Retail clinics create continuity gap in patient care

Insured patients are less likely to see their physicians after visiting in-store clinics, so doctors should find ways to share information, a study says.

By — Posted Nov. 26, 2012

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Once insured patients try retail clinics for simple acute conditions, they are much more likely to rely on them for similar issues in the future, according to a study published Oct. 16 in the Journal of General Internal Medicine. Because of that, continuity of care can be broken, and any practice near a retail clinic needs to make sure information on their patients is transferred.

“The average primary care physician is not going to see much of a difference in their practice volume if a retail clinic opens in the area, but, for some aspects of primary care, we do find a negative impact on the patient-physician relationship,” said Ateev Mehrotra, MD, MPH, senior author and associate professor at the University of Pittsburgh School of Medicine. He also is a policy analyst with the RAND Corp. The Robert Wood Johnson Foundation funded the study.

Researchers analyzed claims data from Aetna on 23,023 patients receiving care for one of 11 simple acute conditions such as upper respiratory infections, sinusitis and otitis media at retail clinics in 2008. The researchers compared those patients with 104,335 others who received services for similar illnesses from primary care physicians. This list of 11 conditions captured 88% of retail clinic visits by Aetna members from 2007 to 2009. Patients had been enrolled in the plan for 365 days before and after their visit, were younger than 65, and lived less than 20 miles from a retail clinic.

The issue, according to the study, is that patients who go to retail clinics are more likely to return to them. They also were less likely to visit a primary care physician for any reason or to have two or more visits with the same primary care physician. The paper did not find a disruption in the continuity of care delivered for chronic or preventive issues primarily because retail clinics had not yet started delivering those services during the period studied. However, researchers said that with clinics moving into those services, gaps could occur there as well.

According to Merchant Medicine in Shoreview, Minn., which researches and consults on walk-in medicine, 1,401 retail clinics operate in 39 states. It remains unclear whether patients are going to them instead of urgent care centers, emergency departments or physician’s offices, but more patients are receiving medical services in this venue. A previous analysis of the same insurance claims database by Dr. Mehrotra published in the September issue of Health Affairs found the patient traffic to retail clinics had doubled every year from 2007 to 2009 to reach 6 million visits in 2009.

Retail clinics are moving beyond their historic purview of sniffles, bumps and bruises to chronic care and preventive services. For example, MinuteClinic, the largest chain with more than 600 venues at stores of its parent company CVS Caremark Corp., is offering free diabetes screening in November. Take Care Clinic, with more than 360 venues in stores of its parent company Walgreens, announced May 31 that the chain would offer tests for hemoglobin A1c and microalbumin, both used to monitor patients with diabetes. It also started providing fecal occult blood test to screen for colorectal cancer.

Increased usage and chronic care services has researchers of the impact of retail clinics advocating for physicians to develop better links to this part of the health system, much like urgent care centers and emergency departments.

“Patients are voting with their feet, and we have to make sure these systems can link up better for informational continuity,” Dr. Mehrotra said. “And continuity of care is that much more critical with chronic conditions.”

Retail clinics often are staffed and overseen by local hospital systems, but lately they have been tightening those relationships as a means of encouraging patients to stay within the system. For example, MinuteClinic announced Sept. 18 a clinical affiliation with OU Physicians, a group of 560 physicians based in Oklahoma City. Some of the doctors became medical directors of MinuteClinics in Oklahoma, and both entities are working toward a fully integrated electronic medical record system. But even in cases where the relationships are not so tight with local doctors and hospitals, “retail clinics are eager to share records with patients’ doctors,” said Tom Charland, Merchant Medicine’s CEO.

Small practices may have more success maintaining continuity of care by encouraging patients to make sure retail clinics send them reports. Retail clinics generally have the means to do so electronically or by fax, but they can’t without the name and contact details of the right physician.

“Patients would not tell the retail clinic their physician’s name, because they were afraid their primary care physician would yell at them,” Dr. Mehrotra said.

American Medical Association policy states that clinics should have protocols for ensuring continuity of care with physicians, and have a referral system for patients in need of a primary care doctor. The Association also opposes the practice of insurers encouraging the use of retail clinics by waiving or reducing co-pays. Health policy analysts say the bottom line is that physicians need to work with this part of the medical system as best they can.

“The only reason retail health clinics exist is that the public wants the care that they perceive they need when they think they need it,” said Jim Dearing, DO, a family physician in Phoenix and a past president of the Arizona Academy of Family Physicians. “There can be disconnects, but, in the long run, you can get the continuity your patients need.”

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External links

“Retail Clinic Visits and Receipt of Primary Care,” Journal of General Internal Medicine, published online Oct. 16 (link)

“Visits to retail clinics grew fourfold from 2007 to 2009, although their share of overall outpatient visits remains low,” Health Affairs, September (link)

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