The Emergence of Retail Clinics

Madeena Hakimi

B.S. Health Science                                                                                                                                                                       

In a country where medical attention and services are scarce to begin with, Afghanistan is the 15th least developed country in the world. Due to years of war, corruption, and severe economic disruption, health care has often been ignored. Years ago, having a primary care doctor or getting administered to the hospital were your only ways of seeking clinical care. However now, retail clinics and small businesses have opened a quicker and more convenient source for help. Retail clinics have started to become more and more popular throughout the world as an alternative to the traditional forms of medical care, a tool where countries such as Afghanistan may use as an economic and public health booster. We will review what a retail clinic is and discuss the pros and cons in regards to healthcare overall.

What exactly is a retail clinic?

Retail care clinics are a fairly new edition to the medical field. These clinics provide a new option in which patients can be treated in place of their primary care doctors or the emergency room (ER). Retail clinics offer evidence-based care, limiting their range of services in turn for effectively adhering to clinical guidelines (Takach & Witgert, 2009). Many of the retail clinics are walk-in without the necessity to call in advance for an appointment and are even open during non-business hours. At least 17% of hospital emergency visits can be treated at a retail or urgent care clinic, saving an astonishing $4.4 billion dollars a year in healthcare costs in the United States alone (Preidt, 2010). Unfortunately, these clinics are not open 24 hours and are not staffed with specialty doctors. This may mean that patients could be sent to the emergency room anyway if they cannot be treated. However, the establishment of retail clinics provide easy healthcare access for the uninsured population, are time efficient, and an affordable alternative to emergency rooms where more urgent needs can be left for. Therefore they should be used by patients, whether they are insured or not.

The first retail clinic was opened in 2000 by entrepreneur Rick Kriger (Hunter, 2009). Retail-based clinics, which are sponsored by healthcare delivery networks, are now the fastest growing component of the health industry (Mullin, 2009).  Initially started as a clinic for the uninsured in the year 2000, all visits were paid for in cash. By 2007, that percentage dropped to only 15.9%, with the remainder of visits being covered by insurance plans (Mullin, 2009).   These clinics now accept major PPO insurance companies that simply require the patient to pay the office visit co pay. If the patient is not insured, the clinic has a self-pay list in which the individual is told the exact price for the treatment before they are seen. This prevents confusion and frustration with insurance plan coverage and ER billing.

The average clinic size is approximately 200-400 square feet and operates with the lowest possible overhead, including a waiting room, one or two examination rooms, and a laboratory (Mullin, 2009). The majority of the clinics are also placed inside large grocery stores, convenient stores and pharmacy chains. Retail clinics such as MediGo are located inside pharmacies in Florida specifically seeking to serve Hispanics in the area who are culturally familiar with receiving healthcare inside stores (Dolan, 2008). All clinics are staffed by licensed providers such as nurse practitioners and physician assistants. CVS, Walgreens, and Target run 73% of the clinics making them the main organizations in operating these clinics. The remainders are mostly operated by existing hospital chains or physician groups such as the Mayo Clinic, Aurora Health, and Sutter (Rudavsky & Mehrotra, 2010).  The top medical conditions treated in the clinics include, but are not limited to, sinus, pinkeye, ear infection, strep, UTI, upper respiratory infections, injections and in some cases even physical injuries. Of the patients aged 65 or older, 74% of the visits were regarding immunizations and injections (Colihan, 2008). Many of the clinics also use Electronic Medical Records allowing patients to return in the future with all their previous health information being just a click away and the ability to transfer medical records to primary care providers easily.

Most patients find themselves using the Emergency Departments in hospitals simply because their primary care doctor isn’t available at the time (Herrick, 2010). This leaves them no choice but to visit the ER in order to receive immediate attention. Conveniently, most retail clinics are available for patients year round, 7 days a week with no appointment necessary, such as the Minute Clinics located inside most CVS stores who have seen over 3,500,000 patients since they have been established. MinuteClinic is now the oldest retail healthcare chain (Minute Clinic, 2010).

Yet, these clinics have been controversial due to their high profit integrated style of operation, who some argue may hinder delivering quality care. Because of their fairly new emergence, several steps are being taken and considered by most states in the United States in order to successfully regulate these clinics. These steps include licensing procedures, advertising restrictions, and referral requirements (Takach & Witgert, 2009). Following through with these guidelines will generate easier execution of more retail clinics in the future and officially present their consistent delivery of high quality care.

 

Opposing Arguments

Not Open 24 Hours   

The main reason many patients turn to emergency rooms is their 24 hour access. Although retail clinics are usually open more hours in a day than a primary care office, they still are not 24 hrs. This leaves patients to either wait for the next business day or to check into the ER during early or late hours in order to be seen. An average of 40% of emergency room visits were during the hours of 4pm to midnight; these hours mainly being the hours that primary care offices and retail clinics are closed (Torrens, 1970). The emergency room never declines patients. Thus, anyone at anytime may check in, insured or not. Retail clinics; however, usually do have the opportunity to deny patients who cannot afford the expenses.  Emergency rooms are available for anyone to check in. While it is mainly for urgent needs, simple conditions such as acute illnesses may also be treated, 24 hours a day (Torrens, 1970).

 

Patient may be sent to the ER anyway

Primarily, retail clinics are staffed by nurse practitioners and physician assistants, not including specialty doctors. They also do not have the sufficient equipment to treat every condition. Retail clinics usually treat common, minor illnesses and sometimes even small injuries; however, major illnesses and severe conditions are always sent to the ER as a precaution (Weinick, Burns, Mehrotra 2010).  For some patients, this may mean wasting time. 35% of ER visits were for conditions that cannot be managed at retail clinics (Weinick et al., 2010).  Mainly, these clinics treat upper respiratory infections, allergies, rashes, and urinary tract infections accounting for almost 95% of clinic visits (Weinick et al., 2010). Although the clinics may not necessarily reject patients to be seen, they certainly may prefer patients to be taken to the ER after being checked in and diagnosed. Head injuries, body scans, casting, and chronic illnesses will not be taken care of at these clinics; there for, most prefer to go straight to the hospital in order to receive immediate care. Over 2% of patients from retail clinics were referred to the emergency due to inability of treatment (Weinick et al., 2010).  Nevertheless, patients may always call in and ask wither they can be treated or not, but some choose to go straight into the ER to save time. 

No Specialists, no Follow-Ups

Retail clinics are known for their immediate, rapid treatment of walk-in patients without the routine patient-doctor relationship. Some argue that retail clinics do not necessarily put the patient’s needs or safety first, primarily focusing on the express discharge and daily revenue. Patients who are looking for long-term relationships with their doctor will not meet their needs at retail clinics (Kobler, 2009). Traditional patients may also look for routine follow-ups and care after their initial visit. Again, most retail clinics are largely concerned about the index visit and not the status of the patient afterwards. Unless initiated by the patient by coming in the clinic to be seen again, retail clinics will not schedule or ask for the patient to be seen again as a follow-up.

It is also unclear if retail clinics will advise patients to receive preventive and chronic care because of the low incentive to do so due to the services not offered by the retail clinics themselves (Pollack & Mehrotra, 2010).  Among the 1,113 of patients included in a survey by Medical Care, over 5% of patients registered in the ER were under the age of 1, and almost half of the remainder were aged 1-14. Infants and children usually require special care where it cannot be obtained from retail clinics. Emergency rooms are staffed by dozens of doctors with a vast range of specialties resulting in constantly providing appropriate care (Torrens & Yedvab, 1970). 

Solely For-Profit Entities

Many clinics have also received criticism from the fact that they are solely for-profit entities. This raises concern that retail clinics are motivated single handedly to increase sales, rather than focusing on patient care (Pollack & Mehrotra, 2010). This causes few to think twice about receiving care in an environment where money is priority, rather than care. Approximately one quarter of the patients discharged from the ER was receiving financial assistance from the government. Retail clinics do not accept welfare payments, where as hospitals do (Torrens & Yedvab, 1970).  Again, this applies the significance of profit to these retail clinics, where as hospitals focus on equal service of care for all. If a patient is in need of care, he or she may walk in to any hospital knowing rejection is not a possibility. Even for the uninsured, financial aid programs and government assistance for ER bills are always an option (Torrens, 1970).  

 

Supporting Arguments

Health Care Access for the Uninsured 

According to a study from the Journal of Hospital Medicine in 2007, over 150,000 hospital discharges has revealed that there are significant insurance related differences in hospital mortality, length of stay, and costs among working-age Americans aged 18-64 years (Turner, 2007). On top of that, an astonishing 45,000 deaths annually are linked to lack of health insurance (Cecere, 2009).  Although acute myocardial infarction, stroke, and other life threatening illnesses cannot be treated at retail clinics, they can certainly be prevented with routine check-ups, physicals, and visits at clinics. Without retail clinics that accept patients without insurance, these routine physicals and visits would be merely impossible. This leads to sick patients avoiding doctor visits and receiving attention in fear of not having enough money to pay for insurance, all while decreasing their health status (Cecere, 2009).  

Some of these clinics have even begun to incorporate preventive health measures such as weight management, nutrition counseling, and exercise instruction to their services helping many of the uninsured develop and maintain healthy lifestyles. For example, Lindora Clinic in California provides a 10-week program to patients to help them manage obesity-related chronic diseases all while providing acute care services. While the exact ranges of services vary, retail clinics are in potential to expand making them more prevalent throughout the health care system (Takach & Witgert, 2009). Those with health insurance but high deductibles may also choose these clinics as an affordable way to receive basic health services.

Alternative to the ER

As its name indicates, the emergency rooms were originally created to provide emergent care for life-threatening conditions. However, throughout the years, more and more visits have been due to non-urgent needs. This has caused concern among health care professionals and the government due to both financial and medical complications. The more non-urgent cases treated in the ER, the more money lost in the system (Guttman & Zimmerman, 2001). Of the estimated 119 million ER visits in a year, 55% of them are for non-emergencies (Herrick, 2010).

In 2008 there were 16 million visits to the ER for non-urgent reasons simply because these patients had nowhere else to go for immediate care (Mehrotra et al, 2008). It is found in several studies that the number one component that makes retail clinics so successful is their convenience. As of summer 2008, 42 clinic companies operated the 982 retail clinics in the US, the five largest being MinuteClinic, Take-Care, Little Clinic, Target Clinic, and Redi-Clinic (Mehrotra et al, 2008). These clinics were mostly located in urban areas (88.2% of clinics) making the locations much closer than the surrounding hospitals. The top reasons why adults choose these retail clinics are either because they are uninsured, do not have a primary care provider, cannot schedule an appointment, or because ER runs on a triage basis thus creating long wait times for minor conditions that shouldn’t be treated in an ER to begin with ( Bodenheimer, 2006). In a study done in 2007 by Press-Ganey, it is found that the average emergency room visit lasts 4 hours verses the 15-30 minutes at a clinic. The costs are substantially higher at emergency rooms as well, increasing both patient out of pocket spending and national healthcare spending (Press-Ganely, 2007).

Even with advanced triage systems and Electronic Health Records (EHR), wait times in the ER can be still be long and dreadful. A study completed to research ER wait times have found that wait times in the ER have increased about 36% (Wilper, 2008). As many as 25% of patients suffering from a heart attack had to wait a shocking average of 50 minutes before being seen by a doctor. The overcrowding of ER patients causes a lack of bed space and equipment, hence causing the long wait times (Wilper, 2008). As mentioned earlier, 55% of ER patients could be treated outside the hospital, thus, if those patients had chosen another point of service, the elevated wait time could be drastically reduced.

Cheaper and More Convenient

Retail clinics have proliferated in response to the economic pressures in our healthcare industry due to the demand in accessible, low-cost care (Hunter, 2009). As retail clinics are increasing in popularity, concerns have been raised regarding the cost, quality, and delivery of care. Yet, throughout studies it has been found that overall cost and time spent at clinics has been lower than those of other health care settings all while delivering the same, if not better, quality of care. Treatment of simple illnesses can save these consumers substantial time and money, costing them an average of only $40-$70 dollars a visit (Mullin, 2009). A survey conducted found that 92% of adults who used these retail clinics were satisfied by their convenience, 89% were satisfied by the quality of care delivered, and 80% were satisfied by the cost (Hunter, 2009).

Patients using retail clinics for common conditions appeared to pay less than the amount charged at primary care offices during a 6-month period after the index visit. This concluding as the patients returned to these clinics overtime, their costs were reduced verses the amount they would pay at primary care or hospital visits (Rohrer, 2009). The average cost for a retail clinic episode was found to cost typically $279 less than an ER visit (Herrick, 2010). Emergency rooms generally charge much higher for visits due to the “emergency room” visit procedure. Although it necessarily may not always be an emergency, the bill will always be charged as one.

An estimated 35% of the nation’s population lives within a ten minute drive of a retail clinic making it a great substitute to the ER (Pollack, 2010). Waiting times are also significantly lower in clinics compared to the ER, again making it more of a suitable decision. The retail clinic industry has now seen over 1 million patients since the start of its inception without a single malpractice case reported. The overall patient satisfaction rate is in the 95-98 percentile demonstrating outstanding performance versus hospital settings. (Cooley, 2009) Hospital settings are constantly in the spotlight and have been known for several malpractice incidents.

Retail clinics have become one of the fastest growing health care transformations here in the United States, with continuing potential. Offering quick attention to some of our basic illnesses, many choose these clinics over other alternatives, yet there is still a lot of debate regarding how they are run and their quality. Most policy makers believe with appropriate licensing and regulations, states may correctly monitor patient safety and care. These clinics are not open 24 hours and are not staffed by specialty doctors, however; it is still a better substitute. With over a decade of operation, there has not been a single malpractice error reported, thus giving them a clean reputation.

Analyzing the complete pros and cons, these clinics can become a suitable health service provider for most of the population in regards to minor conditions. Retail clinics provide the uninsured with easy access healthcare, are both time and cost convenient, and a great alternative to the ER. With the given factors, retail clinics are an effective and valuable option there for should be used effectively for underdeveloped areas of the world.

 

References

Bodenheimer, T. (2006). Primary care–Will it survive? New England Journal of Medicine, 3 (2006) 861–864.

Cecere, D. (2009, September 17). New study finds 45,000 deaths annually linked to lack of

health coverage | Harvard Gazette. Harvard Science. Retrieved November 4, 2010, from

http://news.harvard.edu/gazette/story/2009/09/new-study-finds-45000-deaths-annually-inked-to-lack-of-health-coverage/

Colihan, K. (2008, September 10). Retail Clinics Catch On in U.S. WebMD. Retrieved     November 4, 2010, from http://www.webmd.com/parenting/news/20080910/retail-clinics-catch-on-in-us

Cooley, S. (2009, August). Doctors Debate Mini-Clinics: Pros and cons of retail clinics. My   Family Doctor. Retrieved November 4, 2010, from http://familydoctormag.com/doctors-office/47-in-store-clinics-debate.html

Dolan. (2008). Retail clinic targets Hispanic population, cultural differences. American Medical  News. Retrieved November 11, 2010, from http://www.ama-assn.org/amednews/2008/09/22/bisc0922.htm

Guttman, N., Nelson, M. S., & Zimmerman, D. R. (2001). When the Visit to the Emergency Department is Medically Nonurgent: Provider Ideologies and Patient Advice. Qualitative Health Research, 11(2), 161 -178.

Herrick, D. (2010, January 14). Retail Clinics: Convenient and Affordable Care. National Center for Policy Analysis. Retrieved November 4, 2010, from http://www.ncpa.org/pub/ba686

Hunter et al. (2009).  Patient satisfaction with retail health clinic care. Journal of the American Academy of Nurse Practitioners, 21 (2009) 565-570.

Kobler. (2009, August). Doctors Debate Mini-Clinics: Pros and cons of retail clinics. My Family Doctor. Retrieved November 3, 2010, from http://familydoctormag.com/doctors-office/47-in-store-clinics-debate.html

Mehrotra, A., Liu, H., Adams, J. L., Wang, M. C., Lave, J. R., Thygeson, N. M., Solberg, L. I., et al. (2009). Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses. Annals of Internal Medicine, 151(5), 321-328.

Mehrotra, A., Wang, M. C., Lave, J. R., Adams, J. L., & McGlynn, E. A. (2008). Retail Clinics, Primary Care Physicians, And Emergency Departments: A Comparison Of Patients’ Visits. Health Affairs, 27(5), 1272-1282.

Minute Clinic. (n.d.). CVS. Retrieved November 4, 2010, from http://www.minuteclinic.com/

Mullin, K. (2009). Considering Retail Health Clinics. JONA: The Journal of Nursing Administration, 39(12), 531-536.

Pollack, C., Gidengil, C., & Mehrotra, A. (2010). The Growth Of Retail Clinics And The Medical Home: Two Trends In Concert Or In Conflict? Health Affairs, 29(5), 998.

Preidt, R. (2010, September 7). Urgent Care Clinics Give Alternatives to ER Visits. MedicineNET. Retrieved November 4, 2010, from http://www.medicinenet.com/script/main/art.asp?articlekey=119451

Rohrer, J. E., Angstman, K. B., & Bartel, G. A. (2009). Impact of retail medicine on standard costs in primary care: a semiparametric analysis. Population Health Management, 12(6), 333-335.

Rudavsky, R., & Mehrotra, A. (2010). The SocioDemographic Characteristics of the Communities Served by Retail Clinics. Journal of American Board of Family Medicine, 23(1). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848989/?tool=pubmed

Takach, M. & Witgert, K. (2009) Analysis of State Regulations and

Policies Governing the Operation and Licensure of Retail Clinics. National Academy for State Health Policy.

Torrens, P. R., & Yedvab, D. G. (1970). Variations among Emergency Room Populations: A Comparison of Four Hospitals in New York City. Medical Care, 8(1), 60-75.

Turner, G. (2007, May 14). Customer Health Care. The Wall Street Journal, A17.

Wall Street Journal Online. (n.d.). Many Agree on Potential Benefits of Onsite Clinics in Major Retail Stores. Wall Street Journal Online. Retrieved November 4, 2010, from http://www.marketresearchworld.net/index.php?option=com_content&task=view&id=354&Itemid=77

Weinick, R., Burns, R., & Mehrotra, A. (2010). Many Emergency Department Visits Could Be Managed At Urgent Care Centers And Retail Clinics. Health Affairs, 29(9), 1630.

Wilper, Andrew. (2008) ER Wait Times Getting Longer. Health Affairs, 20(1).