What's Next for Retail Healthcare?
The Trend That Disrupted Healthcare Consumerism a Decade Ago Continues to Evolve.
In the early-to-mid 2000s, when the first retail clinics emerged and quickly proliferated, traditional healthcare providers raised concerns about quality as well as protecting their market share. In the meantime, the ability to get affordable treatment on the fly for minor illnesses such as coughs and sore throats became a hit with patients.
The majority (91%) of patients who recently used a retail clinic reported that they were "satisfied" or "very satisfied" with their visit, according to an April 17, 2017, retail clinic survey from healthcare market researcher Kalorama Information.
Facing the undeniable popularity of various forms of convenience care, healthcare systems have increasingly gotten into the retail game through partnerships with or creation of store-based clinics, standalone walk-in and urgent care clinics, and supplemental telemedicine services.
While the scope of services and delivery mechanisms continue to evolve, the common denominators of such on-demand healthcare consistently come down to convenience, affordability, and access.
These themes are essential to keep in mind as executives ponder the future of retail healthcare and what it means to their businesses.
Early and eager adopters
While some organizations met the retail movement with reluctance, the attitude has not been universal.
Since 2009, Springfield, MO–based CoxHealth has held a presence at numerous Walmart Supercenters. To date, CoxHealth runs five Walmart walk-in clinics and one clinic at a Hy-Vee grocery store. Another Hy-Vee location is in the works.
The system was eager to partner with retailers. "Our community is heavily dominated by Walmart, and it took us a year or two from the time we started talking about it in strategic planning meetings to get in," says David Taylor, CoxHealth's corporate vice president.
Because the region is under-resourced for primary care, the system's 200-plus primary care providers, nurse practitioners, and physician assistants have never regarded the walk-in clinics as a source of competition, Taylor notes.
"We have a lot of support from our family medicine physicians, so we didn't get the resistance that you saw in other places with regard to that. And we couldn't have done it without the physicians," says Taylor. He adds that many physicians have welcomed the chance to boost their earnings through oversight of the retail clinics as part of the partners' collaborative agreement.
Currently, 15 physicians help provide oversight for a pool of about 60 nurse practitioners who staff the clinics. It takes about 2.5 NPs to operate a clinic on a weekly basis, Taylor says.
Although the pipeline of NPs has been relatively healthy in the state, it's gotten tougher in recent years to keep the clinics fully staffed, he says. When the NP pool gets too shallow, a site may have to shut down for a day or two. "We don't like to do that," Taylor says. "But fortunately, we've got clinics within two to three miles we can direct people to."
CoxHealth's retail clinics were set up from day one to accept insurance in the same fashion as all the other facilities they operate, he adds. While Medicare and Medicaid also reimburse for services provided at the retail clinic, self-pay patients are expected to pay at the time of service. All prices are provided up-front.
The role of virtual care
In the not-distant future, Taylor predicts that rather than having to close understaffed locations, patients will be able to receive care via their computer or mobile device.
"Our telemedicine program, DirectConnect, is growing by leaps and bounds," he says, adding that volume is up 60% from last year and the number of video consultations increases every month. "We have worked to create lots of different relationships and access points to our DirectConnect program."
For example, CoxHealth has agreements with local employers, which are customized and vary depending on their respective needs. "One employer might cover the visit for their employees; others have negotiated a discounted rate for the service; others might have a copay. Each is different," he says.
If the service is not covered by a patient's insurance or employer, the charge is a flat $49 per telemedicine visit, paid by credit card before being seen. The system also has agreements with all of its local colleges and universities whereby students can use the service at a discount from the usual $49 rate.
Additionally, there are cameras set up in schools in several local districts so that students can be seen without leaving school. "The parent may choose to come to the school to participate or they can access the visit via three-way video," Taylor says.
Unlike services provided at retail clinics, Medicaid doesn't currently cover video consultations in Missouri. "But it appears coverage will begin this January," he notes.
Over time, telemedicine will increasingly supplement and complement retail clinics, Taylor says.
In the near term, that would mean that when NPs at a given retail clinic are not busy, they would be available to provide telemedicine to patients at other clinics or at home, work, or school.
In the longer term, Taylor foresees a more substantial melding of the two business lines under a similar infrastructure.
He's not alone.
"When you're thinking about retail healthcare, you need to land on two of the major trends in healthcare in this country—the shift toward pushing risk onto providers and into population health, while simultaneously consumers continue to want new and different ways to seek quick medical care for a variety of things," says Chris DeRienzo, MD, MPP, chief quality officer for Mission Health, a hospital system serving the 18 westernmost counties of North Carolina.
Mission Hospital, licensed for 763 beds, serves as the flagship facility.
"Retail healthcare is one of those ways, but virtual health is very quickly becoming a mainstay in that space as well."
Much of the acute care that has been retail clinics' bread and butter can be done through an algorithm system via telemedicine, notes DeRienzo. "When you think about what need is trying to be met, the push toward accountable populations while simultaneously meeting consumers in their living rooms are dual trends that will definitely need to be resolved within the next 10 years."
When it comes to short-term, self-limited needs, telemedicine and virtual medicine represent viable ways to meet consumers' needs and help them avoid having to call a medical office to make an acute care appointment, drive to the office, wait in the waiting room, and eventually be seen. "There are ways that can be more efficiently done to meet that need," DeRienzo says.
So far, Mission Health has piloted the concept with the 18,000 lives under its health plan for employees and their beneficiaries. "I used it once myself," he says. "I could access it anytime that I needed to go on it, so I wasn't having to call and make an appointment. You follow the algorithm through [on any device], and your case is reviewed and then a response comes back to you. That has the value of never having to get off your couch."
This convenience can be especially appealing to a generation accustomed to doing everything from communicating to booking and checking in for flights using their iPhones, he adds.
The importance of urgent care
But for the medium ground between assessing bug bites and performing surgery, urgent care centers provide an opportunity to provide relief without the wait or expense of going to the ED. As they have become more widespread, so has their popularity. According to a study by Accenture, visits to urgent care centers rose 19% from 2010 to 2015.
There are nearly 7,400 urgent care centers and counting in the United States, according to the Urgent Care Association of America.
For Wellmont Medical Associates, opening 12 urgent care centers within its 23-county service area was closely tied not only with its population health strategy but also its values.
"I don't mean this to sound trite, but it really does meet part of our mission. It doesn't help our population if you've got a lot of disparate offices trying to provide care that's not coordinated," says Stephen Combs, MD, CPE, FACFE, FAAP, Wellmont's chief executive medical officer. "For years, people have thought, 'Well, we're Northeast Tennessee, Southwest Virginia. We'll do the best we can.' And that's really not right. It's a great area; we have great providers; we have a great population."
"We offer some of those lower-level services so if you find yourself in a bind and can't get in to your primary care, or maybe don't have one, care is available. But long term, our goal is to get those folks into primary care."
Combs acknowledges that his region is challenged more than some with health problems including obesity, type 2 diabetes, and drug addiction. "But if there are ways we can tie those things together [with the] technology that we have, we can provide the best care anywhere," he says.
Combs says Wellmont's decision to open only urgent care centers and not additional low-acuity retail clinics is a strategy that covers all of patients' care bases without disrupting the rest of the market.
"Our goal for the urgent care centers was to really provide urgent services, not emergency department care, so we have a strict list of services we provide. We didn't want to take the place of the hospital or primary care," Combs says. "We do some occupational medicine at the urgent care centers; we offer vaccines. But for primary care services, we will help set patients up with a physician who meets their needs to provide those services."
The urgent care centers also offer school physicals and sports physicals, notes Karen Williams, MBA, MPH, MGCHA, CHES, NHA, the system's COO. "We offer some of those lower-level services so if you find yourself in a bind and can't get in to your primary care, or maybe don't have one, care is available," she says. "But long term, our goal is to get those folks into primary care."
But as another way to provide access and convenience to patients with immediate needs, Wellmont has begun using video consultations for specific diagnoses and is looking to expand the diagnoses and modes of technology that will eventually tie its electronic strategy to its retail strategy, says Combs.
The quality caveat
In the early retail-clinic days, doctor groups including the American Medical Association and American College of Physicians were especially vocal about the trend's potential downsides, including patient safety risks, damage to the physician-patient relationship, and the business threat to physician practices.
The groups' current policies are more instructive in nature. In June 2017, the AMA House of Delegates adopted a policy to state that any individual, company, or other entity that establishes or operates retail health clinics should follow certain guidance.
Among other things, delegates said that retail clinics should help patients without primary care providers get one; use electronic health records to transfer records to PCPs, with patient consent; and use local physicians as medical directors or supervisors of retail clinics.
AMA delegates also stated that retail clinics should not "expand their scope of services beyond minor acute illnesses" such as sore throat, common cold, flu symptoms, cough, or sinus infection.
Similarly, the ACP released a position paper in 2015 that reflected an evolved marketplace in which the largely NP-staffed clinics and primary care offices could coexist and even partner. The thrust of the new recommendations nonetheless urged that retail clinics serve only as a backup alternative to primary care.
Nonetheless, many retail clinics that originally handled a short list of minor illnesses and injuries now play a role in chronic care management and more.
CVS Health, for example, announced new MinuteClinic services around women's health, skin care, and travel health assessments.
Walgreens, in the meantime, has begun tackling mental health through an online screening questionnaire.
"There's certainly risk if we wind up in a place where all of your acute care is sought outside your medical home, especially without robust communication back and forth between wherever you are getting your care and the primary care team."
Meanwhile, health systems are left to find a prudent balance when evaluating opportunities to optimize their retail offerings.
"Where it gets more challenging is with the interplay amongst chronic and acute conditions," says DeRienzo. For example, managing a patient who has cellulitis and also diabetes is more complicated than treating an acute infection. Or if a patient is diagnosed with bronchitis three times in two months and also has heart failure, it may not be bronchitis after all.
"There's certainly risk if we wind up in a place where all of your acute care is sought outside your medical home, especially without robust communication back and forth between wherever you are getting your care and the primary care team," he says. "That is the balance we need to walk."
But with the right connectivity, a marriage of the virtual and walk-in care worlds as a complement to traditional ambulatory care may indeed be in our futures, he says, especially as primary care physicians take on a greater role in managing patients' chronic care among many different specialists.
Wellmont Medical Associates has been proactive about keeping potentially serious information from falling through the cracks, not just for individual patients but as a whole.
"We look into it if we have a complaint or clinical outcome we could have handled differently," says Williams. "We have a monthly call with our medical directors and the urgent care providers about trends they're seeing, best practices, and what we should be doing and what we should be looking for."
For example, during a recent flu season, providers noted and discussed an uptick in young people coming in to the urgent care centers experiencing shortness of breath. "We really did catch some pulmonary edemas that I don't think we normally would have if we hadn't had those calls," Williams says.
Turning resistance into opportunity
Some systems, on the other hand, took a more hesitant approach to their involvement with retail healthcare.
"We had a bit of a relationship with Walgreens prior to getting into the bigger one, getting to know each other and inculcating the physicians that this was the future and we needed to be a part of this new delivery model," explains James Bleicher, MD, MHCM, regional president of SSM Health's St. Louis-Missouri market. "Consumerism was affecting this industry and care was going to be changed by the forces of public need and wants."
SSM Health is a nonprofit Catholic healthcare system operating in Illinois, Missouri, Oklahoma, and Wisconsin, with 20 hospitals, 63 outpatient locations, a pharmacy benefit management company, a health plan, and two skilled nursing facilities.
SSM had already begun operating its first urgent care centers when Walgreens approached the system to propose a loose partnership with six area clinics in 2012, in which SSM provided some collaborating physician support, pediatric advisory services, and an enhanced referral network for patients seeking primary care physicians, says Bleicher.
"We didn't own anything; they weren't our employees, but our doctors were the collaborating physicians," he says. "There was quite a bit of physician resistance back when we first started working with Walgreens; even just to be collaborating physicians on it, there was a fair amount of pushback from practicing physicians who didn't think that this was the way medicine should be going," Bleicher says. "But, collaborating and helping to ensure the right care was provided was the guiding principle. The long-term view was that we needed to get our feet wet and understand the retail market."
About two years later, Walgreens again approached SSM, this time to pitch a broader relationship that would involve 26 new locations.
Completion of this new iteration took about 18 months, and the present-day arrangement that facilitates the SSM Health Express Clinic at Walgreens is a harmonious one.
When asked whether SSM's current strategy was the result of planning or pressure, Bleicher says, with a heavy sigh, that it certainly evolved. "I don't think in the beginning we thought we would end up where we did," he says. It was very fortuitous that we ended up there. Certainly, we see it as a competitive edge. There wasn't anyone else in town at the time making a big retail play."
And while simply adopting some retail principles into its regular physician offices, such as extended office hours, has also helped keep SSM competitive, that tactic alone achieved only minimal success, Bleicher says. "In general, medical offices are not on busy corners like Walgreens stores, so the convenience factor is never going to be matched for a simple visit."
SSM's present-day physician offices and retail clinics do not operate as rivals, however. Rather, they exist in deliberately mapped "medical neighborhoods," Bleicher says. "We kind of drew circles around the medical offices and the Walgreens and introduced to physicians this concept of a medical neighborhood. We said, 'You'll be working closer with these NPs who are near your site because more than likely your patients are going there.' "
As part of this initiative, physicians and NPs in like medical neighborhoods met face-to-face to discuss clinical protocols. "So then their playbook is developed with and blessed by the physicians in the medical group," Bleicher says. "They know each other better. So if patients call the physicians' offices and they're busy, and it's a simple visit, they will refer to one of the Walgreens clinics that's close by."
One patient, one record
While every system's retail story is different, healthcare leaders agree that a common EHR throughout a system's sites of care is a must.
The concept of "one patient, one record" has been an essential retail-strategy ingredient for Wellmont, notes Combs. If a patient visits an urgent care site for sinusitis, for example, the provider can see from the record that he or she is due for an annual physical or doesn't have a primary care physician.
And it's part of the system's urgent-care policy to take access to this information one step further—and actually make an appointment for the patient to follow up with a primary care provider.
But for retail sites that are located within a retail store, some negotiation may be required to obtain a common record.
"When we started with Walmart, we preferred to have one record. We'd had the same EHR for about 20 years," says CoxHealth's Taylor. "Walmart was also pretty adamant that we had to use the product they were promoting. It was a really good EHR but a separate one from ours, but we didn't have a choice when we first opened."
Within two years, however, Walmart agreed to transition the clinics to the record used by the rest of CoxHealth. "So we're on one EHR today, and that's been a really good thing," Taylor says.
The singular EHR as the source of truth in the care a system is delivering may also be the most powerful tool in promoting population health, he adds.
Although partnerships don't offer healthcare systems the same level of control as creating their own retail or urgent care sites, much can be achieved through strong relationships, says Tine Hansen-Turton, MGA, JD, FCPP, FAAN, executive director of the Convenient Care Association.
"The best partners recognize that each brings something unique to the partnership, and they understand those strengths and weaknesses," she says. "Some hospitals have opened these clinics and had trouble sustaining them because it's a different kind of model. What hospitals and retailers bring to the table are a lot of clients and a whole network of different kinds of providers. What retailers bring is an understanding of how to provide services in a very low-cost format, as well as what drives the consumer. It's understanding each other's roles and values that creates a win-win for what essentially becomes a mutual patient."
Indeed, Taylor describes his system's relationship with Walmart as great, although CoxHealth hasn't gotten all of its requests fulfilled. "We wanted exclusivity, but they chose with their partners not to do that. That was fine," he says.
The relationship with Hy-Vee does provide CoxHealth with a limited area of exclusivity within the Springfield market. The Hy-Vee deal also gives CoxHealth a bit more latitude when it comes to branding.
"They've got multiple partners across the Midwest in their stores and we could call it whatever we wanted, so we called it Quick+Care CoxHealth," he says.
With Walmart, however, the parties agreed on the name: The Clinic at Walmart, operated by CoxHealth.
The bond between SSM and Walgreens has also strengthened over time, Bleicher says.
"Operationally, it's a pretty big deal to bring on 26 clinics, so we've certainly had our growing pains. You're dealing with a Fortune 100 company that brings in a team that's not familiar with what's going on locally. They also have to get higher-ups' say-so on many different things, so there were challenges dealing with that."
But other than spending more time than expected to iron out the kinks, Bleicher says he hasn't seen any downside to the relationship.
Space and scope of practice
While some retail clinics have in recent years broadened their scope of practice to involve chronic care management, CoxHealth has thus far not gotten involved in that arena to a large extent.
In some states, that's a regulatory issue. But Taylor says that the more prominent limiting factor is the physical space of the clinics themselves.
"We had to take the space that Walmart gave us. We've got one clinic that's about 240 square feet—barely the size of two exam rooms," he explains. "And we've got another that is a little over 500 square feet, which we're doing a bit more in."
At the clinic with more square footage, services include care such as asthma management, care for chronic urinary tract infections, and some lab testing and follow-up.
On the West Coast, Sutter Health also considers itself a retail medicine pioneer, having opened its first pharmacy-based clinics, called Sutter Express Care (now Sutter Walk-in Care), about 10 years ago.
"They were basically one room, with one advanced practice clinician and a set fee schedule, where a patient could just walk in and have those very minor illnesses taken care of while in the area," says Ted Matson, Sutter Health's vice president of system strategy.
"They were very, very popular, and over time they grew to a point where we really needed to expand the model to provide more capacity for patients," he says. "We had more than 160,000 visits from patients to Sutter retail clinics between 2007 and 2016."
Thus, in April 2016, Sutter embarked on a new retail model based in large part on the success it had with Sutter Express Care. The new clinics are not only larger, with four rooms instead of one, but they broaden the scope of practice for the NPs and PAs who work there.
"It doesn't help our population if you've got a lot of disparate offices trying to provide care that's not coordinated."
In addition, consumers can use an app to secure their place in line, and upon arrival enjoy amenities including juice, coffee, fresh fruit, videos promoting health and wellness, and charging stations for mobile devices. "They're warm and inviting, very aesthetic. It's a very soothing spa-like environment," Matson says.
"These are all very retail-focused principles. Convenience really is king now, and we needed to satisfy for that. We've had that pioneering spirit for many years and continuously reinvent, reinvigorate, and provide exactly what our customers are telling us. And today, after a year, it's absolutely been a hit with consumers."
As for enhanced scope of practice, the new clinics provide, when warranted, point-of-care lab testing, which could reveal problems such as high cholesterol or blood sugar. "So they'll actually have their first visit there, and we'll bring them back very soon after to begin their longitudinal care that they might otherwise receive in a traditional physician's office," Matson says.
"We're getting the patient connected to their next level of care more quickly and comprehensively because we are connected in our clinics with our regular physician offices and hospitals on a common EHR system," he adds.
And also like other systems have stated, Sutter providers often use that common medical record to help secure patients with follow-up appointments at PCP offices or other appropriate sites of care.
In addition to adopting retail-industry principles of service delivery, Sutter has also followed the commercial industry in using the Net Promoter Score as a measure of success. The NPS indicates how likely consumers are to say they're willing to recommend a brand or service to a colleague. Sutter Health Walk-in Care has scores steadily ranging in the low 90s, Matson says.
"Overall, we are exceeding expectations. With any business plan, we try to be conservative in our targets, but we are currently outperforming metrics we established," he says. "Between the three Walk-in Care locations in the greater Sacramento area, we've had approximately 25,000 patient visits."
Phased openings for Sutter Walk-in Care continue in the Bay Area, he adds. Sutter Walk-in Care clinics in Dublin, Petaluma, San Francisco, and Walnut Creek opened this spring and summer; locations in San Jose and San Ramon and a fourth walk-in clinic in Sacramento are targeted for fall 2017.
"We always look for ways to welcome new patients into our network so they can experience Sutter Health's top-rated personalized care," Matson says. "We also appreciate the opportunity to give existing patients another convenient, comfortable, and accessible option for their same-day, on-demand healthcare needs. Sutter Walk-in Care helps meet these objectives."
Meanwhile, a metric Wellmont shares proudly is that 25% of visits to its urgent care centers result in a direct referral of new patients to Wellmont Medical Associates' primary
"We don't try to steal from our independent physicians," says Williams. "Nevertheless, if somebody does not have a PCP and they're in maybe for a laceration or sore throat and we find that they have hypertension or we think they need more care, then at that point we do make an appointment while they're there."
Another number to watch, which payers monitor routinely, is ED utilization per thousand patients, notes David Brash, FACHE, Wellmont's president and CEO.
"They're incentivized to want to get the patient to the right care environment. They have patients that maybe don't have a PCP or have a PCP that is not open at convenient times, outside WMA primary care offices," he says. "We're making sure that this is an alternative to emergency care for those lower-level type visits, which is really where it fits in the delivery system."
A recent working paper by the National Bureau of Economic Research backs up this goal. In an analysis of ED use in New Jersey for three classes of conditions between 2006 and 2014, researchers found that ED visits for influenza and diabetes fell by 13.6% and 3.6%, respectively, among those near an open retail clinic, "confirming that the increased use of preventive care when a retail clinic is nearby was associated with fewer ED visits for emergent but preventable conditions."
These findings could have important implications for healthcare expenditures, researchers noted. Having a nearby retail clinic was linked to estimated annual cost savings of $817,492 per 100,000 people, or a potential of more than $70 million in cost savings if extrapolated to the entire population of New Jersey. It would take over 700,000 yearly retail clinic visits at $100 per visit to offset the savings resulting from lower ED usage, they wrote.
While Wellmont's ED utilization rates are about 20% higher than Brash says he'd like to see them, the urgent care sites have made a positive impact.
What's more, SSM's Bleicher says that health system executives needn't fear that operating retail clinics will hurt physician groups. "Physicians worry it's going to affect their volume. But we have not noticed any decrease in our physicians' volume in their offices by creating these medical neighborhoods," he assures.
Likewise, CoxHealth's EDs have not seen a drop-in volume from the presence of its retail clinics or urgent care clinics, Taylor says. "We operate four EDs, and the volume has seen double-digit increases for the past three to five years."
Retail-based profitability, however, isn't necessarily a goal. "There's little to no margin in these clinics," Taylor says. "We've got a couple that make a small return, but for the most part you're going to subsidize these. It's an extension of primary care, and there's not a system in the country that has a bottom line on their primary care clinics."
However, Taylor says the retail clinics have provided his system with improved access (seven days per week) and an expanded footprint; patient satisfaction with greater convenience and more immediate access to the provider; a better value for patients and employers by offering care for specific services, at published prices, in a lower-overhead environment; and a market differentiation through strong reception of retail clinics in communities served.
"Our retail sites have served as an entry point into our health system," Taylor adds. "If you need care on an ongoing basis, we try and transition you to one of our primary care physician practices."
Taylor says the retail movement has not yet reached its full potential. "As consumerism grows, along with high deductibles and health savings accounts, people will continue to look at cost of care, and this is one format in which we've been able to do that," he says. The other force that will continue its momentum is consumers' demand for healthcare where and when they want it.
There is a science to planning new clinic locations, he says. "For us, it really came down to a couple of things: rooftops, or how many houses were within a certain perimeter of the location we were looking at, and where our current clinics were relative to those."
This insight was in part learned the hard way several years ago after having to close a clinic opened in partnership with a hospital in Branson, Missouri. "It was in their new retail corridor, but there weren't many houses around it and it just never got much volume. The partner had also opened up their own urgent care center it was competing with, and it just never took off."
CoxHealth has since merged with that hospital, but has refrained from opening another retail clinic in the Branson market.
Meanwhile, in addition to locational factors such as population base and PCP availability, Sutter relies heavily on consumer research to identify the level and extent to which people are seeking same-day appointments, Matson says. "There are a number of ways we estimate that. It's local research, focus groups, and consumer surveys. Then from that we can identify areas of highest need," he says.
"We started with our three new clinics that are past 12 months of initial operations. We're opening now six sites in the Bay Area this year. We do see this as an important part of the consumerism movement, so we will continue to expand relative to their needs."
In all likelihood, such expansion will be continued and widespread.
"I've worked in healthcare most of my life, and have never seen anything get adopted that quickly by the regular consumer in the community," says the CCA's Hansen-Turton. The trade association was founded in 2006 and today represents more than 200 member organizations.
Altogether, there are more than 2,500 convenient care clinics in operation in 43 states and Washington, D.C., according to the association, and CCA member clinics represent 100% of the industry.
That explosive growth is indicative of healthcare organizations' changing attitude toward retail clinics over the past several years.
"It's been a 180. The retail clinic industry has become mainstream healthcare. I would say there's not a health system or large physician group that's not thinking about having a relationship with a retail clinic or doing their own," says Hansen-Turton.
Indeed, a December 2016 HealthLeaders Media Intelligence Report reveals that 37% of organizations surveyed already participate in convenient care clinics through ownership or partnership, while 14% currently do not, but plan to do so within the next three years.
In response to the same question about urgent care clinics, 57% of respondents report they already participate, while 10% currently do not, but plan to within three years.
Hansen-Turton has witnessed this growth first-hand.
"Five years ago, we had to knock on the door to get hospitals to be part of us," she adds. "Today, hospitals knock on our members' doors because they want to have as part of the continuum of care a partnership with a retail clinic. There's definitely been a paradigm shift there."