvement in their own care — and the financial burden that comes with it.

No longer the ‘novelty’ health care alternative they were considered when the first retail-based clinic opened in Minnesota in 2000, there are now 2,300 such clinics in 43 states and Washington D.C., serving more than 35 million patients annually, according to recent estimates from the Convenient Care Association.

Photo courtesy of University of Florida College of Medicine-Jacksonville

Aside from the advantage of extended evening/weekend hours and convenient locations, retail clinics also offer lower average costs than urgent care centers, primary care providers or emergency departments, due in part to the lower salaries of the staff of nurse practitioners and physician assistants and the narrow scope of low-acuity services they provide.

With the current shortage of primary care physicians projected to worsen in the coming years, retail clinics are expected to expand their range into the primary care market, offering services such as routine physical exams. Such development, however, has not been without its critics.

Several organizations, including the American Academy of Family Physicians, the American College of Physicians, and the American Medical Association, have formal positions on retail clinics, voicing concerns that quality of care, impact on continuity of care and communication gaps with primary care providers have not been addressed during retail clinic expansion.

One of the strongest opponents, the AAP warned that retail-based clinics were an inappropriate source of primary care for children, because they fragment care and do not support the pediatric ‘medical home’ concept of coordinated care.

Although most of the present tension between retail clinics and the primary care community has arisen over the treatment of low-acuity conditions, larger retail clinic conglomerates have recently proposed broadening the scope of their practice into chronic care management; this raises a concern for pediatricians who cite the potential for care coordination disruption due to multiple care providers. Infectious Diseases in Children spoke with experts in pediatric medicine regarding the success of — and increased patient reliance on — retail clinics, how the growing retail clinic prevalence impacts the pediatric office, and whether pediatricians should be drawing the line on encroachments from this increasingly popular model of care.

Health sells — but who’s buying?

“Retail clinics are just one part of what I term the ‘convenience revolution’ of health care,” Ateev Mehrotra, MD, MPH, associate professor in the department of health care policy at Harvard Medical School, said in an interview. “Other health care options for children include urgent care centers, telemedicine, kiosks, and even house call companies in which nurse practitioners and physicians come to your home –all of these options are driven primarily by convenience.”

In addition to convenience, recent studies have shown that a major driver of retail clinic growth is the cost. Despite the access provided by the Affordable Care Act, 27.3 million U.S. residents remain uninsured and, along with low-income consumers, are forced to ‘shop’ for more affordable health care options: lower costs and the lack of a standard care provider factor heavily into retail clinic selection.

In a 2008 study published in Health Affairs, Mehrotra and colleagues examined data from more than 1.3 million visits to retail clinics from 2000 to 2007 compared with national data on analogous visits to emergency departments (EDs) and primary care offices. According to study results, retail clinics’ largest demographic were young adults aged 18 to 44 years, only one-third of whom reported that they had a primary care provider.

Moreover, researchers found that 90% of retail clinic visits were used for preventive care for acute conditions, such as sinusitis, otitis media and immunization, which account for only 30% of pediatric primary care visits.

Patients’ responsibility for their own immunization contributes not only to retail clinic revenue but also represents a significant public health service in curtailing the impact of seasonal influenza, complementing vaccination efforts already in place in schools and workplaces. In a study by Uscher-Pines et al in the American Journal of Preventive Medicine, vaccinations were found to be administered in approximately 40% of retail clinic visits, with 1.8 million influenza vaccinations delivered in a single year.

“One of the things the retail clinic model has been able to achieve is easily accessible immunization, which is particularly critical during the influenza season” Sandy Ryan, MSN, RN, FAANP, FAAN, chairman of the Convenient Care Association and vice president of Walmart Care Clinic, told Infectious Diseases in Children. “Additionally, clinics can provide needed childhood immunizations and booster shots for immunizations, such as MMR, meningococcal, and tetanus and diphtheria. In fact, retail clinics were one of the first to put the shingles vaccine in a very convenient location for the public; the cost of carrying that vaccine was expensive for private offices and the complexity of execution of cold chain management made this vaccine one that we could execute easier and more efficiently in a retail setting.”

Arguably, the threat of seasonal influenza pandemics and the effectiveness of influenza vaccines in the hands of nurse practitioners have been partially responsible for driving the explosion in convenient care, which is now poised to play a larger role in the primary care market.

“I believe that retail clinics have become a viable public health option, and the CDC has been very supportive of us, in part because they have seen the uptake in immunizations,” Tine Hansen-Turton, MGA, JD, FAAN, executive director of the Convenient Care Association, said in an interview. “However, to build on this progress means you need a team of providers, and the key to being a team is communication. Our members have invested significant time into the infrastructure so that they can communicate with primary care offices through electronic health care records.”

The dollars and sense of retail clinics

Although retail clinics have been widely viewed as an option to reduce nationwide health care spending — providing a less expensive replacement for costly EDs and primary care visits — cheaper individual visits do not necessarily mean reduced expenditures.

In a study published in Health Affairs, Ashwood et al examined insurance claims data for the 2010-2012 period to track utilization and spending for low-acuity conditions. During the period studied, the researchers found that among retail clinic users, annual per-patient expenditures for retail clinic visits increased by $35, whereas expenditures for primary care offices and EDs decreased by $21 — leaving an additional $14 per patient in annual spending.

Additionally, researchers determined that 58% of retail clinic visits represented new usage rather than substitutions for more expensive care elsewhere.

“The idea that the retail clinic reduces health care spending assumes that the patient otherwise would still have gone to the doctor’s office if the retail clinic was not there,” Mehrotra told Infectious Diseases in Children. “In one scenario, a child has an ear infection but the parent cannot tell if it is serious or not, and the doctor’s office is closed; the parent gives him an Advil and the child is better in the morning. However, in a different scenario, there is a retail clinic in the community and the parent opts to take the child there. What we find is that most visits to a retail clinic represent new utilization vs. a replacement of a doctor appointment, and because most of retail clinic care is new utilization, we see an increase in spending.”

According to data published in Annals of Emergency Medicine, Martsolf and colleagues determined that the opening of retail clinics in proximity to EDs was not associated with a significant reduction in visits to those EDs for low-acuity conditions. Despite the increasing health care demands created by newly insured beneficiaries of the Affordable Care Act, the researchers found that availability of nearby retail clinics did not deter patients from visiting the ED for relatively minor conditions.

“Building more retail clinics does not necessarily reduce ED visits — opening more facilities simply helps meet patient demands that are not currently met,” Jesse M. Pines, MD, from the Center for Healthcare Innovation and Policy Research at George Washington University, said during an interview. “While retail clinics provide increased access to care for patients, the reasons a patient would visit a retail clinic vs. an ED are usually different. In addition, populations that use EDs for low-acuity problems are less likely to have access to other types of care, including retail clinics.”

Despite the lower cost of services for individual patients, the retail clinic model would appear to significantly impact health care cost savings only if it fully replaces more costly care from other facilities, rather than complementing care from other providers.

“While the lack of impact from retail clinics on EDs could be that most retail clinics did not accept Medicaid — the population most likely to use to use the ED for low-acuity conditions — it also begs the question whether clinics are placed in populations that need them most and whether these populations have access to them,” Madeline M. Joseph, MD, chair of the American College of Emergency Physicians Pediatric Committee and professor of emergency medicine and pediatrics at the University of Florida College of Medicine-Jacksonville, told Infectious Diseases in Children.

“However, the larger question I have for retail clinics is the quality of care. If these clinics are expected to stem the tide of patients seeking care at overcrowded EDs, they should ensure the care is up to these ambulatory center standards. We cannot assume that the quality of care is adequate if there are no studies: if you do not measure it, how can you know?”

A question of quality over convenience

Quality of care has been the rallying cry from numerous primary care physicians who have expressed concern that retail clinics may not provide equivalent care to what is available in other settings. However, recent data examining care for acute conditions delivered in retail clinics, which account for most of their services, has indicated that the quality of care is high.

In a study by Shrank et al in the American Journal of Managed Care, researchers compared the quality of care for otitis media, pharyngitis, and urinary tract infection received in retail medical clinics with that received in ambulatory care facilities and EDs. The analysis, based on 14 quality-of-care measures as well as guidelines from the AAP, the AAFP, and the Infectious Diseases Society of America, determined that care received at retail clinics was noninferior to that offered at other facilities.

Although the quality of care may not differ, primary care physicians may question how retail clinics will preserve continuity of care for their patients. Unlike primary care providers, retail clinics address only one aspect of primary care, namely first-contact care; by displacing primary care visits, there is widespread concern that retail clinics could harm continuity and increase the potential for fragmentation of care and missed opportunities for preventive care.

“I can tell you from my own experience in 30 years in practice, many times the seemingly ‘quick visits’ for an episodic illness provides me an opportunity to review the patient as a whole and ensure there are no gaps in care around preventive services or chronic diseases,” Michael L. Munger, MD, president-elect of the AAFP, told Infectious Diseases in Children. “When patients are treated in a silo, only under a strict set of guidelines, there is a potential opportunity that is missed which really contributes to the overall care of the patient.”

In a study published in the Journal of General Internal Medicine, Reid and colleagues addressed the issue of retail clinic influence on continuity with primary care. The researchers determined that patients who visited retail clinics once were more likely to return for ensuing care; while these patients experienced decreased continuity with their primary care provider, the researchers observed no measurable changes in the rates of preventive care or diabetes management.

However, the researchers admitted that their data focused exclusively on short-term impact of retail clinics, and indicated that longer term evaluations might reveal negative impacts of retail clinics on preventive care among younger patients who infrequently visited primary care providers and preferentially visited retail clinics.

“What we have observed repeatedly in retail clinics are patients who have not been seen before in the health care system — 60% of clinic visitors will tell you that they do not have a routine primary care physician,” Ryan said in an interview. “We are seeing patients who come in for a sore throat or an earache, and on exam, we will find that their blood pressure is elevated or they have an underlying condition. “From a professional perspective, it becomes clear that we need to empower our licensed professionals to practice at the highest level of their license and education so they can do more for more for a patient.”

Given the expected increase in primary care provider shortages and rise in the insured population due to health care reform, retail clinics have the potential to grow with the primary care market and aid in reducing the health care burden on other facilities. Improved communication is needed to facilitate more targeted care for patients.

Unfortunately, the exchange of information between physicians and retail clinics is strictly one way at present, with retail clinics expected to update the primary care provider of their actions but are subsequently left in the dark on the primary care provider’s next course of action.

New battlefield in the health care skirmish

Although primary care and retail clinics have formed an uneasy truce — and in some cases, partnerships — in the sphere of low-acuity conditions, recent moves by retail clinic conglomerates into chronic care management services have left primary care physicians and their practices on the defensive.

“I am opposed to any sort of chronic disease management in the retail clinic or anything beyond that scope,” Munger told Infectious Diseases in Children. “That is one of the true definitions of continuity of care, of a continuous, ongoing relationship and it is important that this is done with the patient’s primary care physician to ensure that care is coordinated.”

Even though retail clinics currently play a minor role in overall primary care delivery, physician organizations, such as the AAP and AAFP, have been adamant in holding a hard line against retail clinic expansion.

In a 2014 policy statement, the AAP stated that, “The AAP recognizes that convenience and access to care will continue to be important drivers of how health care is delivered. However, the expertise of the pediatrician and the medical home should continue to be recognized as the standard for care of children, and we encourage all AAP members to provide accessible hours and locations as part of a medical home.”

Likewise, the AAFP has opposed the expansion of the scope of services of retail clinics beyond episodic treatment, and has voiced strong disapproval to the management of chronic medical conditions in the retail clinic setting.

“Retail clinics still need to tighten their ship a bit as far as looking at the quality of care. Prior to any kind of expansion, I feel that the retail clinics need to know that they are doing an adequate job with their current scope of practice,” Joseph said in an interview. “I feel uncomfortable with the quality of care in the clinic right now, and there are simply not enough rules in place in terms of patient safety.”

On the other hand, for the burgeoning retail clinic industry, incorporating chronic care would involve more than a simple expansion of its current services, but also a possible restructuring that could alter the convenience model responsible for its success.

The pillars of convenient location, low cost and extended access times that have made retail clinics so appealing to consumers could radically change with the addition of specialized staff, such as a diabetes educator or hypertension management personnel, which could spur the retail clinic to expand its physical space, raise overall costs, or require scheduled appointments. Or, as Hansen-Turton noted, the next wave of clinic expansion could rely on increasing partnerships.

“I have seen some retail clinics expand into chronic care management, often done in partnership with hospitals that use the local retail clinic as part of an extended network. For chronic care, we should think about where these services are convenient, and consider the busy American consumer — the moms and dads that will be working and balancing jobs — how do you make chronic care accessible in the community?” Hansen-Turton said in an interview. “That is where I have seen the shift in the past few years, with hospital groups that have seen the benefit of having partners closer to where people live and are making that connection.”

Although the retail clinic industry shows no signs of slowing down — the number of retail clinics is expected to exceed 2,800 by the end of 2017 — primary care physicians are ‘taking the fight to them.’ Both the ACP and the AAFP have responded to the rising popularity of retail clinics by encouraging their members to offer same-day and extended-hours appointments for their patients; in addition, many primary care practices are offering email communication for patients to remain in touch with their ‘medical home.’

“It is important to understand that retail clinics are here and they are now part of the medical neighborhood,” Munger said. “It is going to be vitally important that we prevent fragmentation and ensure that we have the necessary communication in place between retail clinics and primary care physicians. Additionally, we need to educate our patients to let them know that most family physicians will, can and are currently offering many of these services, including same-day access and advanced hours. We need to make sure that we are an option and they need to keep us in mind.” – by Bob Stott

• References:
• Ashwood JS. et al. Health Aff. 2016; doi: 10.1377/hlthaff.2015.0995.
• Martsolf G. et al. Ann Emerg Med. 2016; doi: 10.1016/j.annemergmed.
• Mehrotra A. et al. Health Aff. 2008; doi: 10.1377/hlthaff.27.5.1272.
• Reid RO. et al. J Gen Intern Med. 2013; doi: 10.1007/s11606-012-2243-x.
• Shrank WH. Et al. Am J Manag Care. 2014 Oct;20(10):794-801.
• Uscher-Pines L. Am J Prev Med. 2012; doi: 10.1016/j.amepre.2012.02.024.

• For more information:
• Tine Hansen-Turton, MGA, JD, FAAN, can be reached at Convenient Care Association, Market Square East 1500 Market Street, 16th Floor Philadelphia, PA 19102.
• Madeline M. Joseph, MD, can be reached at the University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville FL 32209; email: madeline.joseph@jax.ufl.edu.
• Ateev Mehrotra, MD, MPH, can be reached at Harvard Medical School, 180 Longwood Avenue Boston, MA 02115; email: Mehrotra@hcp.med.harvard.edu.
• Michael L. Munger, MD, can be reached at American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211.
• Jesse M. Pines, MD, can be reached at the George Washington University School of Medicine and Health Sciences, 2100 Pennsylvania Ave. NW. Room 314, Washington DC 20037; email: pinesj@gwu.edu.
• Sandy Ryan, MSN, RN, FAAN, can be reached at Walmart Care Clinic, 702 S.W. 8th St. Bentonville, AK 72716; email: SandraRyan200@gmail.com.

Disclosures: Hansen-Turton, Joseph, Mehrotra, Munger, Pines and Ryan report no relevant financial disclosures.