Retail-Based Health Clinics Grow in Popularity Nationwide: Benefits, Risks Debated by Health Groups

Kim Krisberg

Nations Health. 2007;37(7) 


Sometime in the not-so-far-off future, going to the local drugstore to be diagnosed and treated for a sore throat or aching ear could become a typical health care scenario if the emerging trend of retail-based health clinics proves popular with consumers.

Currently, there are about 500 retail-based health clinics, also known as convenient care clinics, opening in stores such as Walgreens, Target and Wal-Mart that have names such as RediClinic, HealthStop and MedPoint Express. The clinics, usually staffed by nurse practitioners or physician assistants, offer a limited scope of services ranging from cholesterol screenings to immunizations to care for a poison ivy rash, at a cost of between $40 and $70. The trend is of note in a nation home to more than 40 million uninsured residents, any of whom could end up in an emergency room because without insurance or a "medical home," a simple sore throat turns into a costly hospital visit. Advocates say retail-based health clinics help fill a widening gap in health care access and report high patient satisfaction rates. However, a number of professional medical societies are expressing concern that quality of care could suffer, clinics will not be held to the same standards as medical offices and potential financial conflicts of interest could surface.

Among the organizations that have raised concerns is the American Medical Association, which in June adopted a directive instructing the association to urge state and federal agencies to investigate partnerships between retail clinics and pharmacy chains for conflicts of interest, citing "retailers who have stated that store-based health clinics help drive additional store traffic, which can increase sales of lucrative prescription drugs and other non-health related products," a news release stated. Previously, the association adopted principles it asserts should be promoted at store clinics, such as having a well-defined and limited scope of services and clearly informing patients of practitioners' qualifications. AMA is not alone in its concerns, joining organizations such as the American Academy of Pediatrics and American Academy of Family Physicians, both of which have similar policies regarding retail clinics. But despite some opposition from the medical community, retail clinic advocates say they're providing a sorely needed service and could actually help integrate more people into the larger health care system.

"We're not seeing opposition at the community level," said Tine Hansen-Turton, executive director of the Convenient Care Association. "Patients really understand what these clinics are — they're not medical homes, they use them for convenience."

Launched in 2006, the association has 18 company members and has its own set of standards that members adopt. The standards range from urging members to form relationships with medical providers and physicians in their communities to using electronic health records to developing emergency response procedures for patients in need of immediate attention. All of the clinics associated with the Convenient Care Association work to build strong relationships with local physicians and, in fact, couldn't operate effectively if they weren't collaborating with doctors in the community, Hansen-Turton said. With 700 retail-based clinics expected to be up and running by December, Hansen-Turton reported patient satisfaction is at 98 percent, with convenience cited as the top positive feedback.

"Thirty percent of patients that come to convenient care clinics don't have a primary care physician or medical home, so we work very closely to find out who has openings and who can take a new patient," she told The Nation's Health. "We're becoming connectors for the community."

All the clinics within the association use electronic health records as well, so patients leave clinics with their records in hand and can even request a copy be faxed or e-mailed to their primary provider, Hansen-Turton said. Ideally, retail clinics' evening and weekend hours can complement or act as a "back-up" when a patient's usual source of care is unavailable, she said.

"This is a good idea whose time has come," Hansen-Turton said. "The truth is we have a shortage of family physicians, so how do we use all the qualified health providers out there to broaden access to care."

William Hazel, MD, a member of the American Medical Association's Board of Trustees, said retail-based clinics can "play a positive role if done properly, but they are not a substitute for a regular medical home," a term which describes the relationship built between a primary health care provider and her or his patients to help ensure all of the medical and non-medical needs of patients are met. Hazel said AMA wants to ensure such clinics are well-integrated into the larger medical community. He said AMA is not opposed to retail clinics, but is trying to raise questions, such as whether someone who is sick with the flu should seek treatment at a crowded grocery store. In regard to financial conflicts of interest, Hazel said that just as doctors are heavily scrutinized for their interactions with pharmaceutical companies, the implications of a health clinic owned by a pharmacy chain should also be examined.

"They're here and they're growing, and the verdict is out on whether they will be successful or not," Hazel told The Nation's Health. "We just want to be sure that the patients are well taken care of and remain integrated into the medical community."

The American Academy of Pediatrics has taken a stronger stance on retail-based clinics, opposing them "as a source for medical care of infants, children and adolescents." According to a 2006 news release, the academy is particularly concerned with fragmentation of care, lack of access to a central health record, lack of proper follow-up and the public health issues related to treating illnesses in a retail environment. Robert Corwin, MD, a practicing physician in Rochester, N.Y., and lead author of the academy's retail-based clinic policy, said while many retail-based clinics won't see children 18 months old and younger, the age limits are "all over the place," with some clinics serving very young infants. Retail-based clinics say they aren't interested in becoming medical homes, Corwin said, but are offering many of the tenets of medical homes, such as immunizations.

"What we're saying is that infants, children and adolescents should be seen in the medical home model," he told The Nation's Health. "All these visits are important for maintaining a relationship with the family. Children are not small adults, and we think they not only deserve but require a medical home."

Corwin noted that retail-based clinics should also be subject to and required to comply with the same health care facility standards as doctors, adding that the "playing field shouldn't be changed, they should have to go through the same hoops we go through."

Though the academy opposes retail-based clinics for young people, it developed a set of guidelines it hopes clinics will follow, such as calling on clinics who do treat children to follow the academy's clinical guidelines.

"There are some disconnects between the medical home model and the business model," Corwin said. "We just think it's not the place for kids."

Rick Kellerman, MD, president of the American Academy of Family Physicians, said fellow academy members have been urged to consider serving as a supervising physician for a retail-based clinic, getting on a clinic's referral list or using the clinics as an opportunity to examine their own business practices, such as how convenient or patient-centered they are. Like other medical professional organizations, the academy also has concerns, but has developed a set of guidelines it hopes retail-based clinics take heed of. In fact in February, three retail health companies — RediClinic, MinuteClinic and Take Care Health — signed an agreement to provide care in accordance with the academy's recommendations.

"Our No. 1 concern is patient safety, No. 2 is quality of care and No. 3 is whether these are business opportunities or whether they really are designed to provide care and work with the medical community," Kellerman said.

Retail-based health clinics are a symptom of a health care system that doesn't properly support primary care and family physicians, even though studies have shown heightened support leads to better outcomes, better quality of care, higher satisfaction and lower costs, he said.

"It's not just the sore throat, it's the person who starts getting day-to-day care for minor symptoms and then things like depression, high blood pressure, heart disease and diabetes get overlooked," Kellerman said. "We know that systems that take care of the whole patient work better and we don't have a system that does that."

While some medical groups voice their concerns or opposition to retail-based clinics, some nursing organizations are becoming their biggest proponents.

According to a 2006 white paper from the Nurse Practitioner Healthcare Foundation, the "subsequent explosive growth of these nurse practitioner-delivered clinical services in retail settings attests to the market need for accessible, affordable, high quality health care and the ability of nurse practitioners to fill this critical need successfully." The paper's authors emphasized that retail-based health clinics helmed by nurse practitioners can help lower barriers to health care, promote prevention among patients and lessen the burden on hospital emergency departments. The paper also stated that "political leverage by providers in other service delivery models should not be allowed to impede the development of easily accessible (nurse practitioner) services for common health needs." Ken Miller, PhD, RN, immediate past president of the American College of Nurse Practitioners and a board member of the Convenient Care Association and RediClinic, points to decades of published studies showing that the quality of care and health outcomes achieved by nurse practitioners can be better or equivalent to family practice physicians.

"The difference is the entities that own these clinics have limited the number of disease processes they are willing to see," Miller said. "But just because you're only looking at 15 or 20 diseases doesn't mean they're any less capable than the outpatient clinic of a hospital."

Miller said if retail-based health care clinics continue opening across the nation, 10,000 nurse practitioners will be needed in the next five years to staff them, which is why partnerships between nursing schools and the convenient care industry will be so important. He noted that "even states that were resistant to having (nurse practitioner-staffed clinics) are beginning to see we're providing a much-needed service."

"It's not going away," Miller said. "The public is happy with it, the public wanted it and they're satisfied. This will be a normal part of our health care environment in the future."

Realizing that retail-based health clinics could, in fact, become a regular feature on the health care landscape, state policy-makers have also taken on the topic. In Illinois, for example, legislation was introduced in May outlining operating requirements and charging the state's public health department with regulating clinic services. Massachusetts is addressing the issue as well, with new regulations now before the state's Public Health Council for approval. Contacted by retailer CVS about opening the state's first retail-based clinic, the Massachu- setts Department of Public Health decided to develop new, targeted regulations to avoid the numerous waivers such clinics would need to meet current standards, said Donna Rheaume, a spokeswoman for the department. Rheaume said the proposed regulations would allow limited-scope clinics in a variety of alternative sites as well, such as homeless shelters or not-for-profit hospitals.

Massachusetts Public Health Commissioner John Auerbach said there were initial concerns that retail clinics could harm long-standing providers by skimming off easy-to-treat patients and leaving private practices with only the more expensive, difficult-to-treat diagnoses. Many providers felt a healthy primary care practice was a combination of quick, short visits for minor issues as well as long visits for more complicated problems, Auerbach said. But in the end, new regulations that made it easier for a variety of entities to broaden access to care were a "win-win situation."

"I think it's good for public health to be open to innovative approaches," Auerbach said. "We just have to ensure that the innovation and accessibility also includes high quality and that's what we're focused on now."

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