What retail clinic growth can teach physicians about patient demand

Access: It's one word that may ultimately reignite the expansion of retail medicine in 2014 and beyond. CVS Caremark has added 200 new clinics since 2011, with another 850 planned by 2017. While it’s still too soon to predict a large-scale national expansion in clinic numbers, some experts believe their calling card-convenience-should be a consideration for every medical practice in the United States.

Retail clinics made their way into the healthcare market in the early 2000’s and began to grow significantly about 7 years ago. Since 2006 the number of retail clinics nationwide has expanded eight-fold from roughly 200 clinics to nearly 1,600 today.

These walk-in clinics, which tend to be located inside pharmacies, supermarkets, or “big-box” retailers, are typically staffed by nurse practitioners and physician assistants. They treat minor ailments such as strep throat and minor wounds, and offer vaccinations and physicals. Recently, some have begun to manage chronic conditions such as diabetes, high blood pressure, and asthma.

The Affordable Care Act (ACA) is expected to further strain the nation’s primary care capacity. Many view that as a chance for these clinics to play a larger role in providing basic primary care services. Just how large of an impact they may have on the healthcare system in general, and on independent office-based primary care practices specifically, depends on many factors.

As health reform’s implementation unfolds and new care models costs are developed, the future of retail clinics is far from clear. “This could go in a lot of directions,” says Ha T. Tu, senior health researcher with the Center for Studying Health System Change (HSC).

The growth of retail clinics

The retail clinic industry saw its biggest gains in 2007, when the number of clinics more than quadrupled from the previous year. “That period can almost be compared to the dot-com boom of the late 1990s when people were entering the (dot-com) industry without regard for how they would make money. That’s exactly what was happening,” says Thomas Charland, chief executive officer of healthcare consultancy, Merchant Medicine, LLC.

Though the industry’s growth flattened by 2008 and 2009 a number of surveys predicted that with an already existing shortage of primary care physicians and the implementation of the ACA on the horizon, growth would once again pick up at a rapid pace.

A report out earlier this year from the consulting firm Accenture predicted an expansion rate of 25%-30% per year between 2012 and 2015, thereby doubling the number of retail clinics nationwide, and possibly saving the healthcare system as much as $800 million per year in the process.

Many of the projections have been overly optimistic, Charland says. “The only one growing is CVS,” he says. “Apart from Minute Clinic we haven’t seen a lot of growth in new markets and most of their growth in 2011 and 2012 was in existing markets by adding clinics where the population has already achieved some level of acceptance.”

Most of the other big players in the retail clinic space, including Walgreens’ Take Care, Kroger’s Little Clinic, and Target, have remained static during the past four to five years. Walmart has seen about a 50% drop in retail clinics in their stores in the last year and a half.  “It’s dropped off dramatically,” Charland says. 

Despite the slowed growth in the clinics’ expansion, a recent study coauthored by Tu with the Center for Studying Health System Change found that the number of families using retail clinics tripled between 2007 and 2010. Still, just 3% of the population is seeking care in the retail setting. 

A number of dynamics may be behind the small number of people using retail clinics, according to Tu. First, the clinics are concentrated in large metropolitan areas, making them largely unavailable to people living outside big cities. The clinics are limited in the scope of services they provide, which by nature limits their use. And there still seems to be a lack of trust on the part of ­consumers.

“A lot of consumers still question the quality of care in retail clinics or just prefer to get primary care from a primary care physician. Those are all issues behind the relatively limited use of retail clinics,” Tu says.

Convenience attracts patients

Still, the reasons people do access store-based medical care should be a wakeup call for physicians in private practice, experts say.

According to Tu’s study and others before it, the biggest draw to retail clinics is convenience. The ability to walk in during evenings and weekends and to be seen quickly is a big plus.

Almost three in five patients using retail clinic services cited convenient hours as a major factor in choosing them over another source of care, according to the study.  Nearly 6 in 10 people chose to use retail clinics because they were able to receive care without an appointment. Just under half said the clinics’ convenient locations was a big appeal.

“The [medical] profession has a problem and I think the retail clinics have found it. The problem is access,” says Charles Cutler, MD, chair of the American College of Physicians (ACP) Board of Regents. “If you call your doctor for an appointment there may be an opening but at an inconvenient time. You may have to miss work, for example. There is a convenience factor with the retail clinics,” he says.

Robert Wergin, MD, president-elect of the American Academy of Family Physicians (AAFP) agrees. “We weren’t addressing patient needs on a same-day basis,” he says.

As a practicing physician, Wergin took the growth of retail clinics in his area as a sign that he needed to change his practice.  “Instead of being critical I asked, ‘why would my patients go there?’ They are having a need met that I’m not meeting,” he says.

In response, Wergin built a fast-track clinic into his practice to address many of the self-limited ailments retail clinics most commonly treat in a timely manner. The top six medical issues retail clinics see are:

• Sore throats and testing for strep throat

• Ear infections

• Sinus infections

• Female bladder infections

• Conjunctivitis

• General cough and flu symptoms

When patients call with a request for a same-day visit, Wergin says, they’re told to come into his office immediately and are placed in an exam room with an orange flag on the door. “I look at the ear infection and offer treatment. It’s a brief self-limited encounter,” Wergin says. 

And, he’s not alone in his approach. He says 71% of physicians affiliated with AAFP report offering patients same-day access. About 44% say they have extended early morning or late-day hours. And 31% are offering weekend hours for acute care.

It’s a good approach, Charland says, but one that some practices find challenging to adopt. “Generally, smaller practices have a harder time thinking strategically because keeping a practice open is about volume. They are the ones affected by retail clinics only to the extent patients are going elsewhere,” he says.

Wergin acknowledges that retail clinics can add value and that doctors can work with them to the advantage of their patients. The key, he says, is communication and making sure that a record of the patient visit makes its way back to the primary care physician.

Expanding into chronic disease management

While many of the medical academies express an openness toward retail clinics providing basic primary care, they draw the line on any discussion of expanding the scope of services they provide. “The academy is very much opposed to expansion into disease management and things that require ongoing care,” Wergin says of the AAFP’s position.

Yet that’s exactly what Walgreens plans to do. The company’s Take Care Clinics provide treatment and management for chronic conditions such as hypertension, diabetes, high cholesterol, and asthma.

This type of expanded role for retail clinics isn’t the answer to our nation’s healthcare delivery problem, Cutler says. “It’s fractured, siloed, it’s separated and not patient centered,” he says. “The ideal system for medical care would be that every patient is part of a medical home so that she or he doesn’t need to go to a retail clinic.”

But even with the ACA, millions of people will remain uninsured and unanchored to a primary care physician.

“For people who are low-income and who, for whatever reason, even under the ACA remain uninsured, those people might be more accepting of chronic disease management in a retail setting,” Tu says.

The HSC study found that families with at least one uninsured member were more than three times as likely as those with insurance to say they sought care in a retail clinic because they didn’t have a usual source of care.  Families with lower incomes were most likely to use the clinics for their lower cost and because they had no regular source of care.

Still, widespread expansion on the part of retail clinics could pose a threat to the independent physician practice. “The biggest threat to the smaller primary care practice is if the retail clinics come out of the closet and start doing full primary care and if they decide nurse practitioners will develop a following and develop a medical home,” Charland says.

The Impact of Medical Homes

Physicians are being incentivized to form and participate in Patient-Centered Medical Homes (PCMHs), and the model is gaining traction. To date, more than 27,500 clinicians and 5,700 sites nationwide have been certified as PCMHs by the National Committee for Quality Assurance. This model, if dominant in the healthcare delivery landscape of the future, may make retail clinic services unnecessary.

“The system can expand with medical homes and if they do, the [retail clinic] business model doesn’t work,” Cutler says.

CVS is one company that seems to recognize that. It’s taken a different path than the other large players, having established partnerships with a number of large health systems to expand patient access to care. This shifts the company’s retail clinics from competitor to extensions of larger provider organizations.

“The picture is muddied a little bit by the fact that local and well-known systems play a role in retail clinics, which they didn’t a decade ago,” Tu says. “If that’s the model that takes hold…[retail clinics] have a role to play in the integrated delivery systems,” she says.

Opportunities for practice expansion?

Although not yet a great risk to physicians in independent practice, depending upon the market retail clinics, and the services they provide and the new partnerships they have established could pose some threat.

Charland offers the following advice for physicians in private practice concerned about the potential of losing patients to retail clinics:

Take the emotion out

Charland says he’s worked with physicians who became so aggravated by the fact that patients sought care at a retail clinic that they refused the medical notes being offered that outlined the nature of the visit. That’s the wrong approach.

Instead, Charland says, doctors should be tracking every attribute of those visits, the type, time and day of the week. “This is so they have data to learn if they lost an opportunity, and they can engage with the patient to find out how to better serve them.”

Take yourself out of the equation

Charland says the most common medical issues retail clinics are treating don’t require a doctor’s attention, but can instead be treated by midlevel clinical staff. “I ask doctors how involved are you in the strep test of patient care. Most say they don’t do it,” Charland says.

Allowing the patients to walk in and see a nurse or physician assistant right away keeps patient satisfaction high, Charland says.

Pay attention to emerging care models

One newer care model in early stages but gaining traction is the direct primary care practice, a membership-based approach to routine and preventive care. 

“They should start looking at the market from the perspective of employers, especially with 50 to 250 employees because that’s the sweet spot,” Charland says of physicians in private practice. For physicians less than enthused about the movement to practice medicine as part of a larger health system, Charland says, “This could offset the need of becoming an employee.”