Health & Human Services

Primary Care Looks to States for a Booster Shot

Rhode Island doesn't have any retail health clinics. One major reason: toilets. Retail clinics are the facilities in drug stores or big-box stores where patients...
by | August 31, 2009

Rhode Island doesn't have any retail health clinics. One major reason: toilets.

Retail clinics are the facilities in drug stores or big-box stores where patients receive speedy treatment at posted prices for minor medical ailments. The clinics are a very basic form of primary care, and it would seem an oddity that Rhode Island doesn't have them. After all, CVS, the operator of MinuteClinic, the nation's largest chain of retail clinics, is headquartered there.

But when MinuteClinic applied for licenses to open in Rhode Island in 2005, state regulators questioned whether the clinics would abide by a requirement that health care providers have bathrooms and sinks. The company had been planning to have clinic nurses use hand sanitizers and for patients to use customer restrooms in the stores.

MinuteClinic withdrew the applications. But its experience in Rhode Island is an example of how states subtly influence when, where and how primary care is provided. This influence is about to become a lot more important, because the nation is confronting a primary-care crisis. The number of medical graduates going into the primary-care field has fallen by close to 50 percent since 1997. And the demand for their services will increase if Congress extends health coverage to the uninsured.

Clearly, primary-care service must expand. But how? Two approaches have come into their own over the past decade. One is the retail-clinic model. It's cheap and convenient, but handles only a limited number of medical conditions.

The other approach is almost the polar opposite: community health centers. These government-funded, nonprofit clinics provide primary care to anyone. Their doctors and nurses primarily serve the uninsured and Medicaid patients, bringing comprehensive primary care to the people who are most likely to lack it.

States can influence the future of retail clinics through regulations, and the future of community health centers through funding decisions. So, state officials have key choices to make about the availability of primary care for their residents.

Many Americans don't have a primary care doctor at all--either because they don't have insurance or because there isn't anyone available at convenient hours. Retail clinics fill some of that need and have been popping up all around the country. The first one opened in 2000. Today, there are some 1,100 of them--most of them located in CVS or Walgreens stores or in Wal-Marts and Targets.

Retail-health clinics deal with ear infections, sinus infections and sore throats, ailments that are easy to diagnose and simple to treat. In doing so, the clinics provide a way for patients to sidestep doctors' offices and avoid emergency rooms.

That's a modest-sounding role, but it's also an innovative one. Retail clinics operate beyond normal business hours and don't require appointments. They boast low prices, advertised publicly. In most cases, they are staffed by nurse practitioners. In each of those ways, they're different from traditional primary-care practices and provide one answer to the problem of access to care.

It isn't entirely clear how well this approach is working. Some of the clinics have closed and others that were planned haven't opened.

One reason is that the sorts of ailments the clinics treat are heavily concentrated in the winter months, making much of the year far less lucrative. But a secondary problem is that state policy makers have been ambivalent about the concept. Some states, such as Florida, Illinois and North Carolina, have policies that can force Medicaid patients to obtain doctor's referrals before they can visit the clinics--effectively undermining their convenience. Others, such as Texas, have significant limitations on what nurse practitioners can do without a doctor's supervision. Other kinds of regulatory questions, such as those that came up in Rhode Island, are common.

States have had their reasons for not fully embracing the clinics. For one, it's not clear that the facilities serve the people who need access most. Many are located in stores set in wealthy areas.

What's more, there are concerns that discount prices translate into discount-quality care. That's a message that's pushed by primary-care doctors who, even though many of them are overworked, don't want to cede turf to nurse practitioners. Doctors argue that retail clinics bring even more fragmentation to the health care system. "The retail-clinic movement," says Elizabeth Lange, president of the Rhode Island chapter of the American Academy of Pediatrics, "is directly in conflict with the medical-home model," under which care is meant to be neatly integrated, not fragmented further.

To counter this criticism, retail clinic operators are using electronic health records and informing a patient's primary-care doctor--if there is one--when they provide treatment. Increasingly, retail clinics are affiliated with hospitals or doctor's practices, creating linkages with the broader health care system.

But there's no disputing that the care provided is uneven. Massachusetts is one state that has embraced retail clinics as it confronts the primary-care shortage. And yet, there isn't a single one of these clinics in Boston. The city hasn't actually blocked them, but Mayor Thomas Menino and the Boston Public Health Commission have made it clear that they are not welcome. The commission thinks the clinics would disrupt the city's robust network of community health centers and steal the health centers' nurses--leaving them without the staff to operate. "There are many places where retail clinics are needed," says Dr. Barbara Ferrer, executive director of the commission. "That's not the case in Boston."

Community health centers came into existence during Lyndon Johnson's administration and reflect the zeitgeist of the Great Society. For the most part, they're federally financed--states currently provide 10 percent of their funding--and provide primary care regardless of a patient's ability to pay. They are required to operate in areas of greatest need and are managed by nonprofits, which must include a majority of patients on their governing boards.

The community health centers, like retail clinics, have undergone a dramatic expansion in recent years, thanks in part to increased federal funding. They now serve 60 percent more patients than a decade ago. Recently, the federal economic stimulus targeted $2 billion more for the centers.

It's easy to see why policy makers like the community-center model. The centers offer a broad range of services--frequently including access to dentists and mental health professionals--and they help keep people away from the use of emergency rooms for primary care.

And yet, the centers face fiscal trouble. With state budget pressures mounting, state funding for community health centers dropped in the 2009 fiscal year.

So, states face two questions. First, are they willing to accept the free-market expansion of the limited primary care that retail clinics represent? And second, will they pay for the safety net of comprehensive primary care that community health centers provide? Despite Ferrer's fears, there is a case to be made that health centers and retail clinics actually fit together well--and that both can help solve the primary-care access problem.

Tine Hanson-Turton, who directs the retail clinics' trade association, insists that retail clinics serve a distinct purpose. "If you think about health care as a system of care," she says, "you almost need a clinic that is accessible, affordable and convenient."

Clearly, access to primary care stands to benefit from the convenience of retail clinics for minor ailments and the comprehensive services of community health centers for overall care. Almost no one would object to that. But the hard part is getting there.

Josh Goodman
Josh Goodman  |  Former Staff Writer
mailbox@governing.com

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