Practice Management | February 2016
Internists interacting with retail clinics
Primary care physicians are seeing more patients after they've already been to a retail health clinic. Experts say that a more patient-centered model needs to evolve to combat the ease of seeking care outside the doctor's office.
By Mollie Durkin
As health care becomes more patient-focused, patients now have more options than ever for simple maladies and immunizations. Rather than scheduling an appointment at their internists' primary care offices, they can almost immediately have those minor aches and pains treated at a retail health clinic.
In his practice as a primary care physician and rheumatologist, Robert M. McLean, MD, FACP, said he's seeing more patients, some of whom have been under his care for years, visit these clinics. "You find out after the fact. That can be a little disconcerting because you're like, 'Gosh, why didn't you call me?' ... Do they have such a hard time getting through to me that they don't think it's worth it to call? We don't want to admit that, but maybe we're harder to reach than we think," he said.
Access and immediacy for fevers and simple aches and pains, or services such as immunizations, drive patients to seek care at retail clinics. Photo by iStock
However, Dr. McLean, who is also an ACP Regent, said it's likely more of an access and immediacy issue: Patients know their condition probably isn't that big of a deal, but they want to see if someone can fix it right away, when it's convenient for them.
"A more patient-centric model of thinking is really what needs to evolve and is evolving because patients are the ones paying the bills, and they need to decide where they're going to spend their money to get their sore throat or whatever taken care of most efficiently," said Dr. McLean, who chairs ACP's Medical Practice and Quality Committee. "And I think doctors need to realize that. If patients need to get better access, we need to figure out how to provide it. That's the challenge."
The number of retail clinics continues to climb and is approaching nearly 2,000 nationwide, and projections indicate that 3,000 of these clinics will be operating by 2016, according to the Convenient Care Association, the national trade association of companies that provide health care in retail-based locations.
ACP in late 2015 published recommendations (see sidebar) about retail clinics in a policy paper, contending that they may have a role in providing episodic care for simple illnesses but should not supplant a long-term relationship between patients and their primary care physicians.
"These places are not going away, so we need to find a way to work with them effectively on behalf of our patients. You can't ignore them; that would not be good patient care," said David B. Nash, MD, MBA, FACP, a practicing internist and dean of the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia.
Reasons for retail
The number of retail health clinics began to swell in the mid-2000s, when several of the clinics were bought out by larger companies, said Ateev Mehrotra, MD, MPH, a RAND policy analyst who has published many research papers on the topic. For instance, CVS acquired MinuteClinic in 2006, and Walgreens in 2007 bought Take Care Clinic (now called Healthcare Clinic).
"[Over] the last 2 to 3 years, we've seen a large uptick in growth, primarily driven by MinuteClinic," Dr. Mehrotra said, pointing to 2010's Affordable Care Act (ACA) as a driver of this growth because it has expanded insurance coverage. "Now, more patients are getting primary care, and with a fixed supply of primary care physicians, timely access to appointments may worsen, and people are going to be looking for alternatives."
Dr. Nash noted another reason for the growth of these clinics. "I think retail clinics fill an important niche in the broken delivery system, and 1 reason that they're so popular is the lack of primary care doctors," he said. By 2025, the U.S. will have a shortage of between 46,000 and 90,000 physicians, with 12,000 to 31,000 of these being primary care physicians, the Association of American Medical Colleges estimated in March 2015. "If you're a primary care physician in the United States right now, a lack of business is not a problem," Dr. Mehrotra added. "If anything, primary care physicians are overwhelmed by the number of people looking for primary care."
ACP Member Jason Hwang, MD, MBA, said retail clinics are attractive to patients primarily because of convenience and the access that goes along with it.
"The fact that there's a retail clinic typically much closer to you, since it's based at a pharmacy or grocery store, than your average doctor's office, the point of access is much more conveniently located," said Dr. Hwang, co-founder and chief medical officer of Icebreaker Health, a telemedicine platform based in San Francisco. "On top of that, the fact that most of them require no appointment ... also tends to make it more convenient because you can be seen the same day as you walk in, rather than scheduling an appointment and potentially waiting days, if not weeks."
Since most patients find themselves in retail settings much more often than in their doctors' offices, retail clinics have a ripe opportunity to engage them with educational materials, online programs, and other services, said Dr. Nash. "Where we see a bright future for retail clinics is in the patient engagement and patient education front. ... Health reform is driving patients to retail settings, and retail settings are growing in part because of health reform. So it's the confluence of those 2 things, and we see that as a reasonable population health strategy," he said.
Internist concerns
Now that patients have increasingly more options for their primary care needs, some internists are understandably concerned. "When I've spoken to internists, the key questions they ask are about quality and care coordination. The findings are a little bit discrepant between the 2," said Dr. Mehrotra, who is also a hospitalist at Beth Israel Deaconess Medical Center in Boston.
ACP's policy paper recommends that retail clinics use standardized medical protocols based on evidence-based practice guidelines. Studies have shown that, contrary to concerns from the physician community, retail clinics appear to provide equal quality care to physicians' offices in terms of antibiotic prescribing in concordance with guidelines, Dr. Mehrotra said. "We haven't found any significant quality concerns," he said, adding that some analyses have shown retail clinics are less likely than physicians to overprescribe broad-spectrum antibiotics.
State scope-of-practice regulations determine which conditions clinicians practicing at retail clinics are allowed to treat. Nurse practitioners, for example, are trained to prescribe medications, order lab testing, and manage chronic conditions, but certain states restrict 1 or more of these practices. Trouble arises when clinicians at retail clinics stray from their established scope of practice or leap to a diagnosis without thoughtful review of the appropriate tests, said Dr. Nash. "They make mistakes. So do primary care doctors, but I think as long as they stay within the scope of practice, we're OK," he said.
One potential concern with retail clinics is their impact on coordination of care, as a retail clinic visit could represent 1 fewer visit to a physician's office and potentially missed prevention opportunities, Dr. Mehrotra said. Patients who go to retail clinics appear to enjoy the visits, and they keep going back, which causes certain measures of continuity of care, such as the fraction of people who have 1 or more primary care visits in a year, to drop, he said. However, he added that in his research, he has not seen a drop in preventive care or a drop in the fraction of patients with diabetes who receive necessary services among those who visit a retail clinic.
Dr. McLean expressed concerns about a lack of communication between retail clinics and primary care physicians.
"It's 1 thing if someone goes and gets treated and they're all better," he said. "It's when they don't, or there's a question of what happened, or there's a side effect to a medication, that you really need to have access to a lot of those details." Whereas ACP asserts that it is primarily a retail clinic's responsibility to promptly communicate information about a visit to a patient's primary care physician, MinuteClinic, for example, simply tells patients on its website that "the summary of your visit can be sent to your primary care provider with your permission."
Of the low-acuity conditions commonly treated at retail clinics, such as sinusitis and urinary tract infections, about 13% of an internist's visits are for the same conditions, Dr. Mehrotra said. "The vast majority of what an internist is doing couldn't be addressed by a retail clinic, except they're starting to get into this area of chronic illness care," he said. For example, MinuteClinic's list of services includes monitoring for diabetes, hypercholesterolemia, and hypertension. Healthcare Clinic touts the same services, as well as several others, such as monitoring emphysema, osteoarthritis, and minor depression.
To date, there has been no comparison of retail clinics and physicians' offices on management of chronic illness care, Dr. Mehrotra said. Because of insufficient data, ACP currently recommends against chronic and complex disease management in these clinics and stresses that more research is needed.
Even more than chronic illness management, Dr. Mehrotra said internists express concerns about "cream skimming," or cherry picking of the quicker, less complicated patient visits, which have lower reimbursement but a higher profit margin. "One of the concerns I often hear from primary care physicians is that 'Retail clinics took all the easy, higher-margin visits away from me, and therefore I'm left with the more costly visits, and therefore it already negatively impacts my bottom line,'" he said.
For instance, evaluating a 25-year-old man with strep throat is a quick, easy visit, especially compared to seeing a 70-year-old with multiple complex medical problems, as the latter visit could take 45 minutes, Dr. Mehrotra said. "The reimbursement does not match the time required, so the internist is losing money off of those visits."
Insurance interest
Almost universally, retail clinics accept health insurance, and most insurance companies and Medicare cover retail clinic visits, said Dr. Mehrotra, an associate professor in the department of health care policy at Harvard Medical School in Boston. "The only group that historically hasn't really covered retail clinic visits, though that also appears to be changing, is Medicaid plans," he said, noting that the lack of coverage is a reflection of how Medicaid managed-care plans pay doctors through capitation.
Some commercial health plans are going as far as encouraging retail clinic use outright.
"We see some health plans waiving copayments for retail clinic visits as a kind of financial incentive for patients to go to a retail clinic over a doctor's appointment," Dr. Mehrotra said, adding that plans have also resorted to targeted Google advertisements and mailers in attempts to guide people into retail clinics.
The vested interest on the part of insurance companies comes down to dollars saved. On average, Dr. Mehrotra said the data suggest that a retail clinic visit, which typically involves care given by a nurse practitioner or physician assistant, is about 30% to 40% cheaper than a physician office visit. This figure includes not just reimbursement for the visit, but also testing, prescriptions, and other ancillary costs.
"I think the primary motivation is their hope [that] they can discourage ED visits for these types of [simple] conditions because it's 70% or 80% of an ED visit if you go to a retail clinic," Dr. Mehrotra said.
With all these factors contributing to the continued growth of retail clinics, internists may wonder if there is anything they can do to both retain their patients and improve continuity of care. "I think any practice needs to explain what their policy or plan is to try to provide after-hours access or care so that patients don't feel the need to go to one of these because they're unable to reach their physician or someone covering for them," Dr. McLean said.
It also behooves internists to keep after-hours care options in-house, perhaps through facilities that are part of the same network or a larger group, which likely uses the same electronic health record, he said.
"I personally, and I think doctors in my group, have specifically tried to steer people toward the facilities that we think are most appropriate for them to go to if they need to off-hours, and I think in many cases we do need to have these kinds of available options so that people aren't unnecessarily going to the ER," Dr. McLean said.
Primary care physicians are already responsible for coordinating services provided by their specialty colleagues, nursing visits, case managers, and social workers, so retail clinicians are simply additional participants in care delivery, Dr. Hwang said.
"If what I predict actually comes true, it means that primary care doctors provide less and less of the mundane, cookie-cutter-type care that can be provided by somewhere else more cheaply and more conveniently. And if it can be done that way, why would primary care doctors want to stand in the way of that? ... I think it would be the wrong stance to say that it's making it too complicated; it's making it too fragmented. It's really our responsibility to make sure that that doesn't happen," he said.
Although medical training remains disconnected from the retail environment, these clinics may become a training ground for future internists, said Dr. Nash. "I'm not aware of an academic medical center having a medical training experience in a retail setting, but I would predict we will see an ambulatory physician training experience focused in a retail setting sometime, definitely in the next 3 years."
Editor's Note: Dr. McLean's statements do not necessarily reflect official policies of ACP.
ACP's recommendations on retail health clinics
1. Retail health clinics should serve as an episodic alternative to care from an established primary care practice for relatively healthy patients without complex medical histories.
a. Ideally, all patients should establish a longitudinal care relationship with a physician. Physicians should discuss circumstances in which the use of a retail health clinic might be appropriate.
2. Retail health clinics should have a well-defined and limited scope of clinical services that are consistent with state scope-of-practice laws and with the more limited physical space and infrastructure that such a setting permits. These well-defined and limited services should be clearly disclosed to the patient prior to or at the visit.
3. Retail clinics should use standardized medical protocols based on evidence-based practice guidelines.
4. Retail health clinics should have a structured referral system to primary care settings and encourage patients they see to establish a longitudinal relationship with a primary care physician if the patient does not have such an existing relationship. ACP believes that it is not appropriate for retail clinics to refer patients directly to subspecialists without consultation by a primary care clinician in order to ensure continuity of care.
5. ACP believes it is primarily the responsibility of the retail health clinic to promptly communicate information about a retail health clinic visit to a patient's primary care physician, including but not limited to the administration of any vaccination, prescriptions, tests, or postcare instructions.
6. ACP believes insufficient data exist concerning the provision of chronic disease management in the retail health clinic setting and recommends against chronic and complex disease management in these settings at this time. ACP recommends controlled research into the safety, efficacy, and cost-effectiveness of chronic disease management in the retail health clinic setting.
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