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?Recent Research Stirs the Pot
The impact of retail clinics on costs of care has been difficult to assess. Four different cost concepts are important in thinking about this question. The first is cost-per-visit for the patient. When patient payment is in cash, the patient cost-per-visit could well exceed the cost of an insured visit to a primary care physician. This has changed as insurance coverage for retail clinics has become more common and as some clinics have waived insurance copays. Consequently, the cost to the patient of a retail clinic visit likely is less than the cost of a physician visit in many cases.
The second concept refers to the cost to the payer: the insurance company or the employer. This cost is the result of a negotiation process and typically is not known to the public. However, the growing number of payers who provide coverage for these visits suggests that payer costs are less per visit if the patient seeks care at a retail clinic.
Third, there is the per-visit cost to the healthcare system. Retail clinics would seem to have the advantage, given that their overhead costs are less than the costs of maintaining a primary care physician office.
Finally, there is the overall cost to the healthcare system, which depends not only on the cost per visit, but also the number of visits made and other resources used when retail clinics are present, versus when they are not.4
The case for encouraging, or at least applauding, the growth of retail clinics is not as strong if they add to overall system costs. Here is where the two new studies referred to earlier come in.
The first study, published in Health Affairs
advances previous work done by RAND researchers and colleagues.33
It uses data from a commercial insurer to assess use of services for 12 “low acuity” conditions, comparing utilization and costs for retail clinic patients with those who sought care for these conditions at a non-retail-clinic facility. (Obviously, the study design is more complicated than this.) The “headline” result of the study was that “…58 percent of retail clinic visits for low-acuity conditions represented new utilization, and retail clinic use was associated with a modest increase in overall spending”32
(Page 449). The costs of the new utilization were balanced to some extent by lower costs-per-visit for utilization judged to be not “new.” The researchers concluded: “These findings do not support the idea that retail clinics decrease health care spending.”32
(Page 449) Owners of retail clinics immediately challenged the study findings.34
There is a bit of confusing history to this study. In introducing their work, the authors state: “Whether retail clinics actually decrease spending is unknown, since—to our knowledge—the impact of retail clinics on utilization has never been assessed.”32 (Page 449) But authors of a paper published in The American Journal of Managed Care®
) in 2013 addressed the same topic, noting that “the impact of retail medicine on the total cost of care has not been rigorously studied.”35
(Page e148) The authors, some of whom were associated with CVS Caremark, then undertook a study to do so. Using a sample of CVS Caremark employees who sought care at retail clinics in CVS stores, they found that “retail clinic use was associated with lower overall costs of care compared with that at alternative sites.”35
(Page e148) The Health Affairs
didn’t cite the earlier AMJC®
paper. To add to the story, in their AMJC®
paper, the authors noted a presentation at the 2012 AcademyHealth research meeting by the authors of the 2016 Health Affairs
paper. This presentation, which was based on earlier data, also found no evidence of a reduction in costs of care associated with retail clinic use. It was not referenced in the Health Affairs
paper, but was alluded to by the authors in a subsequent letter.33