Retail clinics proving their worth

Are retail clinics a fad or a permanent and viable part of the healthcare landscape?

That was the question explored by health experts at a web-based summit April 25, presented by the Rand Corp. and the University of Pittsburgh. The summit featured Ateev Mehrotra, a policy analyst at Rand and associate professor at the Pitt School of Medicine, and Bernard Katz, assistant professor of family medicine at the David Geffen School of Medicine at the University of California Los Angeles. The clear answer: Retail-based walk-in care centers are here to stay, and they serve a valuable role in extending access to health care to millions of patients, at a lower cost.

Two companies dominate the retail clinic landscape, said Mehrotra — CVS Caremark’s Minute Clinic and Walgreens’ Take Care division. “Together, they make up almost 1,000 of the [approximately] 1,400 clinics in the United States,” he said. But there’s been a rise in clinics operated by large health systems like the Mayo Clinic and Geisinger Health, and in co-branded clinics operated within stores operated by Walmart and other chains.”

“After a period … when there was relatively slow growth, we’ve seen in the last year or so an uptick in the number of clinics opening around the country,” Mehrotra said, citing recent research by Rand. In addition, he said, “we’ve seen a rapid rise in the number of retail clinic visits.”

But along with their “rapid emergence onto the healthcare landscape, [clinics] have generated a lot of controversy” around the issues of “quality, access and primary care physician relationships and costs,” Mehrotra added.

“On the positive side, people have argued that retail clinics, by their use of strict evidence-based guidelines and well-trained nurse practitioners, can provide high quality of care. But there have been concerns, in particular from the physician community, that they’re going to provide lower quality of care and over-prescribe antibiotics,” he said.

In particular, Mehrotra said, while clinics can provide “a new entry point into the health system, including access for all patients,” concerns linger that the use of clinics “could undermine primary care physician/patient relationships, and also because they have negative downstream effects, such as decreasing the use of preventive care.”

On the issue of costs, said the physician, “there has been the hope that retail clinics can decrease [emergency room] visits and overall spending. But there have been concerns that patients will go to the clinic, not trust the care they’ve received and end up seeing their doctors anyway, and actually increase healthcare spending.”

Mehrotra said that Rand’s study of retail clinics should allay those concerns. “On the quality side, we looked at the care provided at retail clinics, and compared that care with care from doctors, urgent care and EDs [i.e., hospital emergency departments]. We found that the number of patients who received an antibiotic was quite similar at retail clinics compared with doctors’ offices and urgent care centers — therefore not supporting the concern that clinics will lead to overprescribing.”

In addition, said the analyst, surveys by Harris Interactive and other firms showed that patient satisfaction and scores for retail clinics were “very similar to what we saw at doctors’ offices and urgent care centers.”

One area of divergence is in the types of patients visiting retail clinics. “The largest fraction of patients who go to a retail clinic are in the 18- to 44-year-old group,” Mehrotra noted. “That’s very different from what you see at a doctor’s office. The patients who are going to retail clinics … are actually similar in terms of demographics … to those who go to an emergency department.”

Rand researchers also found that roughly a third of patients visiting a clinic are paying out of pocket, with two-thirds using insurance. “That’s much higher than what we see at a doctor’s office, and again … similar to what we see in an emergency department,” said the Rand analyst.

Another major difference between retail clinics and other care sites, said Mehrotra, goes to the core of retail clinics’ appeal: their much lower cost to patients and payers. Rand research found that clinics’ total costs of care for patients with three conditions — ear infection, sore throat and urinary tract infection — were almost always lower than what it cost patients for treatment at doctors’ offices and urgent care centers, and dramatically lower than emergency room costs.

“On the total costs of care for their conditions … [including] prescriptions received, any testing and follow-up visits … we find that care at retail clinics is 30% to 40% cheaper compared with the care provided at a physician’s office or urgent care center, and on average about 80% cheaper than what we see at an emergency department,” Mehrota said.

Rand estimates that roughly 100 million total patient visits each year could be shifted to a retail clinic from a physician practice or other care site. That could mean “billions of dollars in potential cost savings if patients shifted their care from those sites to a retail clinic,” Mehrotra said.
As for concerns that clinics would undermine primary-care relationships, he noted, “just under 40% of the patients who go to a retail clinic report they have a primary care physician. So for the majority of the patients who go to these clinics, there appears to be no relationship to disrupt.”

For patients who do have a PCP, he added, there does appear to be some “modest” shift away from primary-care doctors in favor of a retail clinic in the year following their visit to the retail site.

One major provider that has come to embrace the value retail clinics represent is the UCLA Health System, which has entered a collaborative relationship with CVS’ Minute Clinic. “We recognize there is a primary-care shortage in Southern California, and with the expansion of coverage from the Patient Protection and Affordable Care Act, we believe we’re going to need to make available to our patients other ways of receiving care,” Katz said.
To that end, UCLA Health launched a partnership in October 2012 with Minute Clinic, the nation’s largest retail clinic provider with 13 million patient visits since 2007. Under terms of the partnership, signs in all Minute Clinics in greater Los Angeles now alert patients that the clinic is “a clinical affiliate of UCLA Health.” In addition, said Katz, “the medical directors at the clinics are all UCLA primary care physicians.”

Among new steps to expand the partnership, Minute Clinic patients will have access, beginning in June, to EPIC, UCLA’s medical records patient portal. “They will be able to pull up that record in a Minute Clinic when they register,” said Katz, “and the patient can share that information with the nurse practitioner who’s treating them. The nurse practitioner’s clinic notes will then be embedded back into the UCLA electronic health record, and routed to the primary care physician for subsequent review.”

The alliance blossomed despite the reservations some UCLA physicians had “about whether this will interfere with the primary care physician’s role in providing care,” Katz said. “We realized that because patients have easy access to Minute Clinic, they’re going to utilize it anyway … whether we supported it or not. They want ease of access, the lower costs [and] the availability of after-hours care. And while we as a health system do provide urgent care centers and EDs and expanded primary-care hours, we saw our patients were still going to Minute Clinic … because it was more convenient. So we felt it was better to partner in order to at least be able to share information.”

One factor that drew UCLA to Minute Clinic was the clinic’s “support for the medical home model,” Katz said, and for efforts to involve the patient’s primary care physician in all interventions and share information via visit summaries, etc. What’s more, he said, “the scope of services at Minute Clinic is expanding,” with wellness screenings and chronic-condition monitoring for diabetes, asthma, hypertension and hyperlipidemia. “We feel this will help our patients in a medical home setting.”

UCLA Health also is exploring other ways to leverage the collaboration, Katz said. “We see other opportunities where we’ll be able to send our patients to Minute Clinics for lower costs, easier access, administration of immunizations,” and for follow-up care “for patients with chronic conditions at lower cost.”


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