CVS Pharmacy is stepping up its healthcare offerings by rolling out 1,500 “HealthHUBs” by the end of 2021. While its 1,100 MinuteClinics focus on low-acuity services, these “HealthHUBs” will provide for more everyday needs with a focus on chronic disease management while offering services like blood draws and sleep testing.
Then there are nearly 9,000 U.S. urgent care centers, according to the Urgent Care Association, and more than 550 freestanding emergency rooms, according to a report from UnitedHeath Group.
For traditional primary care clinics, these increased services from these clinics shouldn’t dampen the financial bottom line much—after all, primary care physician shortages lead to many clinics being understaffed and overbooked—although rural clinics in small towns may feel a pinch.
But the impact is being felt in other ways: The increased access to healthcare service is changing the role of the traditional primary care physician, and it can too easily lead to fragmented care.
“People who have colds, flu-like symptoms, ear infection, sinus infections, maybe even need basic immunizations, may just decide it’s easier to go to their local CVS or equivalent in-store healthcare provider because they can seek care without an appointment and potentially get in more quickly,” says Andrew Hajde, assistant director of association content at the Medical Group Management Association (MGMA). “In most cases, though, traditional clinics are going to see a lot more chronic patients who need ongoing care or have more complex issues where they need the constant attention of a physician on an ongoing basis.
“You might see a slight, slight decrease in encounters over the next few years. But it’ll probably be balanced out in terms of overall productivity just because they’re higher complexity patients with higher-acuity illnesses.”
The evolving role of primary care physicians
The big separator between traditional primary clinics and retail and urgent care clinics is going to be how acute the patient’s health is, Hadje says. That offers a differentiation for traditional primary care clinics.
According to MGMA data, the median total number of encounters in family medicine clinics without obstetrics services decreased 9.9 percent between 2015 and 2018. The median relative value units (RVUs), though, decreased just 0.3 percent. Those numbers indicate that while doctors are seeing fewer patients, they’re seeing more complex patients and cases.
“I think most people want a relationship with a physician who will really manage their care closely,” Hajde says. “When you go to a MinuteClinic or someplace like that, you probably won’t have a relationship with those providers, and you might see a different person every time you go.
“It’s not to say that you’re going to have a bad experience, but they may not be able to treat you in the same way as somebody who you have built a longstanding relationship with,” he adds.
The problem with increased access points
Increased access points for consumers can be a good thing, particularly in rural areas where there is a shortage of primary care providers, says Gary LeRoy, MD, a family physician in Dayton, Ohio and president of that American Academy of Family Physicians (AAFP).
“The ultimate goal would be to provide comprehensive longitudinal coordinated care for patients from coast to coast, east to west, north to south. But in some of those underserved areas, sometimes we have to get creative in how to fill those voids. And these retail health-type centers can sometimes provide the needed immunizations and healthcare information that underserved areas are in desperate need of.”
This increased access can cause fragmented care, though, because retail clinics don’t have a system for sharing records and patients don’t always remember what took place during a visit or consultation.
“If you get a vaccine at a CVS or some other freestanding facility, and you don’t provide a copy of the documentation they give to you to your primary care physician, it can create a gap in care,” Hadje says. “I have seen patients say they saw a cardiologist or other physician, but they don’t remember the physician’s name, they don’t remember the name of the practice, or where it was. You ask somebody what medications they’re on, they don’t know. They say they take one blue pill, one red pill, one white pill.
“Probably one of the things that frustrates physicians more than anything else is when they have to see patients and they don’t have a complete copy of their medical record for all the facilities they’ve been to. Then they’re trying to piecemeal how to treat a patient without complete information.”
Ann Abraham, MD, a retired family practice physician in Austin, Texas who now works per diem, recounts the story of a patient who went to several urgent care clinics about a persistent cough. She was initially told it was allergies, then bronchitis. They put her on multiple medications. But Abraham diagnosed a knew from her records that the patient had had breast cancer more than 20 years previous and diagnosed her with a pulmonary embolism. If she’d come to Abraham sooner, the embolism could have been discovered earlier.
Or someone goes to a retail clinic and gets referred to a specialist when their primary care physician could handle the treatment. Instead they go to the specialist and the PCP falls out of the loop of care.
“We don’t want to create a situation like with relay races, where people lose because they drop the baton handoff,” LeRoy says. “That’s basically what’s happening here. You put more runners in the race, there are more opportunities to hand off the baton—and more opportunities to drop the baton because they’re not effectively practiced in handoffs.”
How can physicians compete?
Healthcare consumers have become used to getting the products and services they want where and when they want them; they expect the same from their healthcare providers.
“Healthcare delivery in traditional clinics really is going to have to evolve to be quicker, better, cheaper and faster in order for people to be satisfied with it. That’s our new expectation,” Hajde says.
Primary care physicians need to listen to their patients and look at ways to meet consumers’ needs within traditional practices, says Michael Munger, MD, with St. Luke’s Health System in Kansas City.
“The onus is on primary care physicians to deliver what our patients need,” he says. “How can I make sure I’m available to patients? Sometimes that could be as straightforward as making sure you have someone on call for your practice 24 hours a day, seven days a week. That way, you can tell patients that if they need help, they can call you first, so you’ll know what’s going on. Perhaps you’ll just tell them they need to be seen in urgent care, but if they’ve communicated with you before they go, you know that you have something to follow up with. You know you need to close the loop.”
Primary care clinics need to create ways for patients with acute illnesses to be seen that same day. Offering extended hours or technology options, such as televisits and online support, can help with that. Munger notes that many family physicians nationwide have already instituted some form of advanced access, extended hours or capability for walk-in and same-day availability.
Strong relationships with patients and exceptional overall patient service can form the bonds that bring them back to your practice for all their needs. That means making sure your clinic is competing on a technological level. Traditional clinics need online scheduling, text message reminders, same-day access for appointments and price transparency, Hajde says. “Those are all things that if they can’t meet that need, it’s going to be really difficult for traditional clinics to compete with these retail and urgent care clinics.”
LeRoy and Munger say establishing relationships with local urgent care and retail clinics can be beneficial for traditional healthcare clinics, too.
“If I’m a family physician and I have an independent practice, I would be reaching out to the retail clinics around me and making sure I let them know I’m here if my patient shows up,” Munger says. “I ask them, ‘How can we communicate with each other? Can you send me a report? Can I at least know that they were here?’ You want to establish some way that you can coordinate the care.”
If traditional practices and retail and urgent care clinics are going to co-exist, they need to find common ground so they can create a patient-centered medical community, LeRoy says.
“We need to figure out ways to talk with each other and communicate with each other so we are working as a team to create a community of health. They can be part of that community, but we have to talk with each other.”
Patients play a role
Greater collaboration between providers would help address the fragmented care. But the universal technology isn’t there yet. So the burden for quality, continuous care also falls to patients.
“Pushing consumers to become more responsible for their own personal health and care will be huge moving into the future,” Hajde says. “It’s a matter of how physicians, practices, payers, and other people can encourage people to do that through their social determinants of health and other factors.”
Patients need to understand their primary care physician, their medical home, should be the hub of all their care, Munger says. To help that happen, primary care physicians should talk to their patients about when to visit a retail or urgent care clinic, and they should emphasize the importance of accurately and fully communicating what took place during those visits to their primary care physician.
“That’s the best way to ensure care is coordinated,” he says.
Living with retail care
Physicians need to recognize that retail clinics and urgent care are not going away.
“It’s important we educate our members, physicians and the medical community about the capacity of the retail clinics as opposed to just bemoaning the fact that they’re in your community,” LeRoy says. “But it’s a two-way street. [Retail clinics] need to understand what we do and understanding that just because it is called primary care, doesn’t mean that it’s easy care, because there’s nothing easy about what we do.”