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Retail Clinics Are Still Here. Now What?

Have retail clinics changed the structure of our health system? Have they changed the way players in the system compete or interact with each other?
This article was written by Jon Christianson, PhD, Medica Research Institute senior fellow and James A. Hamilton chair in health policy and management at the School of Public Health at the University of Minnesota.
 
There are 2 narratives surrounding retail clinics. Under one, they embody the “mallification of health care,”1 “medicalization of symptoms,”2 fragmentation of care3, and perhaps patient cream-skimming.2 A second characterization of retail clinics is that they are positive “disruptive innovations” in healthcare,4 conjuring up visions of more convenient, accessible medical care for patients5 and consequently better access and lower costs across the healthcare system.
 
One thing is clear: The traditional medical care community has been skeptical about the value of retail clinics,6 if not outright hostile.7 Operated under for-profit corporate umbrellas, staffed by clinicians without MD degrees, and often located in “big box” retail stores, retail clinics provide a sharp contrast to the old Marcus Welby primary care model of the past and its comfortable-sounding reincarnation, the “patient-centered medical home.”8
 
The development of retail clinics has created new opportunities for health services research, with 2 recent publications receiving attention for findings that challenge long-held positions in the retail clinic debate. As context for understanding the significance of these studies, it’s helpful to describe the current status and impact of retail clinics in the American healthcare system. Have they changed the structure of our health system? Have they changed the way players in the system compete or interact with each other?
 
Retail Clinics in Practice
The first retail clinic was opened in a grocery store in the Twin Cities, my hometown, in 20009. The typical retail clinic is staffed by a nurse practitioner and occupies about 400 to 600 square feet, which often includes a reception desk, a waiting area and 2 exam rooms9 (Page 48). Prices are displayed prominently. It is estimated that 30 patients a day are needed for clinics to break even financially, considering only the medical care they provide. Retail clinics deliver about one percent of the number of visits patients make to physician offices10, but up to 7% of visits for 11 common, simple acute conditions.11
 
The prototypical patients served by retail clinics to date have been children, whose parents value the after-hours convenience, and young adults, who have no strong connections with a primary care physician.9,10,11 There is a relatively high rate of return visits for people using retail clinics,9,10 suggesting user satisfaction, and people using retail clinics are less likely to return to primary physicians for subsequent visits,12 perhaps raising continuity of care concerns.13
 
There have been 2 relatively recent comprehensive overviews of the growth and status of retail clinics.9,10 Both note that retail clinics have encountered several “speed bumps” (in Minnesota, “potholes” might be more apt) in their expansion.14 Their numbers grew steadily in the early 2000s, but the great recession essentially brought that growth to a halt, raising questions about whether retail clinics were indeed at “the cutting edge of a ‘convenience revolution’”10 in healthcare. Growth has picked up since then, with some forecasts as high as 2800 clinics in operation by the end of 2017.15
 
Ownership of retail clinics is extraordinarily concentrated. CVS has the largest presence, with 950 clinics in 2014 and a stated (at that time) goal of 1500 clinics by the end of 2017. Walgreens follows with about 400 clinics, and Krogers with 20016. In the past, Walmart leased space to retail clinics but now is switching to an ownership model, a move that is being closely watched because of Walmart’s enormous size and scope.17 In a recent development, approximately 260 clinics are owned by hospital systems10. The concentration of ownership means that the growth or decline of retail clinics in the United States health system depends on the decisions of a small number of organizations. For example, if CVS were to withdraw from the retail clinic market, the number of clinics nationally would be reduced by 50% or more.
 


 
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