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Published On September 22, 2010

POLICY

Megastore Medicine

Retail clinics brought grocery-aisle convenience to strep tests and flu shots. Now they’re aiming to manage chronic conditions.

DESPITE BEING ONLY 40 YEARS OLD AND REASONABLY FIT, Jeremy Katz has high blood pressure, elevated cholesterol and a “nasty family history” (his description) of heart disease, colon cancer and type 2 diabetes. Katz, who lives in Salisbury Township, Pa., takes several medications and has to see his doctor frequently. It’s tough to find time for those visits, so Katz was interested to learn that two drugstore chains, CVS and Walgreens, recently launched programs at their in-store clinics to help people manage chronic medical conditions. The idea of being able to drop in at the drugstore for a quick blood pressure check while doing other errands seemed worth considering. Then the pharmacy would e-mail test results to his regular physician.

But the more Katz pondered that scenario, the more questions he had. Would the reading be accurate if he was hustling around dropping off FedEx packages and buying groceries? And what if the screening showed a spike in his blood pressure? When that happened in January, it turned out Katz had a kidney problem, and he spent a long weekend in the hospital. Would the nurse-practitioners who staff retail clinics have picked up on that? Their job would be made harder by his involved medical history. “It’s complicated for a patient to remember—and for a clinic in a Walgreens to tease out,” he says.

Katz’s ambivalence might be emblematic of what’s to come as hundreds of the nation’s retail health clinics—which until now provided only in-and-out treatments for common ailments—roll out plans to manage such chronic conditions as hypertension and diabetes. In announcing this expansion, the clinics’ corporate parents say they are filling a serious need. Hypertension, the focus of the new Walgreens program, afflicts 74.5 million people in the United States, many undiagnosed. The retail clinics are nothing if not convenient—found in the likes of Target and Walmart as well as in drugstores—and if that makes people more likely to get their blood pressure checked, it could prove valuable in reducing the incidence of stroke, atherosclerosis, kidney disease and heart failure.

But profit motives, too, have been a factor in the clinics’ decision to broaden services, and many physicians are skeptical about the clinics’ ability to take over much of the doctor’s own role. Some physicians have even resolved to beat the clinics at their own game, making their practices more accessible. While the outcome may not be decided for some time, there’s little question that the proliferation of retail clinics has already become a significant development in how health care is delivered.

WHEN THEY FIRST APPEARED IN MINNEAPOLIS IN 2000, retail clinics were a curiosity, occupying corners of pharmacies. They generally included such user-friendly features as clearly posted pricing (often in the $55 to $65 range) and hours of operation that stretched into evenings and through weekends. Operators of these businesses limited costs by staffing them with nurse-practitioners and physician’s assistants. Most states require that a physician collaborate with the NPs and PAs, but the extent of that collaboration differs.

At first the medical community was wary. Would care be adequate? Would NPs and PAs know what to treat and what to refer to a physician? But during the next six or so years, the clinics’ increasing prevalence, with few apparent problems, won over many skeptics. The clinics started small, limiting their scope to several common, easily treated acute conditions—normally, upper respiratory infections, bronchitis, middle and external ear infections, pharyngitis, conjunctivitis and urinary tract infections. Many clinics also offered immunizations, simple lab tests and blood pressure screenings.

Insurers soon saw the potential of clinics to reduce the cost of medical visits and began folding them into their networks of providers. Patients, meanwhile, liked the accessibility, speedy turnaround and transparent pricing, according to the RAND Corp., an independent policy research organization. By 2005 even the medical community offered a measure of acceptance. The American Academy of Family Physicians created a retail clinic policy and made formal agreements with five large retail chains. The AAFP endorsement came in return for a guarantee that clinics would limit their scope to relatively simple, urgent-care conditions. That focus helped the clinics reach patients who often didn’t show up in doctors’ offices.

IN AUTUMN 2006, THE RETAIL CLINIC BUSINESS BEGAN TO MUSHROOM. During the next two years, the number of sites grew from around 200 to more than 1,000 as some of the largest pharmacy brands in the United States plunged in. CVS acquired MinuteClinic, an industry pioneer that then had 83 locations, making CVS the largest operator of retail clinics, and soon after Walgreens scooped up Take Care Health Systems and its 50 clinics. The Little Clinic, based in Brentwood, Tenn., opened 117 clinics in Kroger and Publix supermarkets. The idea even captured the fancy of retail giants. Walmart said it would open hundreds nationwide, and Target announced plans for a large number of in-store sites. RAND estimated that as many as 6,000 retail locations would be in operation by 2013.

But last year, this fast-forward growth came to a jarring halt. CVS closed 104 underperforming MinuteClinics during the first half of 2009; Walmart abandoned its plan to open 400 clinics by 2010, and after parting ways with RediClinic had only about 30 clinics left by midyear. In September 2010, there were 1,179 retail clinics in the United States—virtually the same number as a year earlier.

Part of the retrenchment may have to do with the recession. But there’s also a problem with the clinics’ business model. They thrive when people tend to get sick—from late October through flu season, which typically lasts until early spring—but during the summer, traffic fades. Noting this pattern, the operators of the larger chains began exploring an approach that would allow the clinics to remain viable throughout the year.

Some initiatives have more to do with marketing than with offering broader services. One chain, Florida-based Solantic, recently began offering gift cards, membership plans for employers and, most strikingly, three-day “feel-better guarantees.” If patients don’t get over their sinus infections or bronchitis in 72 hours, they get a free return visit. Some clinics quietly did add services, such as physicals for children joining sports teams, screenings for such ailments as diabetes and tuberculosis, and wellness exams.

But the industry’s leaders had something more ambitious in mind. CVS and Walgreens, which together constitute nearly three-quarters of the retail clinic market, announced plans earlier this year to venture into chronic-care management. Routine care for such ailments as hypertension and diabetes accounts for as many as 200 million patient visits per year, according to the Deloitte Center for Health Solutions. If retail clinics could tap that market, it would solve the seasonality issue.

TO HEAR THE CLINICS AND THEIR ADVOCATES DESCRIBE IT, the growth into chronic-care management was not so much a business imperative as it was a way to address a pressing public health issue. In April, Take Care Health Systems, the Pennsylvania-based retail clinic chain operated by Walgreens, began offering free blood pressure screenings for two months at all 359 of its locations, with plans to begin diagnosing and treating hypertension during the summer.

“Even among people who know they have hypertension, the majority don’t have it under control,” says Take Care Health spokesman Gabe Weissman, who adds that half of patients diagnosed with high blood pressure soon fall off their treatment plans. “With our unprecedented level of access, we really think we can move the needle on this.” If a clinic patient has an above-normal blood pressure reading, she’ll be urged to come back for another check. If, after at least three tests, her blood pressure is still elevated, nurse-practitioners at the clinic will follow National Institutes of Health guidelines for treating hypertension. The patient will get preventive advice and follow-up calls from the clinic to make sure she’s sticking to the prescribed program. Because all of Take Care Health’s patient records are computerized and linked to a national database, tracking the patient’s progress will be easy. (In comparison, only about 1 in 10 doctors’ offices has electronic records.)

Take Care Health officials and other clinic proponents say they’re also responding to patient demand. After growing accustomed to going to the clinics, people wanted them to do more, says Tine Hansen-Turton, executive director of the Convenient Care Association. Yet Sandra Ryan, chief nurse-practitioner officer of Take Care Health, is quick to say the clinics aren’t trying to replace primary care physicians. Thirty to forty percent of Take Care Health’s patients say they don’t have a family doctor, “but we’re committed to linking them with a provider,” she says. Patients who need follow-up care get a list of primary care physicians in the area.

STILL, RYAN SAYS, TAKE CARE HEALTH WILL EVENTUALLY AIM to push further into disease care and management, and that raises the question of just what retail clinics’ endgame is. Tom Charland, CEO of Merchant Medicine, a research and consulting firm in the field of walk-in medicine, thinks bigger ideas may be lurking. Suppose a patient is diagnosed with hypertension, doesn’t have a physician and doesn’t want to find one. Will the retail clinic become home base for all of that patient’s treatment? “Recent developments raise the question of whether the clinics intend to become medical homes,” says Charland.

The patient-centered medical home is a significant new concept in health care. The idea is to create a network of caregivers—nutritionists, mental health professionals and social workers, among others—who work alongside a patient’s primary care provider to prevent or treat illnesses. In theory, at least, this configuration extends the principles of preventive care and disease management well beyond what physicians might do on their own.

To put a nurse-practitioner in a retail clinic rather than a physician at the center of a medical home wouldn’t necessarily be a radical departure. NPs already provide medical homes in many rural areas in which primary care doctors are in short supply, according to Charland. But could that also be viable, businesswise, in places that have plenty of physicians?

No one knows the answer yet, but a 2008 RAND study found that clinics “could serve as a safety-net provider for some patients who now seek care in emergency departments.” The clinics also have the potential to increase access to preventive medicine, according to the study, which concluded that “to the extent that convenience is a factor, retail clinics may offer a new venue for helping increase immunization rates.”

Convenience is the primary selling point for the clinics, and hospital systems and even some physician groups have begun to understand that. Baptist Hospital East in Louisville launched a clinic in a Walmart in December 2009, becoming one of more than 120 hospital-linked sites—a 60% increase from 2008, according to Deloitte. “Hospitals are the one category where we’re seeing growth in the industry,” Charland says.

Meanwhile, other medical practices, facing competition from retail clinics, are making it easier for patients to see a doctor. AAFP president Lori Heim, a physician in Laurinburg, N.C., has urged family practitioners to change the way they do business, and while some have expanded their hours, many more have made room in their schedules for additional same-day appointments. “There has been a tremendous uptick in family physicians who have redesigned their practices,” she says.

THOSE CHANGES COME AS TEH AAFP'S RAPPROCHEMENT WITH RETAIL CLINICS HAS ENDED. In 2009, Take Care Health informed the AAFP that it intended to expand its services, and after it became clear early this year that CVS’s MinuteClinic had similar plans, the physician group announced it was terminating its relationship with all retail health organizations. “Having these clinics expand into chronic care and disease management is absolutely the wrong way to go if you’re concerned about quality of care,” says Heim.

That feeling has led some physician practices to respond with animosity to any contact with the clinics. In one instance, Charland says, he saw a receptionist in a doctor’s office tell a clinic not to fax over records because the doctor didn’t want them. But this isn’t just a turf war, Heim says. In her view, an NP at a clinic simply isn’t in a position to get to know a patient and understand what may be going on behind the scenes. It takes a physician who has established a rapport and a sense of familiarity with a patient to find out that her husband just lost his job, for example, and that she may no longer be able to afford a certain medication. “That’s extremely valuable information if you’re trying to manage something chronic,” Heim says.

But David Perry, a physician in Emmaus, Pa., thinks doctors’ concerns about clinics’ ability to participate in the care of chronically ill patients might be overstated. Perry has an unusual perspective. After working in an emergency room for 15 years, he opened a mobile business called East Penn House Calls. This makes him a competitor to both clinics and traditional practices. “No primary care physician has 24 hours, seven days a week to be available to patients,” Perry says. “Historically, somebody has always filled that weekend role,” typically a nurse-practitioner or a physician’s assistant.

He concedes that some of the physicians’ hostility may be connected to the prospect of diminished revenue streams—and Charland agrees. Whenever he hears critics claim that clinics are inadequate because nurse-practitioners aren’t up to the task, he dismisses this as “purely an economic reaction.”

EXACTLY WHAT THE ROLE OF RETAIL CLINICS WILL BE DEPENDS ON MANY FACTORS, ranging from the strength of physician opposition to insurance company decisions about what they’re willing to cover. While insurers now generally pay for patients to receive routine or urgent care at retail clinics, the clinics will likely need to renegotiate contracts to add in procedures. “It’s not a given that insurance companies are going to provide coverage,” Charland says, noting that physician complaints could make insurers hesitate. “But chronic disease management costs insurance companies a lot of money, and retail clinics have proved to be successful at driving down costs.”

At this point, there is still much to be decided, and to that end, organizers of a January 2011 symposium in Scottsdale, Ariz., plan to invite all the stakeholders to examine what might work and what might not. Ultimately, Charland thinks retail clinics can’t go in halfway if they’re serious about chronic-care management. “It’s important to put a stake in the ground saying you’re going to be a part of the medical home,” he says. “Without that, I don’t see how you can do care management. Take diabetes: It’s a moving target, because over the months and years a patient’s body is changing.”

All of which is why Jeremy Katz will hold off on visiting a retail clinic to manage his hypertension. “If I didn’t know what I had going on and a clinic helped me figure out I was hypertensive, I would be thrilled,” he says. “But then I would be hightailing my butt over to my doctor to get treated.”

 

DOSSIER

1. “Retail Clinics: Update and Implications,” by the Deloitte Center for Health Solutions, 2009. For a business-focused perspective on retail clinics—and the underlying economic imperatives behind their expansion into chronic care—this report is as thorough as it gets.

2. “Retail Clinics, Primary Care Physicians, and Emergency Departments: A Comparison of Patients’ Visits,” by Ateev Mehrotra et al., Health Affairs, September/October 2008. For those who doubt the relevance of retail health clinics, this study is eye-opening, showing that patients suffering from 10 acute health problems are flocking to them.

3. “Comparing Costs and Quality of Care at Retail Clinics With That of Other Medical Settings for 3 Common Illnesses,” by Ateev Mehrotra et al.,Annals of Internal Medicine, September 2009. The most noteworthy finding: The care at retail clinics is just as good as that given by doctors’ offices and emergency departments—at least for otitis media, pharyngitis and urinary tract infections.

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