Thursday, July 23, 2015

Convenient Ambulatory Retail Care

If you have any interest in the powerful expansion of retail ambulatory care, as delivered by nurse practitioners and physician assistants in pharmacy and supermarkets, I invite you to read two articles in the July 23 issue of the New England Journal of Medicine:

“The Expansion of Retail Clinics- Corporate Titans vs.Organized Medicine,” by J.K. Iglehart, national correspondent for the Journal.

“Convenient Ambulatory Care – Promise, Pittfalls, and Policy, “ by three authors from the New York City and Health and Hospitals Corporation.

The articles messages are unmistakable: walk-in clinics in pharmacies and supermarkets, now numbering 1900 and owned by corporations and staffed by nurse practitioners and physician assistants, and walk-in clinics, 6400 of them, staffed by family physician and emergency room physicians, and owned by various health care entities, are growing like topsy.

Together ambulatory care setting visits account of one third of health care spending. Why the rapid growth of wall-in clinics? The reasons are varied, but walk-in clinics appeal to health care consumers. They can expected lower prices, extended hours, to be seen immediately, low-acuity care, immunizations, some preventive care, and insurance coverage, and they do not require a primary care physician to get care.

Here are the main players in the commercial market.

CVS, clinic name – MinuteClinic, 980 clinics

Walgreens, clinic name – Heslthcare Clinic, 400 clinics

Kroger, clinic name – the Little Clinic, 159 clinics

Target, clinic name – Target Clinic, 80 clinics (on June 15, 2015, CVS acquired Target pharmacies and clinics, which will be rebranded as MInuteclinics)

Most of these clinics share information and referrals with primary care physicians. Urgent care centers have relationships with health care organizations such as EpicCare, various proprietary hospital system, eClinicalWorks, or Athenahealth.

Walmart’s is also in the ambulatory game. The huge retail chain has announced it will operate “Walmart Care Clinics,” in conjunction with QuadMed to arrange for community-based physicians to provide clinic oversight. Walmart now runs 17 clinics in Texas, South Carolina, and Georgia.

Overall, CVS with 7600 stores, WalGreens with 8200 stores and Walmart with 4500 stores, have plenty of room for expansion of retail clinics.

A number of medical organizations – the American Medical Association, the American Academy of Family Physicians, and the American Academy of Pediatrics have questioned retail clinics quality of care. The Academy of Pediatrics have been the most strident, saying retail clinics are an “inappropriate source of primary care for children because they fragment children’s health care and do not support the medical home.”

According to J. Hwang and Mehrotra, writing in the Harvard Business Review in 2013, retail clinics, despite their rapid growth, have failed to transform health care because of regulatory and reimbursement barriers. Nevertheless Iglehart observes, “changes in policy under the ACA, a loosening of state restrictions on nurse practitioners’ practice, and the movement toward value-based car won’t erase all the obstacles facing retail clinics, but the train has definitely left the station.” Whether retail clinics will contribute to the ACA “train wreck,” a term coined by Max Baucus, former Democratic senator from Montana and now ambassador to China, or transform health care is for history to judge.