Payers warm up to retail clinics

Retail health clinics, typically located in pharmacy chain stores, offer members convenience and payers lower costs. As an alternative to physicians’ offices and emergency departments, retail clinics’ impact on care coordination and overall quality is still in dispute.

Operators contend that all their respective clinics are connected with electronic health record (EHR) systems, which offers them an opportunity to coordinate care.  Also they provide care summaries to patients’ primary care physicians and encourage patients to establish a relationship with a physician if they do not have a medical home or regular source of care-even helping them find available practices.

Family physicians, however, are still wary that these clinics are an intrusion in the physician-patient relationship and that the nurse practitioners who staff these facilities are not qualified to manage chronic conditions like a physician-led team, according to the American Academy of Family Physicians (AAFP).

Regardless, major retail clinics are in growth mode again, buoyed by patient preference as well as the healthcare reform law that will unleash millions of newly insured members into the market. To capture more of these consumers, retail clinics are expanding services to include preventive care, physicals and weight management.

“Nationally, payers warmed up to retail clinics,” says Thomas Charland, CEO of Merchant Medicine LLC, a research and consulting firm that covers retail and urgent care clinics. “Even to the point where a number of the health plans not only embraced it, but offered lower copays to members to create steerage toward these clinics and away from the emergency room.”

Clinic business

As of September 1, there were 1,475 retail health clinics in the United States, according to Merchant Medicine, up from 901 clinics at the end of 2007. After rapid growth from 2003 through 2008, retail health clinic expansion was flat in 2009 and 2010.

The business cycle was due to the economic recession, but also the ebb and flow of consumer demand for services. For example, upper respiratory infections drove much of their business but were seasonal, which required the clinics to alter their business models.

“For the off-season, there was a lot of cash burn,” says Charland. “They wanted these clinics to be open and convenient so they staffed them year-round, and the providers were literally just reading books. There were no patients.”

When the clinics were losing money, their in-demand NPs would find new jobs, Charland says.

Fall and winter were the busiest times for acute visits, so retail clinics added services to increase demand in slow months: summer camp physicals for the spring and school sports physicals for the late summer, primarily to attract time-starved parents eager for any licensed healthcare practitioner to sign the required forms. Other non-traditional non-acute services such as weight management and smoking cessation have been added, as well as biometric screenings, tuberculosis testing and blood glucose testing and monitoring.

“I don’t think they are taking it to the extent where they are practicing as a medical home,” says Charland. “But they’re moving in that direction."

Care continuity

Driving consumer and payer acceptance is the fact that 50% to 60% of patients visiting retail health clinics lack a regular primary care physician to begin with, according to the Convenient Care Assn., the trade group representing retail health clinics. As a consequence, these patients have no continuity in their care to disrupt, says CCA Executive Director Tine Hansen-Turton, JD.

“If anything, the clinics are important as an entry point into care for these patients,” Hansen-Turton says. “For patients who do not have a PCP, the clinics emphasize the importance of having a healthcare home, and make attempts to ensure the patient will find a regular source of care.”

Over the years, health systems and physician groups recognized this opportunity and partnered with retail health clinics to secure PCP and specialist referrals and monitor the quality of care delivered by the NPs. Cleveland Clinic, for example, has as a clinical affiliation with CVS’s MinuteClinic in Ohio and Florida, and Ochsner Health System in New Orleans partnered with Walgreens’ Healthcare Clinic (formerly Take Care Clinic).

Affiliated practices and health systems even educate patients on Healthcare Clinic services and coordinate care for additional services as appropriate, according to Heather Helle, divisional vice president, Walgreens Consumer Solutions.

“We can serve as an extension of their practices,” she says in an email to MHE, “…while health systems serve as a resource for specialty care, second opinions and rapid access to service outside of the scope of our clinics such as X-rays and EKGs.”

These types of affiliations will become the norm as formerly uninsured patients gain coverage and face a shortage of primary care physicians, according to consulting firm Accenture in its report “Retail medical clinics: From Foe to Friend?”

The relationships are key to “a secure niche in the marketplace.”

In the eyes of payers and employers, reducing the silos of care is a major concern. The prevalence of EHR systems used by the clinic providers offers reassurance. All Convenient Care Assn. members, including MinuteClinic and Healthcare Clinic, operate with EHR systems, as oppose to about 72% of office-based physicians who use at least a basic system, according to the U.S. Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology.

Patients seen at the retail clinics receive a copy of their medical record after the visit, which they can share and discuss with their other providers. If the patient has a regular primary care physician, the record is faxed to the practice or transferred electronically.

Walgreens’ Helle says that currently patient information collected at Healthcare Clinics is exchanged either by direct call or fax.

“We are in process of making available electronic transfer of patient visit information for those PCP/specialists who are interested in receiving it in electronic format,” she says.

Although retail clinics are forming alliances with large physician groups and health systems, independent family physicians and pediatricians have not warmed to the operators.

In 2010, the AAFP revised its first official policy (dating from 2005) regarding the clinics in light of their expansion of preventive care services.

New evidence has emerged that supports the AAFP’s concerns about fragmentation. An analysis of 127,358 patients who visited retail health clinics for one of 11 common ailments showed that they were less likely over the next 12 months to visit a primary care physician for a similar complaint, according to the Journal of General Internal Medicine study by the RAND Corp., first published online in October 2012. Patients who visited retail clinics were also less likely to see the same physician for their medical needs, according to the results.

Conversely, however, researchers found no evidence that the clinics “disrupted preventive medical care or management of diabetes,” according to the study.

“It may look to payers as if they can get an individual piece in a cheaper format, but that may be penny wise, pound foolish,” says Jeffery J. Cain, MD, FAAFP, president of the AAFP. “If you get a little cheaper part with a lower price for a less effective visit, you end up with higher utilization overall because of increased referrals, increased, unnecessary ER visits and hospitalizations. You’ve saved money on the office visit, but lost money on the global care of the patient.”

Even so, the market is still demanding the convenient services of the clinics.

Dr. Cain points out that AAFP members are responding to market demands by expanding hours and structuring their practices for walk-in visits. A 2012 survey of members showed 71% of family physicians offer same-day appointments, 45% have evening hours and 31% offer weekend appointments.

“Often times those minor visits are used by family doctors to talk with patients about other aspects of their care,” Dr. Cain says. “The visit may start with looking at a sinus infection, but we end up talking about their cholesterol or the last time they had their diabetes checked.”

Future growth

Accenture predicts that by 2015 there will be 2,868 retail health clinics with the capacity for 10.8 million patient visits, up from 5.1 million in 2011. Patient volume should sustain those new locations because they will likely be included in most plan networks and a HarrisInteractive/HealthDay poll shows that adults who have visited retail clinics grew to 27% in 2012 from 7% in 2008.

Employers, too, seem to be supportive. Fifty-six percent of employers offering health benefits cover retail health clinics, according to the Kaiser Family Foundation and the Health Research & Educational Trust’s 2013 Employer Health Benefits survey. Of those employers, 17% provide a financial incentive to receive services in a retail clinic instead of physician’s office.

“From the insurer’s perspective, they want the patient to go to the lowest-cost access point that is still appropriate to care for their needs,” says the CCA’s Hansen-Turton. “This makes sense from a financial perspective, and also from the standpoint of reducing the burden on emergency services.”

Whether or not they impact overall quality of care in the long term is yet to be seen. “Retail clinics are still in their infancy,” said RAND study co-author Rachel O. Reid of the University of Pittsburgh School of Medicine in a prepared statement.

Observers believe the systemwide effect of retail clinics on preventive care or continuity of medical care must be studied further.

Morgan Lewis Jr. is a Pennsylvania-based freelance writer.