Retail clinics are starting to do more primary care

by Joyce Frieden

Retail clinics aren’t just for strep throats any more; they’ll also be managing diabetes and other chronic diseases.

“It’s a new service strategy,” Sandra Ryan, CPNP, told attendees at a meeting on retail clinics sponsored by the Convenient Care Association and the Jefferson School of Population Health.

“We’re evolving our clinic offerings,” said Ryan, chief nurse practitioner officer for Take Care Health Systems, which operates retail clinics inside Walgreens pharmacies, “from episodic treatment to looking at how do we get more chronic disease management, how do we do more prevention, how do we do more screening?”

Most of the so-called retail clinics are located inside pharmacies or grocery stores (hence, the name) although a few are freestanding. Staffed primarily by nonphysician providers, they’ve generally treated acute illnesses such as colds, strep throat, and urinary tract infections; some have also provided vaccinations and sports physicals.

But that’s going to be changing, according to Ryan. “We have recently done some research that showed that people are willing to be treated for high blood pressure, asthma, and high cholesterol” at retail clinics, she noted.

“Knowing there’s an unmet need for treatment and management of chronic conditions in the U.S., and knowing that the cost is increasing, we think retail clinics are on the forefront to meet that need.”

Becoming Part of the Team
Take Care has already begun its first steps in that direction in a few clinics, which are offering spirometry testing for asthma patients and HbA1c tests to screen for diabetes. The chain also is doing hypertension screening and diagnosis. Once patients are diagnosed with hypertension, “we are currently referring them out” for care, but the company is looking at becoming part of the hypertension management team, Ryan said.

Donna Haugland, chief nursing officer at MinuteClinic, which operates retail clinics inside CVS pharmacies, noted that about 11% of Americans have now visited a retail clinic at least once. She added that the cost of managing diseases such as diabetes, which affects 23 million people nationwide, “far surpasses acute illnesses.”

“With fewer and fewer physicians going into primary care, we need more access sites to help control the chronic disease problem we’re running into. . . . We in the retail [clinic business] think we’re perfectly positioned to help in the effort to combat chronic disease,” said Haugland.

“We can identify patients and get them into the healthcare system so they can begin care,” she continued, “and then we can bring them back and help educate them. As they get into the system, we can send them back to primary care and work with primary care in an integrated healthcare system to boost standards of care.”

Thinking Outside the Box
Ryan said chronic disease visits would work differently than the short acute-care visits that make up the majority of retail clinics’ business now. “Our model is built around 20-minute drop-in visits, so some of the restructuring [might involve] more scheduled appointments,” she said. Since retail clinics have peaks and troughs in traffic, with busier times in the morning and afternoon, chronic disease visits — which might be 30 minutes long — would need to be scheduled at less busy times.

Haugland said adding chronic disease management will require retail clinics to “think outside the box. … Do we expand and put a diabetes educator in another space? Do we have some scheduled appointments and some walk-in?”

She added that because the retail clinic business is somewhat seasonal, with the heaviest times during the winter and spring, “we need to find a way to build summer seasonality so the business can stay healthy.” That’s where chronic disease management could come in.

Transparency is Key
Retail clinics first came on the scene in the middle of the last decade, and there are now some 1,200 of them operating in 32 states, according to the Convenient Care Association, a retail clinic trade association founded in 2006.

They appear to be serving a patient group underserved by primary care physicians, according to Ateev Mehrotra, MD, MPH, of the University of Pittsburgh School of Medicine and colleagues, who studied national surveys of visits to retail clinics, primary care physicians, and hospital emergency departments (Health Affairs 2008; 27 (5): 1272- 82).

Mehrotra noted at the meeting that almost two-thirds of retail clinic patients do not have a primary care physician.

He and his colleagues found that more than 90% of retail clinic visits were for just 10 problems: upper respiratory infections, sinusitis, bronchitis, pharyngitis, immunizations, otitis media, otitis externa, conjunctivitis, urinary tract infections, and screening lab test or blood pressure checks.

Those same 10 conditions accounted for just 18% of visits to primary care physicians, he said.

In another study still in press, Mehrotra and colleagues interviewed retail clinic patients to find out more about why they went to the clinics. For the uninsured patients, “one of the things that was a key driver . . . was the transparent pricing,” he said.

One woman taking her son to the clinic told the researchers, “I could take him to a doctor but I would not know how much things would cost. But here the cost is up front.” Retail clinics typically post their pricing, often on large signs.

Physicians Fight Back
Not surprisingly, retail clinics have been targeted nearly from their inception by physician organizations, which charge that the clinics disrupt continuity of care and provide lower-quality care than physicians’ offices or hospitals.

In a 2006 policy statement, the American Academy of Pediatrics (AAP) said flatly, “The AAP opposes [retail clinics] as an appropriate source of medical care for infants, children, and adolescents and strongly discourages their use, because the AAP is committed to the medical home model.”

The group went on to note that “Seeing children with minor conditions, as will often be the case in [a retail clinic], is misleading and problematic. Many pediatricians use the opportunity of seeing the child for something minor to address issues in the family, discuss any problems with obesity or mental health issues, catch up on immunizations, identify undetected illness, and continue strengthening the relationship with the child and family.”

The American Medical Association issued a more cautious report on the clinics at its June 2006 annual meeting: In general, “the AMA supports free market competition among all modes of healthcare delivery and financing, with the growth of any one system determined by the number of people who prefer that mode of delivery, and not determined by preferential federal subsidy, regulations, or promotion,” the association’s Council on Medical Service said in its report.

The council added, however, that “there are some areas of obvious concern with the operation of such clinics, particularly as they relate to patient awareness, physician oversight, and continuity of care.” The council recommended eight principles for retail clinics to follow; the principles were adopted by the organization’s House of Delegates at the meeting.

Included among them were:

* Store-based clinics must have a well-defined and limited scope of clinical services, consistent with state scope of practice laws. Clear definitions of the scope of clinical services offered at store-based health clinics will demonstrate the limitations of the services provided, and should increase the knowledge of patients who seek services at such clinics.

* Store-based clinics must establish protocols for ensuring continuity of care with practicing physicians within the local community. Store-based health clinics should develop systems that appropriately coordinate care between store-based health clinics and physician offices in the local area. Continuity of care is necessary to ensure that patients are receiving optimal medical care for their conditions.

* Store-based clinics must clearly inform patients in advance of the qualifications of the healthcare practitioners who are providing care, as well as the limitation in the types of illnesses that can be diagnosed and treated. Patients should know in advance what types of medical services are offered and understand that healthcare practitioners working in store-based health clinics might not be able to diagnose and treat certain conditions. It is important that patients are aware that store-based health clinics are not a substitute for visiting a physician, and occasional clinic visits should be complemented by regular care visits with a physician.

Taking It to the States
Physician groups also are fighting back in state legislatures by backing laws to regulate the clinics.

“The objections we’ve seen have fallen into three buckets,” said Caroline Ridgway, policy director of the Convenient Care Association. “One bucket would be clinic operation,” such as legislation proposed in Illinois to regulate the size of retail clinics. “In some cases, we’ve seen attempts to mandate that the clinic have its own separate entrance, so that patients would not be allowed to access the clinic via its retail host.”

The second “bucket” holds practitioner-related issues, such as laws to restrict the clinics’ scope of practice, and the third “bucket” encompasses what Ridgway called “non-sequitur” issues, such as proposals to bar health facilities from operating in proximity to places like grocery stores where alcohol and tobacco are sold.

But there’s at least one place where physicians and the association have worked together to make it easier for clinics to operate. That’s in Texas. The state had very strict laws on physician supervision of nurse practitioners, who provide much of the care that’s delivered in retail clinics.

“Each doctor could only supervise three nurse practitioners,” explained Katharine Witgert, program manager at the National Academy for State Health Policy. “They had to be on site 20% of the time, and [physically] review 10% of the charts.”

In 2009, thanks in part to lobbying by physicians and clinics, the legislature voted to ease some of those restrictions. Physicians can now supervise up to four nurse practitioners; they only have to be on-site 10% of the time; and they can conduct chart reviews remotely, Witgert said.

She added that Massachusetts is the only state thus far to have written regulations that specifically address retail clinics.

Massachusetts regulations also require that retail clinics who see patients that don’t have a primary care physician try to connect those patients to a primary care provider, she noted.

Joyce Frieden is a MedPage Today News Editor.

Originally published in MedPage Today. Visit MedPageToday.com for more practice management news.

email

Comments are moderated before they are published. Please read the comment policy.

  • anonymous

    Give them an inch and they will take a mile. It is the same whether you are dealing with Nurse Practioners or democrats. Come to think of it, they are probably synonymous.

  • http://bittersweetmedicine.com/ Dr Lemmon

    The future looks bleak. We cannot stop it.

    I wish reading for the bar exam was still allowed.

  • Patient X

    I like the freedom to choose a retail clinic. They are cheaper than many doctors office and I know what I have pay up front. I have a high deductible and retail clinics make my health care more affordable.

    For anonymous, isn’t this a good free market solution for health care?

    • fam med doc

      Dear Pt X,

      As a board certified Family Physician and in solo medicine, I believe I might have an interesting point of view that applies directly to people like you. As a solo physician, I understand the and agree with the ideas of “a good free market solution”. And by all means, if you believe that going to a retail clinic serves your health needs, by all means do so.
      The reality is they can provide poor healthcare. A recent study already observed that retail clinics prescribe significantly more antibiotics for URI’s (upper respiratory tract infections- also know as colds) compared to physicians. This is poor care and frankly, scary. Antiobiotics do not work against viruses, only bacteria. There are thousands of viruses that cause URI’s, but only about 20 bacteria. Even simple stats should cause anyone to see that if there is a URI, it is likely viral in nature.
      Yet, these NP’s are prescribing a significant more amount of costly, needless, and potentially harmful antibiotics compared to their MD conterparts in primary care. Why? Partially its knowledge base, partly skill set, and partly pressure. If you go and pay your cash for a visit at this “retail clinic”, you most likely expect to receive your antibiotic. Physicians are trained to do the right thing at a much higher level. We succomb to such pressure less than our much less trained NP counterparts due to years of training. For example, I had 4 yrs of med school, 3 years of residency, and 1 yr of a fellowhship. The NP has two years.
      How is it that you would want to go to a NP with 4x less training than an MD? I assure you that their knowledge base is poor in comparison. You write they are “cheaper” than most doctors office. Well, you get what you pay for. And its not quaility with NP’s.
      Family Medicine Doc

      • Patient X

        Doctors are so expensive. When I have a problem, I hesitate to see a doctor because of cost. The retail clinic makes it affordable for me and I can get things checked out for a fraction of the cost. There is less financial risk, especially for those things I am not sure about.

  • Doc99

    Obamacare has jump started the process. Megatrend!!

  • IDDoctor

    I am so opposed to clinics like this and feel it is a conflict of interest for physicians to allow these clinics to operate…and now they want toe xpand their services for chronic conditions like diabetes and HTN? I am sorry…but some PCP’s can’t manage diabetes well enough…so why should we think a retail clinic can do it better? Internist’s and FP’s need to get off their duff and refuse to accept this new paradigm. For that matter…I would never trust a mid-level to managemy diabetes…some diseases are best left to the fully trained physician (not the nurse who takes an additional year of training) or a specialist (Endocrinologist). Furthermore, with the acute care issues like UTI’s…I wonder how many patients are misdiagnosised as having a UTI when they go to these clinics…I mean most PCP’s (MDs and DOs) can’t interpret the simple U/A with micro much less we allow NP’s and PA’s to do that? (I am an ID doctor so I feel I have some insight into the misdiagnosis of UTI’s)…I bet the person is given a antibiotic (so the pharmacy can make some money on that visit. And they generally don’t choose generics…they choose brand name since that makes teh most money for these pharmacies…I mean during my training during residency….I say many a pediatric patient who went to one of these retail pharmacies and was given a diagnosis of otitis media and given azithromycin instead of the tried and true Amoxicillin….why was a z-pak given over the generic penicillin…MORE MONEY FOR THE PHARMACY. I’ll bet ya the kid didn’t have OM and furtehrmore, even if he did there is a great study from Europe that says obseravtion over the next 3 days (with maybe a pain reliever like Aulgran) is sufficient for most patients. Anyways…there are ample examples of things like this that would support the notion that these clinics are really there to make money for the pharamcy…hence why they are there in the first place…you honestly think Walgreens would allow a clinic to be inside it if it didn’t fatten the bottem line?

    I think the medical societies and speciality societies need to take a stand and get these clinics out of here…and should wholeheartedly refuse to allow them to start treatiung chronic conditions. In fact, a way for this to happen (hey this would probably even force congress to act and fix medicare reimbursement)…all doctors should refuse to work for several days and we can see what transpires. Either the health care system will come to a standstill and the public won’t get the care they need or it will go on as if doctors weren’t needed. I doubt that would happen…but it is a possibility. However it would get the public and congress to determine if doctors provide a necessary role in keeping the public healthy and then may serve as a catalyst that they need to take care of us and value our services, instead of always flogging us as the money-grubbing physicians who make too much money (without knowing anything about the debt we are in, etc). Who knows, these retail clinics may go the way of the dodo bird; the medicare SGR may be fixed permanently and maybe the expansion rights of mid-levels will be tailored back to where they belong…i.e. being supervised by a fully licensed physician.

  • TrenchDoc

    The retail clinics will evolve into primary care clinics and they will because there will be a large void to fill when all of us older PCPs retire soon or go into conceriege medicine. They will learn the same hard facts we have:
    1 Chronic Disease management requires lots of well trained staff anf you can’t pay them minimum wage.
    2. The overhead is high
    3. The reimbursement is low
    4. Patients want the care NOW and it had better be cheap and can I get my free samples in the drive through.
    5. Lawyers are gonna love it because the corporate owners of the retail clinics have deeper pockets to pick than some PCP.

    • fam med doc

      i read an article in a medical journey last month that said basically the same thing: the retail clinics proliferation had slowed as they have realized that the overhead cost of a clinic is too high to make a profit.

  • Jadedmd

    I think these clinics are a good option for some with a minor problem, especially if not insured. Screening and education are ok too. But chronic disease management really is best done with continuity, not sure if this type of operation would be able to support that

    • cmg

      some medical care is better than no medical care.

  • jsmith

    The reality is that physicians are getting out of the business of providing primary care to the masses. (Concierge might grow.) As a PCP, I think that is a bad thing for my field and for the public’s health, but you can’t stop what’s coming.
    It will be a royal mess. I’m glad I won’t be there. Unfortunately, the internists and FPs will all be hospitalists so they will have to clean up the mess the retail fools make. The subspecialists will also be on the hook. It’s no fun to co-manage a sick pt with an idiot.

  • family practitioner

    Few random points;

    1. There is not much difference between retail clinics and urgi care other than setting. Both are flawed, although enterpenuerial, attempts to fill in for the lack of primary care access. Just like urgicare has not shut me down, neither will retail clinics. It is one of the biggest myths of modern day medicine that these acute care settings save the system money by keeping patients out of the ER. If anyone ever bother to study it, they would find that these settings actually increase utilization by encouraging people to be seen for things that do not require a visit, ie bug bites and sunburn.

    2. I find it telling that the retail clinics are already offering unnecessary procedures, ie pulmunoary function tests for asthma (this is usually not needed, although SOMETIMES

    2.

    • family practitioner

      (sorry gut cut off)

      3. The real villains are family practitioners and internists that sell their souls for offsite supervision; although I feel the same way about physicians that sell their souls to be medical directors for HMO’s. Without them, both these systems would collapse.

  • imdoc

    There must be opportunity lurking in this model somewhere. Certainly primary care physicians have been defeated by the current model. Maybe a large well financed pharmacy will have more ability to take on the existing system and get real free market systems going. It doesn’t have to be a race to the bottom if doctors can find a way to create value. From what I have seen, trying to play defense and limit nurse practitioners and others doesn’t work. Physicians seem to be much more successful at limiting each other from performing services (that pay…) better than they do ancillary professionals. Considering that we have nurses giving anesthesia, it is a much better fit for them to do screening colonoscopies and excising moles than trying to manage complex chronic disease. I worked in hospitals in which family practice was “not allowed” to do stress tests as only a cardiologist could perform that important and highly risky test. A few years later, when reimbursement fell, suddenly the NP for the cardiologist was doing the stress tests – with the cardiologist off somewhere in the cath lab. In a true free market in which a multitude of practitioners were not limited, overpriced services would fall and important services which require training and expertise would get both funding and respect. What is true becomes evident – an ID doc or oncologist, to name just a couple, having nothing at all to fear from lesser trained para-professionals because the depth of cognitive skill is significant, as is risk. If you are doing low risk, high paid procedures…well who knows? The medical system is all competing for a shrinking pool of money.
    Ok, now I will wait for all the responses from proceduralists that will tell me how complex and valuable their services are and how we should all stand together…