Penelope Lemov is a GOVERNING correspondent. She was GOVERNING's health columnist and was senior editor for several award-winning features.E-mail: email@example.com
There's a health care revolution underway. But it's not being fomented by doctors and hospitals or by governors and legislators. Rather, the seeds of a radical new approach to delivering health services are taking root deep in the heart of an industry whose life's blood is efficiency and affordability.
Wal-Mart, Target, CVS and a host of other chain stores are setting up retail clinics: medical outposts that sit inside their stores, right alongside the shampoo, Pampers and ketchup. Customers can walk into the clinic, see a price list for services, sign up for an appointment and, if the wait will be more than a couple of minutes, cruise the store aisles for Christmas wrap or a can of soup.
Retail clinics may appear to be nothing more than good business for the retailers that host them--a simple service that brings shoppers into the store and boosts profits for their pharmacies. For state and local governments, though, the clinics are laboratories of change and officials are watching to see how they might impact health policy and regulation. Their low prices and convenience (clinics are open evenings, weekends and some holidays) meet a need that the existing health care system does not. But the radical nature of the clinics goes beyond that. They are, in effect, deconstructing medical care-- doing unto the health care system what the global economy and outsourcing have done to other industries: picking off routine tasks that can be performed by less-skilled, lower-paid workers and making an efficient, patient-friendly business out of it.
There's more afoot. The retail clinics may suggest a way around the misuse of emergency rooms for primary care. They could even have implications for Medicaid and the way state programs deliver basic care to beneficiaries during non-office hours. "Primary care is a neglected field in the United States, lagging other economically advanced countries," says Uwe E. Reinhardt, a professor of economics and public affairs at Princeton University. The clinics can teach the rest of our health system how primary care could be done and brought to the public.
Physically small--barely even a full-size room in some outlets--most of the clinics are staffed by nurse practitioners who are authorized to write prescriptions. Off-site physicians supervise their work. In their current and most widespread iteration, the retail clinics stick to very basic health services, such as flu shots and treatment for ear infections. The idea is to target problems or needs that can be addressed according to simple and well-accepted protocols. A patient with a sore throat, for instance, can have his throat swabbed to test for a strep infection and, if the test is positive--results are available within 5 minutes--be handed a prescription to cure the malady.
Prices for services are there for the asking or are displayed on a sign. MinuteClinic (Motto: "You're sick. We're quick"), which operates clinics for several big retailers such as Wal-Mart and CVS, posts its prices on a flashy electronic board such as one might see in a fast- food restaurant. That's not surprising since MinuteClinic's CEO was once the head of Arby's.
The posting of prices is particularly important for less affluent customers who don't have insurance. In working with the uninsured, Margaret Law, director of Innovation for the Underserved at the California Healthcare Foundation, says people are always telling her about going to get care at a doctor's office, emergency room or community clinic, and then being stunned by the size of the bill. In those settings, nobody can tell the patient how much care will cost until the visit is over. The patient is then presented with a bill for $200 to $500, often for such basic care as an ear infection. "They don't have the money, and they worry about that before seeking care," Law says. "With the retail clinics, they know the cost. They can say, 'I have $39 today, I can go there.'"
Convenience is the other big draw for customers. Most retail clinics aren't open 24 hours a day, but they typically are open until 8 or 9 o'clock in the evening. For the working poor, the extended hours are key: Most can't afford to take time off from work to see if a sore throat is just a cold or a serious infection. And the location of the clinics in stores that are familiar is an added comfort.
The other revolutionary aspect of the clinics is its business model. Unlike in the rest of the health care system, any decision to continue, expand or close operations is not based on any perceived need or altruistic motive. The retail clinic lives by a simple creed: It won't run at a loss. "If it's not profitable," Law says, "it will go away."
Right now, the clinics are going strong. There are currently several hundred retail clinics in operation, with services being rendered by a handful of dominant providers, such as MinuteClinic, Take Care Health and RediClinic. Health-business analysts predict that between 2,000 and 10,000 basic-care clinics will be operating in retail outlets by 2010. And they are likely to expand beyond the nurse-practitioner model. A few companies are opening physician-staffed clinics that can offer customers an expanded list of care, and a handful of physician groups are starting their own clinics in retail outlets.
Meanwhile, several insurance companies are encouraging their subscribers to use retail clinics. The clinics, after all, offer insurance companies a simple way to save money--$40 for a retail clinic visit versus $100 to $200 for a physician office visit for the same minor problem. Some insurers are either lowering or waiving co- pays for patients who seek care at retail clinics. Some California insurers are even exploring whether to set up their own clinics for their customers.
For the uninsured, however, the retail clinics are one of the few available outlets for low-cost care, and they are attracting such patients. According to a Wal-Mart survey of customers at its clinics, between 25 and 40 percent of clinic visits are by patients without health insurance. As to whether the clinics could be a way to reduce the misuse of emergency room for primary health care, Wal-Mart's survey suggests the potential is there: 20 to 40 percent of surveyed customers said they would have used an emergency room had the clinic not been available.
For state and local officials, the clinics raise the usual concerns about quality of care and possible need for regulation. At this early point in the trend, retailers' reputations are on the line and care is based on carefully standardized procedures. Nurse practitioners follow evidence-based-medicine protocols and guidelines set down by state medical boards. Moreover, the medical problems for which they provide care are limited to minor ailments. Clinics are not a place a patient would go for cancer care or even a broken foot. But as the clinics multiply and more players enter the field--or if some retailer were to try to keep prices low by cutting corners--those limits and the adherence to protocols of care could change. "They have high standards now," says Rick Kellerman, a physician in Wichita, Kansas, who is president of the American Academy of Family Physicians. "But as they proliferate, they could overreach on what they treat and who treats it."
Apart from regulatory issues, the clinics present health policy officials with profound changes in the way health care is delivered and by whom. One of the bigger concerns is whether, by chipping off a few basic services, the clinics encourage further fragmentation of the health care system and take it another step away from the much-vaunted and greatly desired notion of a medical home.
Everyone in the health care system would prefer that patients' care be overseen by someone who has gotten to know them and has a complete record of their health and lifestyle choices, but that ideal doesn't exist for tens of millions of people. And that, in part, is what is driving the current boom in retail clinics. "What these clinics have done is identify some weaknesses in the current system," Law says.
Family or primary-care physicians--the group of doctors whose practices tend to overlap with retail clinics--have their concerns, with the medical-home issue chief among them. But Kellerman says the AAFP is not opposed to retail clinics as they exist today--with a limited scope of practice and supervision by a physician. What the AAFP would like to see improved, according to Kellerman, is communication between clinics and family physicians to ensure that a patient's record of care at the clinic is forwarded to the physician and that she receives appropriate follow-up care.
On its Web site, the AAFP lists five attributes it believes a retail clinic should have, such as a referral system to physician practices. "What we're saying is that the clinics are going to be there, here are the desired attributes," Kellerman says, pointing out another major concern: "Who's going to make sure they meet those standards?"
Whether or not the fast-growing clinic movement finds approval within the medical community, it is not clear whether the clinics will be able to maintain the high level of consumer acceptance they initially have experienced. And that issue goes to a fundamental question about the health care system: Are there categories of conditions that could and should be treated by someone with less training--and who is paid a good deal less for those treatments--than a physician? Clearly, there are some. Where it used to take a skilled doctor to diagnose a strep throat, today it can be done with a simple test. However, will patients accept paying a nurse practitioner to take a saliva drop and run it through a test for strep throat? Will they go to non-physicians for other ailments and believe they are receiving competent care?
"The first step in that test bed is the retail clinic," Law says. The clinics have identified categories of ailments that can be treated by less-trained professionals. At the end of the day, though, consumers have to believe the retail clinics meet their needs and deliver quality--whether or not that's the same quality as the medical establishment thinks is quality. "If patients are paying their own money, they'll make a decision about whether the clinics are of sufficient value," Law says. "We may find in a year or two that they don't. But so far they seem willing."
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