Retail Clinics Branch into Chronic Disease Treatment

Pretty soon, retail clinics won't be just for strep throats any more -- they'll also be for managing diabetes and other chronic diseases.

"It's a new service strategy," Sandra Ryan, chief nurse practitioner officer for TakeCare Health Systems, said at a meeting on retail clinics sponsored by the Convenient Care Association and the Jefferson School of Population Health. TakeCare operates retail clinics inside Walgreen pharmacies.

"We're evolving our clinic offerings from episodic treatment to looking at how do we get more chronic disease management, how do we do more prevention, how do we do more screening?" she said.

Becoming Part of the Team

The meeting featured speakers from several of the retail clinics, most of which are located inside pharmacies or grocery stores, although a few are freestanding. Up until now, they've generally treated acute illnesses such as colds, strep throat, and urinary tract infections; some have also provided vaccinations and sports physicals.

But that's going to be changing, according to Ryan.

"We have recently done some research that showed that people are willing to come be treated for high blood pressure, asthma, and high cholesterol" at retail clinics, she noted. "Knowing there's an unmet need for treatment and management of chronic conditions in the United States, and knowing that the cost is increasing, we think retail clinics are on the forefront to look into going into more chronic diseases."

TakeCare has already begun its first steps in that direction in a few clinics, which are offering spirometry testing for asthma patients and HbA1c tests to screen for diabetes. The chain also is taking on hypertension screening and diagnosis. Once patients are diagnosed with hypertension, "we are currently referring them out" for care, but the company is looking at becoming part of the hypertension management team, Ryan said.

Donna Haugland, chief nursing officer at Minute Clinic, which operates retail clinics inside CVS pharmacies, noted that about 11 percent of Americans have now visited a retail clinic at least once. She added that the cost of managing diseases such as diabetes, which affects 23 million people nationwide, "far surpasses acute illnesses."

"With fewer and fewer physicians going into primary care, we need more access sites to help control the chronic disease problem we're running into," Haugland said. We in the retail [clinic business] think we're perfectly positioned to help in the effort to chronic disease."

Thinking Outside the Box

Ryan said chronic disease visits would work differently than the short acute-care visits that make up the majority of retail clinics' business now.

"Our model is built around 20-minute visits, so some of the restructuring [might involved] more scheduled appointments," she said. Since retail clinics have peaks and lows in traffic, with busier times in the morning and afternoon, chronic disease visits -- which might be 30 minutes -- would need to be scheduled at less busy times.

Haugland said adding chronic disease management will require retail clinics to "think outside the box.

"Do we expand and put a diabetes educator in another space? Do we have some scheduled appointments and some walk-in?" she said.

She added that because the retail clinic business is somewhat seasonal, with the heaviest times during the winter and spring, "we need to find a way to build summer seasonality so the business can stay healthy." That's where chronic disease management could come in.

Retail clinics have grown in number since they first came on the scene in the mid-2000s. There are now 1,200 retail clinics operating in 32 states, according to the Convenient Care Association, a retail clinic trade association which was founded in 2006.

For Health Costs, Transparency is Key

To learn more about who was visiting retail clinics and why, Dr. Ateev Mehrotra of the University of Pittsburgh School of Medicine and colleagues studied national surveys of visits to retail clinics, primary care physicians, and emergency departments. They found that retail clinics appear to be serving a patient group that is underserved by primary care physicians.

Mehrotra noted at the meeting that almost two-thirds of retail clinic patients do not have a primary care physician.

In the study, Mehrotra and colleagues found that more than 90 percent of the retail clinic visits were for just 10 problems, including upper respiratory infections, pharyngitis, immunizations, otitis media, conjunctivitis, and urinary tract infections. Those same 10 conditions accounted for 18 percent of visits to primary care physicians, he said.

In another study still in press, Mehrotra and colleagues interviewed retail clinic patients to find out more about why they went to the clinics. For the uninsured patients, "one of the things that was a key driver of their going to the clinics... was the transparent pricing," he said. He said that one woman taking her son to the clinic told the researchers, "I could take him to a doctor but I would not know how much things would cost. But here the cost is up front."

Physicians Fight Back

Physician organizations, however, say that the retail clinics disrupt continuity of care and provide lower-quality care than physicians' offices or hospitals. In a 2006 policy statement, the American Academy of Pediatrics (AAP) said, "The AAP opposes [retail clinics] as an appropriate source of medical care for infants, children, and adolescents and strongly discourages their use, because the AAP is committed to the medical home model."

The policy statement went on to note that "Seeing children with minor conditions, as will often be the case in [a retail clinic], is misleading and problematic. Many pediatricians use the opportunity of seeing the child for something minor to address issues in the family, discuss any problems with obesity or mental health issues, catch up on immunizations, identify undetected illness, and continue strengthening the relationship with the child and family."

The American Medical Association issued a more cautious report on the clinics at its June 2006 annual meeting. In general, "the AMA supports free market competition among all modes of health care delivery and financing, with the growth of any one system determined by the number of people who prefer that mode of delivery, and not determined by preferential federal subsidy, regulations, or promotion," the association's Council on Medical Service said in its report.

The council added, however, that "there are some areas of obvious concern with the operation of such clinics, particularly as they relate to patient awareness, physician oversight, and continuity of care."

Taking It to the States

Physician groups also are fighting back in state legislatures by backing laws to regulate the clinics.

"The objections we've seen have fallen into three buckets," said Caroline Ridgway, policy director of the Convenient Care Association. "One bucket would be clinic operation," such as legislation proposed in Illinois to regulate the size of retail clinics. "In some cases we've seen attempts to mandate that the clinic have its own separate entrance, so that patients would not be allowed to access the clinic via its retail host."

The second "bucket" would be practitioner-related issues, such as laws to restrict the clinics' scope of practice, and the third "bucket" would be what Ridgway called "non-sequitur" issues, such as proposals to bar health facilities from operating in proximity to places like grocery stores where alcohol and tobacco are sold.

One place where the association has worked together with physicians to make it easier for clinics to operate is in Texas, where the state traditionally had very strict laws on physician supervision of nurse practitioners, who provide much of the care that's delivered in retail clinics.

"Each doctor could only supervise three nurse practitioners," explained Katharine Witgert, program manager at the National Academy for State Health Policy. "They had to be on-site 20 percent of the time, and [physically] review 10 percent of the charts."

In 2009, the legislature voted to ease some of those restrictions: physicians can now supervise up to four nurse practitioners; they only have to be on-site 10 percent of the time; and they can conduct chart reviews remotely, Witgert said.

She added that Massachusetts is the only state thus far to have written regulations that specifically address retail clinics. The Massachusetts regulations also require that retail clinics who see patients that don't have a primary care physician try to connect those patients to a primary care provider, she noted.