Retail clinics expanding services more than locations

Some physicians are skeptical of the suitability of walk-in clinics for treatment beyond episodic care.

By Pamela Lewis Dolan — Posted Oct. 12, 2009

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Retail clinic operators want potential patients to know that they do more than treat the common cold and administer flu shots.

In recent months clinics have announced the addition of several new services, such as asthma and diabetes management; more vaccines, including for HPV and shingles; school and sport physicals; diagnoses and treatment of conjunctivitis; and treatment of various skin disorders.

Clinics contend the added services are the result of customer demand. But critics counter that it's another effort to pull patients away from primary care offices and improve clinics' bottom lines. At the very least, critics say, it's an attempt to attract business during the slower times after flu season.

Tom Charland, president and CEO of Merchant Medicine, a Shoreview, Minn.-based retail clinic consultancy firm, said he has seen plenty of media coverage about the expanded services. "But I don't really see anything new." Clinics might be adding new vaccines to the offering, but that's really no different than administering flu shots, which retail clinics have done since their inception, he said. And services such as cholesterol checks, skin checks and school physicals have always been offered, and are things nurse practitioners are capable of and well-trained to do, Charland said.

Charland thinks part of the renewed interest in nontraditional services is the result of the clinics' struggles to stay afloat over the past few years, especially during the non-flu season.

Troyen A. Brennan, MD, executive vice president and chief medical officer for CVS Caremark, which owns and operates MinuteClinic, said it's true clinics in select markets have struggled as a result of oversaturation in areas where the demand wasn't enough to sustain them year-round. The chain shut 89 of its 545 locations for the summer and are now re-opening them for flu season.

But the addition of services isn't about a need to stay busy or improve the bottom line, Dr. Brennan said. The growth of the company has been "stunning" -- a year-over-year growth of more than 25% in volume -- based on what it's been doing all along, he said.

People have been asking for these additional services for some time, and the clinics are delivering, Dr. Brennan said. Many services, such as school sport physicals, have been offered before, but were recently added to the clinic's electronic medical record system. The exams and treatments are being offered as evidenced-based and are more comprehensive since their inclusion in the EMR, he said.

Tine Hansen-Turton, executive director of the Convenient Care Assn., said patients see how convenient and low-cost the clinics are and look to them to meet additional needs because of a lack of access to primary care physicians.

A recent RAND study found quality of service in the clinics is similar to that of a physician practice, but costs 30% to 40% less.

But Ted Epperly, MD, president of the American Academy of Family Physicians, is concerned that study might be misleading to patients who seek care at the clinics.

The study looked only at three common complaints -- sore throat, urinary tract infection and earache. Yet the study might give people the false impression that it is safe to visit the clinics for things outside of "three often simple diagnoses," Dr. Epperly said in a statement.

The American Medical Association supports retail clinics only for their use in treating episodic care. However, "the expansion of medical services from these locations is concerning and may have unintended consequences for patients," said Rebecca Patchin, MD, chair of the AMA Board of Trustees.

Dr. Patchin said patients who receive care at the clinics should have an established relationship with a physician. The clinics also should have a referral process in place either to direct patients back to their primary care physicians for follow-up or for additional care outside the scope of the clinic's practice, she said.

"Although nurse practitioners and retail health clinics can provide an access point into the funnel of complex health care, they are not the end point of that funnel. In fact they only contribute to the fragmentation to care, not to the integration and coordination of care that happens at primary care physician practices," said Dr. Epperly.

But retail clinics said they are not trying to compete with primary care offices. In fact, they want to be partners with them, said Hansen-Turton. Clinic chains have been seeking partnerships with existing medical facilities in recent years in order to provide an integrated system with many access points to care.

With integrated systems, retail clinics can help primary care physicians, clinic proponents claim. They can pull out patients who can be treated by nurse practitioners, making room in the schedule for sicker patients who need a doctor.

Dr. Epperly said there have been examples of this working well, such as MinuteClinic's partnership with The Cleveland Clinic. The problem, he said, is that partnerships like that don't exist in rural America. The RAND study noted that 88.4% of clinics are in urban areas, with just 10.6% of the U.S. population living within a five-minute drive of a clinic, and 28.7% living 10 minutes away. "I don't see [retail clinics] knocking on those doors. And that, quite frankly, bothers me," Dr. Epperly said.

Dr. Brennan said MinuteClinic has ongoing efforts to not only create more partnerships with the existing health care facilities, but to strengthen those partnerships by providing more services in order to alleviate the burden on the primary care physicians.

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