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Retail Clinics Can Be a Valuable Source Partner

Medical Staff Briefing, August 20, 2007
Walk-in health clinics are becoming more and more prevalent each day, offering healthcare consumers quick, convenient access and low prices. But these so-called convenience care facilities don't necessarily mean competition for traditional healthcare models and may, in fact, boost referrals and thin out common patient choke-points at ERs and urgent-care facilities.

Medical staff leaders need to keep an eye on the retail clinic trend because such facilities will undoubtedly affect traditional medical practices and hospitals now and in the future. Well-known retailer Wal-Mart is the latest chain store to announce its foray into the convenience care market. Wal-Mart intends to open as many as 400 in-store convenience care health clinics in the next three years, expanding to up to 2,000 clinics within seven years.

Wal-Mart is not alone in the rapidly expanding market. Larger retailers such as CVS/Pharmacy, Target, Rite-Aid, H-E-B, Publix, Kroger, and Walgreens all host retail healthcare clinics at limited locations throughout the country, and retailers are planning thousands more down the road. Health marketers expect the clinics to be profitable because they fit into a healthcare niche by offering convenience, access, and affordability.

It's no surprise that retailers are embracing the trend. More consumer traffic in stores means more sales. As many as 35 percent of retail clinic customers leave with a new prescription and 95 percent of those prescriptions are filled by the host retailer's pharmacy, according to a California Health Care Foundation (CHCF) report prepared by California consulting firm Scott & Company, Inc. The CHCF report also indicates that 55 percent of retail clinic patients spend money in the host store on either over-the-counter remedies or general merchandise.

Explosive growth
The retail clinic industry started in 2000 with Minute-Clinic (then named MedRx) in Minnesota. In January 2006, there were 62 retail clinics in the nation. That number was up to 255 by December and to 380 by June 2007, says Mary Kate Scott, founder and CEO of Scott & Company, Inc. She expects 700 retail clinics in the U.S. by the end of this year.

"The key stats to keep in mind are not how many there are now, but how many are on the books," says Preston Gee, a senior managing director with Phase 2 Consulting in Austin, TX.

If all of the retail clinics planned in the U.S. come to fruition, there could be as many as 10,000 by 2012, according to John E. Thomas, vice president of healthcare delivery systems for Market Strategies, Inc., of Livonia, MI. Thomas notes that although those numbers may be aggressive, marketing experts say conservative predictions point to there being at least 5,000 retail clinics in the U.S. by 2012.

Consumers want convenience and accessibility
The explosive growth of convenience care clinics isn't hard to understand. For basic care, they offer convenience, affordability, and accessibility that traditional healthcare providers generally do not, some data suggest. A survey released in April by Market Strategies, Inc., shows that 12 percent of retail clinic customers are replacing their primary care physicians with walk-in clinics.

"There's a hassle factor," says Gee. "Filling out forms and sitting in an office and feeling kind of intimidated by the whole medical milieu--we don't like that. You can go to a [retail clinic] you're comfortable with and buy a beach ball while you're waiting."

Additionally, retail clinics generally are open late and on the weekends, allowing patients to stop at their local Target or Walgreens after work for strep treatment and to shop for lemon-honey throat lozenges while they wait for a nurse practitioner (NP). Some sites even use pagers, such as the kind used in restaurants, to alert patients that a provider is available. Instead of a two- to three-month wait for an appointment with a traditional physician, retail clinic patients can often get treatment in 15 minutes and peruse a fast-food style menu of services to find out the exact cost. Prices range anywhere from $4 to $120. Most treatments fall in the $30-$50 range, and insurance companies now cover 40% of convenience care clinic visits with a $15-$30 copay, according to Scott & Company. Payers such as Cigna, Humana, Aetna, BlueCross/BlueShield, and UnitedHealth Group now cover the retail visits, which are cheaper for insurers. Retail clinic costs average roughly $70 for insurers versus $300 for an average ER visit.

A Scott & Company, Inc., report states that other market forces driving retail clinic proliferation include:
  • An acute long-term shortage of primary care physicians
  • Consumers paying more for healthcare out of pocket
  • New services and technology for home care
  • High cost of health insurance
  • High-deductible health plans gaining traction
  • Technology allowing for new care settings, new pace of diagnosis, and lower costs
  • Investors backing innovation in healthcare delivery


For the most part, NPs and physician assistants (PA) staff retail clinics to provide limited services, such as treatment for cough/respiratory ailments, female bladder infection, flu, seasonal allergies, athlete's foot, ear infections, hives, etc. Most clinics also offer basic immunizations and screenings.

In many retail clinics, a physician serves as medical director to oversee clinic operations. The lower salaries of NPs and PAs (compared to physicians) help retail clinics keep overhead low.

An online Harris Poll taken in 2006 shows that about 92% of retail clinic users were satisfied with the convenience and 89 percent were satisfied with the quality of care.

Acceptance is growing
Many physicians have been wary of retail clinics, but it appears that the attitude across the medical profession has softened to one of guarded acceptance or resignation that retail clinics are not going away. The American Medical Association (AMA) passed a resolution last year calling for convenience care clinics to adopt the following eight principles:
1. Have a defined and limited scope of services, consistent with the state scope-of-practice laws
2. Use standard medical protocols derived from evidence-based practice guidelines to ensure patient safety and quality of care
3. Establish arrangements by which healthcare practitioners have direct access to and supervision by those with medical degrees consistent with state law
4. Establish protocols for continuity of care with local physicians within the community
5. Establish a referral system with physician practices or other facilities for appropriate treatment if patient care is beyond the scope of services provided by the clinic
6. Clearly inform patients in advance of the qualifications of the healthcare practitioners who are providing care, as well as limitations in the types of illnesses that can be treated
7. Use electronic health records
8. Encourage patients to establish care with a primary care physician for continuity of care

There are other signs that so-called convenience care may cause traditional care providers to evolve their delivery approach or at least play an important referral role for primary care providers. The American Academy of Family Physicians (AAFP) is taking a realistic view of retail clinics, says Rick Kellerman, MD, president of AAFP. "The major lesson is that patients want convenience," he says, noting that an AAFP report calls for improved healthcare access in general. "Mothers who work and have a sick child do not want to take off work and wait a day or two for the child to be seen."

To that end, the AAFP is encouraging its members to simultaneously embrace retail clinics and to learn from them by adjusting their own practices. The AAFP has told its members that they can collaborate with retail clinics in their areas by serving as a supervising physician or as a referral physician for medical problems beyond the retail clinic scope, says Kellerman.

"We have also told our members they can compete with retail clinics by expanding office hours and decreasing waiting times through innovations in scheduling," he says. "We have witnessed a number of physician office innovations: sick clinics at noon and after hours, no-wait visits during the day, [etc.]."

The convenience care industry is also gaining stability. In an effort to represent their industry, retail clinic leaders founded the Convenient Care Association (CCA) in September 2006. The CCA focuses on creating consumer-driven, high-quality standards, marketing, and establishing regulatory policies.

Many retail clinic companies have made it clear that they seek to supplement traditional healthcare and work with, not against, established physicians.

In February, leaders from three of the larger retail clinic companies--MinuteClinic, TakeCare Health, and RediClinic--met with the AAFP and agreed to support five desired attributes in their clinics:
  • Scope of service. Retail clinics must have a well-defined and limited scope of clinical services.
  • Evidence-based medicine. Clinical services and treatment must be evidence-based and quality improvement oriented.
  • Team-based. Clinics should have a formal connection with physician practices in the local community, preferably with family physicians, to provide continuity of care. Other health professionals, such as NPs, should only operate in accordance with state and local regulations as part of a team-based approach to healthcare and under responsible supervision of a practicing, licensed physician.
  • Referrals. Clinics must have referral systems to physician practices or to other entities appropriate to the patient's symptoms beyond the clinic's scope of work. Clinics should encourage all patients to have a medical home.
  • EHR. Clinics should have EHR systems sufficient to gather and communicate patient information with a family physician's office, preferably one that is compatible with the Continuity of Care Record supported by the AAFP.


Susan Apold, PhD, president of the American College of Nurse Practitioners, said in a statement in January that the current healthcare system does not meet consumer's needs. She endorsed the convenient care industry, in which more than 110,000 NPs work. "Already making our mark among patients and their families, it is time for the nursing approach, talent, and skill to be recognized as the enormous part of the healthcare solution that we are," Apold said. "The convenient care industry realizes this. Now is the time for the rest of the nation to embrace it as well."

Effects of clinics
Retail clinics may also ease the demand on crowded ERs, according to Ken Miller, PhD, vice dean for internal programs at the University of New Mexico College of Nursing in Albuquerque. He also points out that the rise in retail clinics simply provides another avenue for all healthcare providers to practice.

"One of the benefits of these clinics is that they will take the burden off of emergency rooms by decreasing the numbers of patients who use emergency rooms for their primary care needs," Miller says.

The emergency department (ED) is the wrong place for nonemergency primary care, especially when such care costs $250-$300 versus $50 for a retail clinic, Gee says.

Will Garin, vice president of marketing for SmartCare, which runs retail clinics in 15 Wal-Mart Supercenters in Colorado, says hospitals shouldn't fear a loss of revenue to convenience care, and that SmartCare strives to complement an established physician relationship.

Garin says SmartCare provides referrals and encourages patients to have a regular physician.

"Hospitals play a different role in healthcare, as do urgent-care centers," Garin says. "SmartCare is not a hospital, emergency, or urgent-care facility. We are a quality resource for pressing, nonemergency issues like sore throats, bladder infections, and strains, sprains, and pains."

Another effect for hospitals to consider is whether the growth of retail clinics will mean stronger competition to hire and retain quality NPs and PAs. Experts are leaning both ways.

Bob Smithing, who runs the Web site www.npcentral.net, says the question is tough to answer. One benefit he sees is that retail clinics offer NPs another opportunity for employment in a nontraditional setting. "I think hospitals are going to be looking for quality nurse practitioners [more] if they get into that product line of having the same type of clinics," Smithing says. "If they're not in that marketplace, then I don't think it's going to impact them in their selection of NPs."

Start new relationships to improve service and increase revenue
It is not hard to imagine that 10,000 new retail clinics in the U.S. by 2012 could affect traditional healthcare providers such as family physicians.

The AMA and the AAFP appear to be granting the convenience care industry some guarded recognition by encouraging standards and referrals.

Gee says the effects will depend on individual markets but that partnerships between retail clinics and physicians are a positive possibility.

"[Physicians] can create an inside track to downstream referrals," he says.

Physicians with too many patients may benefit from a retail clinic opening in their area, Gee adds.

On the other hand, new practices could see store-based clinics as a significant factor in drawing patients. Either way, physicians should have the retail clinic surge on their radar screens.

"The most unenlightened position would be to say this is a passing fad," Gee says. "That does not appear to be the case. I think it represents a sea change--that it's a seismic shift in healthcare, in general, away from traditional medical settings."

Statistics show that as many as half of retail clinic customers who need a referral are sent to physicians or groups named specifically by the clinic.

The opportunity to build referrals clearly exists, and physicians can take simple approaches such as calling retail clinics or meeting with medical directors to initiate a relationship.

"You need to build those bridges," says Kenneth T. Hertz, a senior consultant at the Medical Group Management Association Health Care Group in Louisiana. "You need to open dialogue."

Garin says SmartCare works collaboratively with physician networks, healthcare systems, urgent-care providers, and hospital systems to provide guests timely access to all levels of care.

"We believe that consumers are best served when they receive more specialized or advanced care from the appropriate providers, be that primary or specialty physicians, urgent-care facilities, or hospitals," Garin says.

Large healthcare systems are also opening their own convenience clinics. Sutter Health of California, Geisinger Health System in Pennsylvania, and Memorial Hospital & Health System of Indiana have all opened retail clinics.

Whether retail clinics will revolutionize healthcare as some marketing experts predict is still up for debate, according to Kellerman. But it would be foolhardy for physician leaders to ignore the trend.

"The market will tell us whether they are here to stay," Kellerman says. "Some retail clinic companies will survive; some will not . . . Some have plans for expansion; others have already closed or will close clinics. There will be a shakeout over the next couple of years."

Erin Callahan is the editor of Medical Staff Briefing. She may be reached at ecallahan@hcpro.com. This story first appeared in the August edition of Medical Staff Briefing, a monthly newsletter by HCPro Inc. For information on all of HCPro's products, visit www.hcmarketplace.com.