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When doctor reimbursements shrink, there's only one way to see the truth.

Medical Economics Cartoon: When reimbursements shrink

Heart disease and cardiometabolic syndrome, a combination of metabolic dysfunctions characterized by insulin resistance, impaired glucose tolerance, dyslipidemia, hypertension, and central adiposity have become global epidemics.  An estimated 47 million people in the U.S. live with these disorders, which place a huge financial burden on the U.S. healthcare system and on the practices of physicians trying to manage these patients. A 2015 study in the Journal of Diabetes and Metabolism found that in 2014, national medical expenditures attributable to cardiometabolic risk factor clusters in the U.S. totaled $80 billion, with $27 billion of that spent on prescription drugs.
	
	“The impact [of cardiometabolic syndrome] on the healthcare system is massive because it branches out in every direction. Inability to work, immobility. It has an impact on the workforce, on insurance costs, on hospitalizations. I think we need to really act quickly if we want to stop it,” says Jennifer Haythe, MD, a cardiologist with the Center for Advanced Cardiac Care at Columbia University Medical Center in N.Y.
	
	While many patients manage cardiometabolic syndrome and heart disease with medications, physicians find that a combination of lifestyle changes, including dietary and behavioral changes, are key to keeping these patients healthy.
	
	


	
	It’s important for physicians to get to know these patients’ unique needs in order to personalize a treatment approach that will work, says Mark Menolascino, MD, medical director of the Meno Clinic in Jackson Hole, Wyo.
	
	“You need to know what’s important to people. Do they want to live a long life, or an optimal life?” he says. “Take a few minutes to understand their goals and health wishes and then try to come up with strategies of lifestyle that fit those goals,” he says. For example, there’s no use suggesting a patient take up bicycling if they live in a place with no safe bike trails or lanes, he says.
	
	In addition, it’s important for physicians to inspire change through positive reinforcement and avoid shaming or blaming the patient, says Lucienne Ide, MD, Ph.D., founder of Atlanta-based Rimidi, a cloud-based software that supports clinical workflows around cardiometabolic disease management.
	
	“Patients should feel that the physician is here to support them on their journey and to see that they are making progress, be that a blood glucose goal, a lipid goal, or a weight loss goal,” Ide says.


	
	Patients with cardiometablic syndrome usually are starting out at a deficit of health, nutrition and physical activity. Big changes are just not realistic, Ide says.
	
	“I’m a big fan of the tiny changes movement,” Ide says. “Just [tell patients to] start with something small that is attainable that they can feel good about.”
	
	Menolascino encourages patients to add more activity incrementally to their existing routines. This can include such steps as parking farther from the store and doing several laps around the parking lot before going in or walking up and down stairs at work several times on a break.
	
	“As doctors we have to pick one thing that fits [patients] belief systems that they can be successful at,” he says.
	For patients who are motivated by wanting to take fewer medications, Haythe reinforces that lifestyle changes can enable reductions in, and even stopping, some medications altogether.
	
	For those patients who opt for medication over lifestyle changes, she tries to empathize but still encourage change. “I’ll say things like, ‘It’s very hard to get to middle age. Everybody’s body changes. But you could become much healthier and feel much better if you make real changes to your life.’”
	
	She also offers patients a success story about someone who has made these changes and feels better. “I try to empower them to have confidence that it can be done and it’s not hopeless,” she says.
	
	Though lifestyle changes should take priority, for some patients medication and even surgery (gastric bypass or gastric sleeves) may be the necessary starting point, Ide says, and shouldn’t be seen as a sign of failure. “If a patient is just not in a place where they can make a substantial change, a medical intervention may be what they need to move down that pathway and get stability,” she says.


	
	Physical activity is one of the most important steps a person with CMS and heart disease can take for their health, says Chetan Khamare, MD, FACC, a cardiologist at the Premier Heart and Vascular Center in Tampa, Fla. He says the American College of Cardiology (ACC) used to recommend 30 minutes of continuous cardiovascular exercise five days a week, but now they’ve found that just adding an extra ten minutes daily, up to 40 minutes per day, leads to a 25 to 30 percent additional reduction in cardiovascular events.
	
	He also points his patients to an online risk calculator provided by the ACC, which helps establish a baseline of risk for such conditions as heart attack and stroke, and offers physicians a starting point for interventions. He finds that when patients take the agency to use the calculator they’re more likely to commit to healthy behaviors, especially since it’s scientifically validated.
	
	Peer support is also useful in getting patients to be more active, Haythe says. “Tell patients to find a friend to go walking with. Start with just ten minutes outside every day.”
	
	“If your friends aren’t healthy, there’s data to show you probably aren’t either,” Menolascino points out, so he encourages patients to find a group that can help them make healthy choices. He cites the example of a church group that added  nutritional lessons to Bible study classes and motivated its members to eat healthier.


	
	Most patients with cardiometablic syndrome and heart disease need to make fairly drastic dietary changes, says Pilar Stevens-Haynes, MD, director of non-invasive imaging at South Nassau Community Hospital in Oceanside, N.Y. But few patients will make all the changes overnight, she says, and physicians need to be encouraging but patient.
	
	Stevens-Haynes sends patients home with a food diary to help them pay attention to what and how they’re eating. Then she’ll encourage them to start with cutting or lowering one thing: canned or boxed food, for example, which is high in salt, or replacing juice or soda with water, or avoiding bread. She then sets a follow-up appointment in three months to see if there have been improvements, such as losing a few pounds, or lower blood pressure, which might enable them to reduce a medication.
	
	Khamare puts eating into a simple set of parameters: “I tell patients if you can grow it in your garden or if you can kill it-within certain parameters-you can eat it. Don’t unwrap it, don’t unbox it. Don’t order it at a drive through.”
	
	However, he recognizes that patients will not follow his recommendations immediately, saying that many patients are in a state of denial about their habits. “I’ll give patients one simple goal so that it’s achievable, realistically, and tell them to have a cheat day once a week.”
	
	If the patient can meet that one goal, then at the follow up appointment he sets another goal, and so on.


	
	Stevens-Haynes says her patients have more success when they use apps and  tracking devices like Fitbits and smartwatches. Her patients rave about an app called My Fitness Pal, which allows patients to track calories and macronutrients, and can even scan products in the store and easily input nutritional data.
	
	These devices and apps can also reveal just how active or inactive a person really is. “The perception in general is that we’re much more active than what we really are,” Stevens-Haynes says.
	
	Haythe has learned that the patients who really commit to these changes feel better, reduce or come off medications more quickly, and see increased self-esteem.


	
	Getting patients to make lifestyle changes doesn’t have to be solely the job of the physician, says Menolascino. “A lot of doctors don’t really know about the psychology of eating and the psychology of behavioral change,” he says. “That’s what health coaches are for.” He thinks physicians should either have an in-house nutritionist/dietician or health coach or develop a strong referral base for them.
	
	Haythe adds that nurses and nurse practitioners can also be helpful. “A diabetes nurse practitioner can do education and prescribe medication, for example. I recommend having those people in [physician] practices.”


	
	Tracking key health indicators is an important part of helping patients stay healthy, Khamare says. He recommends that every practice track such indicators as hypertension, uncontrolled cholesterol, and weight. While every EHR is different, there are ways to set up analytics to track this data.
	
	Ide also promotes the idea of remote patient monitoring from home, via a Fitbit, electronic scale, or a Wi-Fi-enabled blood pressure cuff that sends real time data directly to a physician’s EHR. This allows the physician to stay abreast of health changes between office visits. “Physicians might see a patient four times per year, but [patients] are living with their disease every day of the year,” she says.
	
	With remote patient monitoring, not only does the physician gain valuable data, they can communicate support via electronic messages. “Then maybe I could message a patient after a month and say ‘hey, I see you’ve lost two pounds, great job.’” She says that creates a positive feedback loop that might otherwise be missing, and helps patients feel that their doctors care.
	
	Even better, Medicare now reimburses for some remote patient monitoring and for time physicians spend reviewing data under chronic care management codes.
	
	“It’s important for physicians to know there’s a lot happening in tech that is designed to support them,” Ide says.

An incremental approach to improving outcomes.

How to manage cardiometabolic syndrome

In June 2019, the World Health Organization formally labeled burnout a medical condition. I believe this to be a mis-diagnosis, as burnout is not an illness.
	
	Rather, physician burnout is a symptom of a healthcare system broken by innumerable cracks, a system refusing to call attention to its disfiguration and failings. The public and lay press have latched on to the idea that physicians are burned out-with fatal implications of personal failing, exhaustion and shortcoming.
	
	This is a distraction, a redirection away from the fundamental pathologies in our healthcare system. This dangerous paradigm of burnout runs the risk of eroding public trust in medical professionals, and avoids confrontation with the ultimate systemic failings that stoke the fire.
	
	If the system is unwilling to identify its faults, I will vocalize those that have led me to huddle at my desk and cry to myself at night in an empty office. The first and most pervasive is the shift from the care of those in need to the business of medicine as a volume proposition for revenue generation. Bloated administrative salaries and unnecessary overhead parallel lavish marketing expenditures. Many systems have entered the sordid business of luring customers and seeking five-star reviews, as opposed to putting care of patients and communities first. There appears to be little to no accountability for the “non-profit” status so many systems carry.
	
	What results are so-called “customers” that arrive to visits with increasing expectations of their time and experience. This is coupled with rising complexity of illnesses, rapid pace of change of evidence at the point of practice, and little or no additional time or resources for each patient seen.


	
	Ultimately, while many physicians don their white coat to care for those in need, they are confronted by a system that has stolen their autonomy and relegated them to the silent position of “provider.”
	
	My symptoms of burnout in practice have come as a result of being overwhelmed with the extent of illness, of too many conversations about death, depression, addiction, and suicide on a daily basis. It is a feeling that I do not have the time to make the number of right and safe choices for my patients, or respond to the amount of care that they need in a given day.
	
	It is often an impossibility for me to finish the day and feel ethically and morally satisfied. No duty hour rules can shield against such emotional onslaught.
	
	The list of cracks in the system goes on. Much has been written about extensive documentation requirements that are unnecessarily cumbersome in outmoded EHRs. The ordering of unnecessary tests for the sake of liability not only compounds our untenable cost crisis, but undermines physician decision making and intuition.
	
	Insurance companies play shell games with medication and medical bills, and prior authorizations add a superfluous and demeaning layer to patient care.
	
	Too often the consequences of these failed machinations land on the shoulders of the physician at the point of care. This disrupts hallowed patient-physician relationships and wastes precious time that could otherwise be spent in caregiving and counseling.
	
	Thankfully, in recent years we have witnessed some proactiveness in preparing trainees to recognize burnout. Likewise, our systems now provide new resources and counseling to respond to it.
	
	These approaches are essentially bookends to the underlying condition but fail to fully confront the causes. In doing so, they unintentionally, yet implicitly, suggest that burnout is an unfortunate inevitability. Such an approach is akin to telling a young man that diabetes is a disease, and then sitting back until the first signs of elevated hemoglobin A1c. It ignores so many of the elements in the interim that can be influenced to prevent the outcome in the first place.
	
	We treat burnout in much the same way, almost as if it is an expected side effect, a rite of passage or even a badge of courage.


	
	Our healthcare systems fundamentally ignore the call for decreasing stress, offloading documentation burden, and restoring autonomy and joy to practice. Adding a suicide help line and an annual doctor’s day golf outing is far from a systemic cure.
	
	One local health system formed a burnout committee in response to overwhelmed physicians, and the first initiative was a monthly wine night held on Thursdays. None of the primary care physicians I spoke to were able to attend, as they were all busy in the office working on documentation until after 10 p.m.
	
	Many systems have added similar interventions such as lunchtime yoga sessions or coffee coupon cards for physicians. We respond to the symptoms of the disease, instead of working on preventive measures to address the problem at its core. These “treatments,” in other words, ignore the heart of the problem.
	
	Unfortunately, the symptoms of burnout tend to beget more burnout. Much more than a spreading plague of negativity, compounded stress from a broken system has pressed physicians to bear the burden or pass it on to equally stressed colleagues. Neither responses are particularly healthy.
	
	As physicians, we are far too willing to ignore our own health and humanity, and far too willing to transfer our own stress on to our colleagues.


	
	There is one area that I can speak to that is within our grasp as physicians to resolve: How we treat ourselves.
	
	While I have witnessed acts of intense selflessness, compassionate camaraderie, and bonds among teams, I have also observed infractions of character, defamation, and belittling. Lost somewhere in our intense focus on doing no harm to our patients, we often neglect the application of non nocere to ourselves.
	
	Yet, within the world of medicine, there is so much unspoken harm we do to one another. The overworked emergency room physician is berated by the overworked hospitalist for the tenth admission of the night. The attending surgeon belittles the intern for poor closure technique as the intern scrambles to fulfill the administrative tasks that are a hospital priority. The time-pressed primary care physician hastily sends a patient to the emergency room unnecessarily for something they could have addressed in-office with more time available. The specialist dumps a plethora of patient problems back to primary care. It becomes a vicious cycle in which, lacking time to deliver care in the right way, physicians pass patients like hot potatoes.
	
	We burn each other with these repeated moral injuries, and instead of blaming the root cause of these actions, we instead scapegoat each other.
	
	I am burned out on discussion of burnout. Incremental changes will only allow disparate inadequacies to flourish and become more prominent. As physicians we have our collective voices to call out the injustice inherent in these failures. But we also have the capacity to avoid self-harm, both to ourselves and to our colleagues. While we embrace the shift away from the discussion on burnout, and the coming necessary systemic changes, physicians need consider a broader application of their charge for non nocere and seek to do no harm to patients, colleagues, and yes, even ourselves.

While many physicians don their white coat to care for those in need, they are confronted by a system that has stolen their autonomy and relegated them to the silent position of “provider.”

What's the true cause of physician burnout?

David Boles, DO, owns a family medicine clinic with four physicians in Clarksville, Tenn. In recent years, he has seen an upsurge in competition from retail clinics, urgent care centers and a freestanding emergency clinic.
	
	Those alternative care sites have hit his bottom line hard by taking away the lion’s share of the minor acute-care visits that used to be his practice’s bread and butter. That has left him and his colleagues to deal with the harder cases that they get paid less for in relation to the amount of time they take.
	
	“If I see 25 patients in a day, it will be 25 complicated patients,” he says. In the past, he recalls, his practice saw a lot of patients with the flu during flu season and did most of the patients’ immunizations. But now the alternative care settings-including four new urgent care clinics and the freestanding ER-are taking all the easy cases. As a result, he often finds it difficult to keep his midlevel practitioners busy.
	
	Boles’ situation is not unique. Russell Kohl, MD, a board member of the American Academy of Family Physicians (AAFP), says he’s heard similar complaints from some AAFP members. Jillian Schneider, manager of the department of medical practice for the American College of Physicians (ACP), acknowledges that alternative care settings are also a challenge for internists. And Scott Cullen, MD, a consultant with ECG Management Consultants, says that fast-growing alternative care settings pose significant competition for some primary care physicians.
	
	Along with physical care sites, telehealth services are part of the provider mix that is meeting some of the demand for minor acute care. FAIR Health, a research organization, says that telemedicine utilization leaped by 1200 percent from 2012 to 2017. The bulk of that growth appears to represent consumers’ use of telehealth services.
	
	Although a growing number of practices-especially larger groups--are doing telehealth visits with their own patients, a recent ACP survey found that just 18 percent of internal medicine practices had the technology needed to do secure video visits, and a third had online consult capabilities.
	
	Meanwhile, the number of alternative care settings is soaring. At latest count, there were about 2,200 retail clinics, of which more than half were operated by CVS or Walgreens. The number of urgent care clinics jumped from 6,946 in 2016 to 8,774 in November 2018, according to the Urgent Care Association.


	
	People use alternative care settings for low-acuity conditions because they offer convenience and access. Sick patients don’t want to wait to see a primary care doctor in a conventional office. Often, they can’t leave work to visit a physician practice during office hours. They may not be sure whether they need to see a doctor, or they may just need a prescription.
	
	Price can be a differentiator. Urgent care centers are more cost effective than standalone ERs, which charge close to what hospital emergency departments do, but they charge more than physician practices do, on average. And, among physical sites, retail clinics charge the least for primary care.
	
	FAIR Health’s analysis of a large national claims database, for example, found that median charges for a CPT 99202 visit ranged from $160 in an urgent center to $138 in an office to $104 in a retail clinic. Median allowed amounts for CPT 99202 were $93 for urgent care centers, $66 for offices, and $73 for retail clinics. CPT 99203 median charges were $213, $207 and $129, respectively. Urgent care centers were allowed $114, offices, $92, and retail clinics, $85, for CPT 99203. According to other reports, a telehealth visit may cost $50 to $80.
	
	Considering that primary care offices must also see patients with chronic conditions and cope with an ever-increasing, complex blizzard of rules and regulations, the lower or similar payments to primary care offices place them at a disadvantage, Boles notes.
	
	“The expectations on primary care are so overwhelming,” he says. “Then you throw on top of that a walk-in clinic right down the street that doesn’t deal with any of those things and sees this person for a minor problem and gets paid similar to what we do for an office visit. They get the icing, and the real meat of the issue is left to us.”
	
	Seeing mainly complex patients is a losing proposition for an independent family physician, explains Richard Young, MD, who works for a safety-net hospital in Fort Worth, Tex., and who researches the local market for an affiliated family practice residency. “If I take care of four problems in a visit-say a patient has high blood pressure, diabetes, back pain and a rash-I’ve given away half my services, because the CPT coding system quits paying me after I’ve seen two things.”
	
	What can primary care practices do to meet this competition? Schneider urges them, first of all, to investigate the possibility of collaborating with alternative care sites. Retail and urgent care clinics can refer patients who need more extensive diagnosis and treatment to primary care offices, she says, and primary care providers can advise patients to go to certain walk-in clinics when their offices are closed. Of course, the alternative care sites must agree to send documentation of each encounter to the patient’s primary care physician.


	
	Practices should also extend their hours, Schneider says, even if it’s only on certain days of the week and/or selected weekends each month. Practices should plan their extended hours to meet the particular needs of their patient population, Cullen advises. On different days, for example, Jeff Pearson, DO, a family doctor in Carlsbad, Calif., has early morning and evening hours designed for patients who are on various schedules, he says.
	
	Kohl agrees extended hours are important, but notes that they can create staff scheduling challenges. When he was in private practice, he recalls, he and his nurse practitioner were on staggered schedules: he handled the early hours and she covered the evenings, and the staff schedules were staggered to match.
	
	


	
	The vast majority of FPs offer some version of same-day scheduling, another technique that increases access. Not too many doctors open up their entire schedules to whomever happens to walk in or call in. But a generous number of open slots can help patients get in when they need to be seen. In his former practice, Kohl kept all of his afternoon appointments open, and they all filled up.
	
	Similarly, Robert S. Kaufmann, MD, a general internist in Atlanta, says that his five-doctor group has regular walk-in slots for patients with low-acuity problems.


	
	Schneider also suggests that practices post the prices for their most common services, just as the alternative care settings do. Even though a provider’s charges may not equate to what the patient will pay out of pocket, she says, “People want to know what’s going to hit their pocketbooks.” If practices want to give patients a better idea of out of pocket costs, she adds, they can ask their major payers what their allowed charges are on the most common services.
	
	Pearson says he’s been posting his prices ever since he started out in practice. Today, all of his charges are on his website. 


	
	In today’s world, Cullen says, it’s essential for a primary care practice to have a digital platform. Primary care physicians must be able to interact with patients online, not only to give advice, but to set up appointments, deliver test results, and provide educational materials. 
	
	These online activities, as well as secure video visits, depend on patient portals. Not many patients, however, take advantage of these sites, according to a 2018 Government Accountability Office’s study that shows only 30% of Medicare patients used them. Cullen says the more value patient portals deliver, the more they’ll be used. Schneider urges practices to promote their portal to patients, talking about it at every visit and providing handouts on how to use it. In a clinic she used to manage, she says, staff would show patients how to log onto the portal on a computer in the waiting room.
	
	It’s also essential to use social media, Schneider says. This is particularly true if practices hope to reach the millennials who are among the biggest customers of retail and urgent care clinics. Practices can employ Facebook, Twitter and Instagram to get out the word about their services and hours of operation, she notes.
	
	


	
	E-consults and video visits represent another promising avenue to connect with younger patients. One Tulsa practice that recently started offering e-visits for 10 minor acute conditions has seen quite a bit of patient uptake, Schneider says.
	
	According to ACP’s telehealth survey, the majority of practices that have the technology aren’t using it. Now that reimbursement for telehealth is widely available, Schneider says, the main barrier is lack of training. EHR vendors who license video visit modules are not training providers on how to use them, and physicians also have to teach their patients how to use the technology.
	
	Kaufmann’s telemedicine vendor provided the hands-on training that the physicians and staff needed to feel comfortable with virtual care. When the group’s doctors are busy, they do audio-video consults on minor acute problems so that patients don’t have to come into the office. “We can provide service without making them wait,” Kaufmann says. At the same time, telemedicine has added a new profit center for the practice, he adds.


	
	Kohl says the AAFP is less concerned about the competition from alternative care settings than  about the fragmentation of care that can result. At least in one respect, that problem is diminishing, he says: Recently, he has seen more retail and urgent care clinics send information about patients’ visits to their regular family physicians.
	
	Still, he says, alternative care settings “represent a misunderstanding of the value of comprehensive, continuous care.” Patients at walk-in clinics don’t receive the same type of attention to all of their risk factors and current conditions.
	
	Pearson recently restarted a cash-only solo practice after several years working for a large group, and this has turned out to be an effective way to compete with alternative care sites, since he can provide more personalized care.
	
	“I don’t have a seven-minute window,” he points out. “They get better service. Also, when they go to urgent care, they’re being seen by a PA a lot of the time. When they come to me, they’re seeing a seasoned doctor with 35 years’ experience.”
	 

Retail pharmacies moving hard into primary care

The leading retail pharmacy chains, Walgreens and CVS, are aggressively expanding the healthcare services they offer to customers. Here’s a roundup of their latest moves.


	
	CVS announced plans earlier this year to open 1,500 “HealthHUB” locations across the country in the next three years, another major move that shows that traditional physicians practices will face further competition from mega corporations.
	
	CVS already has more than 1,000 MinuteClinics in the United States, in which non-physician providers, usually a nurse practitioner, provides acute care for minor illnesses and injuries, along with basic screening services.
	
	The HealthHUB concept goes beyond that, and represents “a powerful example of how CVS Health can provide consumers with convenient, personalized and integrated access to local healthcare,” according to a CVS press release.
	
	Each HealthHUB has a “care concierge team” that works with customers to guide them through various services, including acute care, nutrition counseling, and chronic disease management for high blood pressure, high cholesterol, and type 2 diabetes.
	
	CVS already has HealthHUBs as pilot programs in a handful of Houston-area stores. The plan is to convert about 50 CVS locations in 2019 in Houston, Atlanta, Philadelphia, and Tampa. The rest of the expansion will occur during the following two years.
	
	“Going forward, we also have truly exciting opportunities to introduce programs and products that will change the way people think of and address their health,” said CVS Health Chief Financial Officer Eva Boratto, in a news release.
	
	CVS competitor Walgreens also is planning healthcare pilot programs in Houston, partnering with VillageMD to open primary care clinics adjacent to five Walgreens stores before the end of 2019.
	
	CVS is also seeking a merger with insurer Aetna, a multi-billion-dollar deal that would reshape the healthcare landscape. The proposed merger has faced increase scrutiny, however, as the federal judge tasked with signing off on the deal said on June 4 that he had anti-trust concerns regarding the merger.


	
	Walgreens, the national drugstore chain, is launching a primary care service for adults starting with the Houston market and possibly expanding into other cities at a later date.
	
	Walgreens is partnering with VillageMD, a provider of tools and support to primary care  physicians, to open clinics adjacent to five Walgreens stores in the Houston area, with the first locations scheduled to open by the end of 2019. Unlike many clinics in drugstore chains, this venture will focus primarily on the use of physician providers. Operating under the “Village Medical at Walgreens” moniker, the 2,500-square-foot clinics will provide primary care services from VillageMD doctors who are integrated with pharmacists, nurses, and social workers to meet patient needs.
	
	VillageMD will use its docOS system, which integrates data and technology to get a 360-degree view of patients’ health needs, according to a press release from Walgreens. The software helps identify missing diagnoses and gaps in health, allowing doctors and patients to better manage chronic conditions that impede health and increase costs. The technology includes check-ins via phone, kiosk, home-based monitoring, and telemedicine.
	
	“This collaboration with VillageMD demonstrates our ongoing commitment to create neighborhood health destinations that bring affordable healthcare services to customers and provide differentiated patient experience to the communities we serve,” said Pat Carroll, MD, Walgreens chief medical officer and group vice president, in a release. “VillageMD has a strong track record nationally of improving outcomes and reducing the cost of healthcare through their transformative primary care model. With more than 120 primary care physicians in their medical group in Houston, we look forward to working with them as we focus on the health and well-being of the community.”
	
	Walgreens operates 9,560 drugstores in the United States, Puerto Rico, and the U.S. Virgin Islands. Approximately 400 of its stores offer some form of a healthcare clinic for patients. VillageMD has more than 2,500 physicians across eight markets and is responsible for $2.8 billion in healthcare spending.

The increase in competition from retail clinics and urgent care centers brings new challenges for independent medical practices.

How to compete  with retail clinics

Slideshows

Feelings of burnout among doctors has pervasive effect on happiness, work-life balance and patient care, according to our exclusive survey results.

August 25, 2019 edition

Medical Economics Cartoon: When reimbursements shrink

How to manage cardiometabolic syndrome

What's the true cause of physician burnout?

How to compete with retail clinics

2019 Physician Burnout Survey: Results show growing crisis in medicine