Retail clinics in drug or grocery stores can be an essential part of the nation's healthcare delivery system in a post-health reform era, providing low-cost, high-quality care for millions of newly insured patients who otherwise would crowd emergency rooms or go untreated.
That's the conclusion from several studies, including ones done by RANDHealth and the University of Minnesota. "Doc-in-a-box" convenience down the street can play an important role enabling patients to get basic care— such as treatment for a sore throat—especially since family practitioners are in short supply, they say.
"The research we have conducted to date has not supported any concerns raised about retail clinics," says Ateev Mehrotra, MD, assistant professor at the University of Pittsburgh School of Medicine and RAND policy analyst, who has written several papers on quality, cost, and effectiveness of such rapid-care clinics.
The Convenient Care Association, the trade group representing retail clinics owned by national chains like Walgreens or CVS, sees the industry growing exponentially because they work.
"We think we'll provide a critical access point, especially for newly insured who may need to be re-engaged in the healthcare system," says CCA Executive Director Tine Hanson-Turton.
But organized physician groups have a very different view.
The American Medical Association worries that store-based clinics may not have appropriate referral plans for patients with illnesses requiring more complex care.
"We recommend store-based clinics have appropriate physician oversight on site and that patients be clearly informed of the qualifications of the person providing care," says Rebecca Patchin, MD, AMA chair.
She adds that store-based clinics should have appropriate physician oversight on site, and that patients "should be clearly informed of the qualifications of the person providing care. Convenience should never compromise safety."
The AMA suggests that state and federal agencies "investigate ventures between retail clinics and pharmacy chain with an emphasis on inherent conflicts of interest in such relationships, patients' welfare and risk, and professional liability concerns."
The California Medical Association is vehemently opposed, and has fiercely fought to keep drug and grocery store-owned retail clinics out of the state, says Dustin Corcoran, CEO of the California Medical Association.
"They're not in the best interest of the patient" for three reasons, he says:
- The care provider hired by the grocery or pharmacy to diagnose patients may be treating a disease or condition that is "beyond his or her scope of practice," he says. Often the provider is a physician's assistant or nurse practitioner who may not recognize symptoms with more serious implications without a physician's assistance, he says.
- The process interrupts continuity of care if the retail clinic provider does not relate the diagnosis or recommended care to the patient's primary care provider.
- For the most part, retail clinics as they are usually set up are not designed for patients, but as a business model. "They're looking for a way to get people in the door to buy beef jerky and Gatorade," Corcoran says.
Critics also say clinics may pose conflicts of interest between the drug or grocery chain's desire to sell prescriptions and over-the-counter products, and what's in the best interest of the patient.
Will those retail clinic providers recommend, or be required to encourage, that patients buy products they don't really need? Might the clinic's owners expect sales thresholds?
Sutter clinics
An exception is the three clinics run in suburban Sacramento, CA, by Sutter Health, which leases space from Rite Aid stores. "When the retail clinic is affiliated with physicians so that proper care is ensured, it goes a long way to alleviate our concerns," Corcoran says.
Sutter launched its Express Care three years ago in six locations, says program director Pete Dzwilewski. It closed three of the clinics that weren't doing well, but for the other three, "there's been year-on-year growth" with each clinic seeing about 20 patients per day.
Clinic providers, usually nurse practitioners and physician's assistants, are employed by Sutter, not Rite Aid.
And they are supervised by Sutter physicians. Patients' symptoms, diagnoses, recommended care, and prescriptions written are all logged into an electronic medical record or transmitted by mail to the patient's non-Sutter provider, Dzwilewski says.
Without those guarantees, the CMA warns patients against getting care at such clinics, which are not likely to build much of a base in California because of two laws that discourage the practice, Corcoran says.
The first is the state's bar against the corporate practice of medicine, which prohibits any company—profit or nonprofit—from directly hiring a physician. The only way to get around that would be for a grocery store or drug store to lease space to a physician, who then would hire the providers who actually see the patients.
But under the second California law, physicians are precluded from supervising more than four nurse practitioners or physician's assistants, a rule that doesn't exist in states where retail clinics are prevalent. In those states, physicians may employ and supervise dozens of retail clinic providers.
"There is no stretch one can make to say this is good medicine or good delivery of care," Corcoran says. "The answer, frankly, is that it's neither."
Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, however, sees a middle ground.
"I think you have to expand primary care in just this way," he says. "We don't have nearly enough primary care out there and efforts to place it in retail clinics, while making good business sense, make good public health sense."
But, he adds, "what we need is clear ethical standards to govern these new types of clinics" that is without clinic providers pushing patients to buy certain products or more products than they need.
"And there should be constant reminders to the patients and providers to follow up with and keep the doctor informed" on their care, he says.