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.

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