Demand for convenience puts clinics in stores

Retailers clear space for basic medical treatment to boost their own revenues.

By Robert Kazel — Posted Sept. 13, 2004

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Even as some medical practices devise open-scheduling systems to offer same-day appointments, large retail chain stores in several states are viewing patients who lack patience as a ripe new market.

The stores are leasing space to clinics that treat conditions such as sore throats, ear infections and the flu. The clinics are generally located next to the store pharmacy and staffed primarily by physician extenders. They entice sick shoppers with a primary drawing card: speed. Most patients are in and out in 15 minutes, and no appointments are needed or taken.

For example, Minneapolis-based MinuteClinic has opened about a dozen clinics staffed by nurse practitioners and physician assistants in Minnesota Cub Foods and Target stores over the past four years. They rely on physician-designed decision-making software to help diagnose minor ailments, or to decide whether a patient needs to see a physician elsewhere. A MinuteClinic-affiliated doctor is on call.

MinuteClinic once envisioned its locations as places on which uninsured people would rely for essential care on a cash-only basis. But now nine in 10 patients pay with insurance, said Linda Hall Whitman, PhD, the company's CEO. With that in mind, the company is launching what it hopes to be the start of a national expansion -- as many as 400 clinics in 20 metropolitan areas in the next three years -- by opening in eight Target stores in the Baltimore area.

The store-based clinics are responding to increasing numbers of patients who won't tolerate long waits for appointments or any delay in a waiting room, said Timothy Komoto, MD, past president of the Minnesota Academy of Family Physicians. "We, as a society, want the quick fix. We want it now. These facilities are filling that perceived need."

For the stores, there's another purpose. "These [clinics] drive traffic into stores," said Daniel Butler, vice president for retail operations at the Washington, D.C.-based National Retail Federation. And, retailers say, they then drive that traffic to the stores' high-revenue pharmacy counter.

Willarda V. Edwards, MD, president-elect of MedChi, the medical society of Maryland, said she likes that the clinics offer patients easy and fast access to care, and said she leaves time for walk-ins at her Baltimore internal medicine practice. But she said inevitably some patients will go only to the in-store clinics and won't get preventive care at a doctor's office.

"There's a missed opportunity, potentially, for [those patients] dependent on [store-based clinics] for their care," she said. "I would hope the patients know these are not going to be the be-all and end-all of their care."

What's in stores

Though on a smaller scale than MinuteClinics, other clinics also have recently opened.

Two Kroger stores in Louisville, Ky., have leased space to medical kiosks staffed by nurses. MEDspot in Ft. Wayne, Ind., offers treatment by nurse practitioners at a local Scott's grocery. Aurora Health Care, a nonprofit hospital and clinic system in Milwaukee, opened two cash-only Quick Care kiosks staffed by nurse practitioners inside Aurora-owned pharmacies and wants to open at least four more this year. The system also runs a physician-staffed primary care group in a Pick'n Save supermarket.

The physician extenders who see patients in the store-based clinics generally are authorized by law to prescribe most medications, though restrictions and supervision rules vary from state to state. Staff fax reports of clinic visits to a patient's primary care doctor, if there is one.

Patients at the clinics, unlike at most urgent care centers, are treated for only a clearly defined set of non-chronic illnesses, and these are listed, along with prices, on a menu-like sign. Common vaccinations also are available.

For clinics at Target stores, patients faced with a wait are given pagers to carry as they shop.

Stuart Lowenthal, managing partner of FastCare, said the Kroger kiosks were frowned upon by some area doctors, at least in the initial months. "The physicians think we're taking some business from them. That's not the idea at all. ... There's plenty of business for everyone."

Doctors who have witnessed the growth of the clinics in the Twin Cities probably accept them as long as they stay "focused specifically on a narrow group of small ailments," said Paul Matson, MD, president of the Minnesota Medical Assn. and an orthopedic surgeon in Mankato.

Still, it's preferable if patients consider their primary care doctor to be their "medical home," and it's troubling that patients might seek help at a fast-service clinic for a major health problem, he said.

"Something that appears to be a simple ear infection might be something different, like mastoiditis," he said. "I would hate to see convenience at the price of quality of continuity of care. ... The primary care physician has the education and training to ferret out the difference between [illnesses]."

The AMA's policy on physician extenders is that they should work in collaboration with doctors, under their supervision, but leaves the exact definition of supervision and the appropriate ratio of extenders to doctors to states to decide.

Rebecca Patchin, MD, an AMA trustee and a pain-management specialist in Riverside, Calif., said a physician extender can be an effective "first frontline triage person" using decision-making software developed by doctors. "There are many situations where a physician is not available on site and good, quality medical care is delivered," she said.

But not all pressed-for-time patients are jumping on the store-clinic bandwagon.

FastCare's Lowenthal said their clinics, which cost about $150,000 apiece to set up, treat just five to eight patients daily in the summer, and double that in the winter.

"In four years, if we're not up to 20 to 30 or more, we're not going to make it," he said.

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