Retail Clinic Utilization Associated With Lower Total Cost of Care
Published Online: April 16, 2013
Andrew Sussman, MD; Lisette Dunham, MSPH; Kristen Snower, MBA; Min Hu, MPH; Olga S. Matlin, PhD; William H. Shrank, MD; Niteesh K. Choudhry, MD, PhD; and Troyen Brennan, MD
Medical walk-in clinics located in retail stores have become increasingly prevalent since first appearing in 2000.1 There are now more than 1400 retail clinics and the volume of patients treated increased more than 10-fold between 2007 and 2009 (personal e-mail communication with Tine Hansen-Tuton, MPA, JD, Convenient Care Association, June 6, 2012).1-5 These clinics generally employ a nurse practitioner or physician assistant to care for patients with a defined set of conditions that include acute medical problems (eg, sore throat, upper respiratory infection) and vaccinations on a walk-in basis, without appointments.6 Recently, monitoring services for chronic diseases and general physical examinations have been added.
Some have argued that the retail clinic could represent a positive development in American healthcare, suggesting that the care is both high quality and low cost.7 Quality of care at retail clinics has been assessed by several investigators. Mehrotra and colleagues found that quality of care for patients treated at retail clinics with sore throat, ear infection, and urinary tract infection was at least as good as that at alternative sites of care on 14 objective quality measures.8 Another study demonstrated 99% provider adherence to clinical practice guidelines for sore throat treatment.9 Studies of pediatric patients have revealed similarly high levels of adherence to clinical practice guidelines at retail clinics.10 Meanwhile, the costs per episode of illness have been observed to be 40% to 80% lower than those for services provided in physician offices, urgent care sites, and emergency departments (EDs).8
The impact of retail clinic medicine on the total cost of care has not been rigorously studied. After a literature review, we found only 1 study on total medical costs in the 6 months following a retail clinic visit, suggesting they are decreased, but this study did not examine the cost of pharmacy expenses or the total cost of care for patients seen at retail clinics.11 One hypothesis would suggest that retail clinics serve as a lower-cost substitute site of care for needed services. Alternatively, total costs of care might be higher for retail clinic users if the clinics stimulate increased utilization, especially in light of the access that they provide, including weekend and evening walk-in care without appointments.12 If patients additionally seek care from their regular care providers for the condition for which they were seen in the retail clinic, total cost and utilization might be higher. Similarly, if they seek care at retail clinics for conditions that would otherwise not be treated by professionals (self-care), overall utilization might be higher. Understanding the effect of retail clinic care on the total cost of delivered healthcare is essential as we seek new models to deliver high-quality care at lower overall costs.
A propensity score matched-pair, cohort design was used to analyze the healthcare spending pattern of CVS Caremark employees and dependents who were continuously eligible for medical and pharmacy benefits between June 1, 2008, and May 31, 2011. MinuteClinic is the largest retail clinic chain in the United States, with approximately 600 clinics in CVS pharmacies in 25 states.
All de-identified medical and pharmacy claims were obtained for all members with services between June 1, 2008 and May 31, 2011 following internal and external guidelines designed to guarantee confidentiality and integrity of personal health information. The medical claims identified by a computer generated unique subject identification number were:date of service, diagnosis codes as defined by International Classification of Disease, Ninth Revision (ICD-9), procedures identified by the Current Procedure Terminology, Version 4 code (CPT-4), gross cost of service, hospital revenue code, the provider tax ID number, and the member’s status as insured employee or dependent. The pharmacy claims identified by a computer generated unique subject identification number were: fill date of the prescription, generic product index (GPI) code, National Drug Codes (NDC), and gross cost of the drug. Internal de-identified employment data was aggregated and used to identify the environment of the subjects’ workplace for the CVS Caremark employees.
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