Redi or not,
here come retail health clinics

By Jonathan Nelson

Just inside the entrance to Round Rock’s new 190,000-square-foot H-E-B Plus! stands the grocery chain’s newest customer service: RediClinic. For a flat fee of $45, you can walk right in and get checked out for whatever ails you. You don’t need an appointment, you’ll be in and out in 15 or 20 minutes and if there’s a wait, you can grab a pager from the front desk and start shopping. The medical assistant will buzz you when the nurse practitioner is ready to see you.

With names like MinuteClinic, Take Care, Little Clinic and Quick Quality Care, retail health clinics are popping up in shopping centers all over the country. Each model is slightly different but the core concepts are the same: extended weekday and weekend hours, an easy-to-understand pricing menu and quick service with little or no wait for treatment of the most common ailments. Most are staffed by mid-level providers, they offer a selection of immunizations and some, like RediClinic, perform diagnostic screenings and physical exams.

Questions about quality and concerns about competition have family physicians wary of the clinics. Sure, it’s convenient to see the nurse practitioner and receive treatment for your cold symptoms, but what happens when the real cause of that cough is bad emphysema or a lung tumor? Melissa Gerdes, M.D., of Whitehouse, Texas says this sort of misdiagnosis is part of what worries her about retail health clinics. She worries that the model is serving convenience to patients at the cost of quality. “That’s a big concern.”

“It’s devaluing medical services,” she says, “because [the clinics] are giving them a little menu of what you can get at reduced prices, which is attractive to patients and insurance companies, but it kind of devalues their problems compared to regular medicine.” Like many family physicians, Gerdes is concerned that if retail health clinics draw acute care business away from their practices, making ends meet will become harder than ever.

Not to worry, says Steve Berkowitz, M.D., chief medical officer of St. David’s HealthCare, the Central Texas hospital system that provides physician oversight to RediCinic’s Round Rock site. He doesn’t see the clinics as competing with family physicians. According to him, more than half of the people who seek care at RediClinics don’t have ongoing relationships with primary care physicians, so he believes the clinics represent an opportunity to introduce them to the idea of a medical home.

The fact is, corporate powers see these clinics as profitable enterprises for a reason. “I think there is a subgroup of patients that demand absolute convenience,” Berkowitz says. “The market is telling us something and we need to be responsive to that subgroup of patients.”

The market is also telling us to be prepared for exponential growth in this sector. Outside of Texas, RediClinic’s parent company, Houston-based InterFit Health runs clinics in Fayetteville, Ark., Owasso and Broken Arrow, Okla. and Manhattan, N.Y. RediClinic is the only retail health clinic that has entered the Texas market where it has an exclusive agreement to lease space from H-E-B. Other than the Round Rock site, the company has five locations in the Houston area and two in San Antonio. Last year, America Online CEO Steve Case launched Revolution Health Group, which has since acquired a minority stake in InterFit and is providing the capital to open 75 new clinics by the end of 2006. Expect 15 to 20 of these to be in Texas.

Minneapolis-based MinuteClinic operates over 70 clinics in nine states at Target, Cub Foods and CVS Pharmacy locations. The company plans to have 300 clinics in 17 states by year’s end.

West Conshohocken, Pa., is home to Take Care Health Care Systems, LLC, which has partnerships with Albertson’s, Brooks Eckerd Pharmacy, Rite Aid Corp. and Osco Drug. The company is currently in talks with Walgreens and it has “contracts in place to open nearly 200 centers within the next 12 months, and establish over 1,400 centers in over 70 markets by the end of 2008,” according to a company press release.

Investors smell an opportunity for profit, so they are making major capital investments in the industry. The companies setting up retail health clinics are well-funded ventures that simply lease space from the retailers. In trying to compete, family physicians are faced with the reality that they lack capital investment. Also, retail health clinics keep their overhead costs low by staffing mid-level providers and they keep liability costs in check by focusing on a narrow set of low-acuity health needs.

Retailers collect rent from the clinics, which should bring in customers who may purchase over-the-counter and prescription medications at their pharmacies. According to numbers from AAFP News Now, retail clinics charge an average of $49 to treat most conditions while physician offices charge between $85 and $110 for similar services.

That cost difference is catching the attention of managed care and health insurance companies. Medicare, Aetna, Blue Cross/Blue Shield, Cigna, United Healthcare and others cover services at many retail clinics, and as more patients opt for consumer-driven plans and health savings accounts, retail clinics’ lower cost and price transparency will attract more business.

Many large employers see the clinics as a way to cut costs and reduce time away from work. Wal-Mart has become a major player, partnering with RediClinic, Quick Quality Care, Solantic and Memorial Health’s MedPoint Clinic. The retail behemoth plans to open more than 50 clinics nationwide in 2006.

Last October Wal-Mart released an internal memo that suggested several ways to cut benefits, one of which was a recommendation to add more health clinics in stores. “Over the long term and with several important modifications (e.g. innovations to create lower-cost visits) these clinics could become an important part of our health care strategy, especially as a substitute for emergency room visits,” the memo states.

Blue Cross/Blue Shield of Minneapolis waives co-pays for their employees who use the clinics. MinuteClinic opened shop in the Minnesota state capitol complex in March and state employees get $5 off their co-pays for going to the clinic. The state expects to save $55 per episode of care, according to a report in the Pioneer Press. While RediClinic has not yet begun accepting insurance, they have arranged a discount for H-E-B employees in their host stores and they advertise on their Web site that they have negotiated rates and co-pays with certain large employers. As the retail health industry grows, expect more of these “deals” with large employers and insurers.

A recent Wall Street Journal Online/Harris Interactive poll suggests people are open to the idea of receiving basic medical care at retail health clinics. Among the 2,245 adults polled, 78 percent “strongly or somewhat” agreed that the clinics provide an easy and fast way to receive basic medical services and 41 percent said they would be likely to go to one of the clinics. The poll also registered a healthy dose of skepticism, with 75 percent of those polled acknowledging that they would be concerned that serious medical problems might not be accurately diagnosed.

Are their concerns valid? Is there a question of quality at retail health clinics? They are too new to measure, but at least where RediClinic is concerned, Steve Berkowitz of St. David’s HealthCare says no. “The RediCare protocols are very good and they are appropriately supervised by physicians, so I disagree with any statement that would insinuate they’re not giving good medical care,” he says.

To practice in Texas, nurse practitioners must have physician supervision, meaning a physician must be on call at all times during a clinic’s business hours and must be on-site at least every 10 days. The physician supervisor must also review 10 percent of the patient charts. RediClinic exceeds the state stipulations by requiring that supervising physicians be on-site 20 percent of the clinics’ operating hours.

As the entity responsible for supervision of the Round Rock RediClinic, St. David’s HealthCare contracted an emergency medicine group to perform those duties. Berkowitz says St. David’s has no financial interest in the arrangement and it offers emergency services and its physician referral service when the clinic needs them.

There are two sides to the RediClinic practice model: Get Well and Stay Well. On the Get Well side, the clinics provide education and treatment for around 30 of the most common medical conditions, including strep throat, cold, poison ivy, urinary tract infection, pink eye, diarrhea and the like. Stay Well services consist of more than 50 medical screenings and panels including allergy tests, blood pressure, cholesterol, kidney and liver function, heart disease and stroke. Routine men’s and women’s physicals, sports and school physicals, vaccinations and disease counseling and monitoring also fall in the Stay Well service list. Any Get Well visit costs $45 and patients can choose from a menu of Stay Well services that range from $11 to $150. The menu is posted right on the wall in the clinic’s waiting area.

“It’s important for us first of all to be affordable and second of all to simplify the health care process for our customer,” says Sandra Kinsey, general manager for the RediClinic division of InterFit.

She says the clinics see 10 patients a day on average, and those patients tend to be between 21 and 40 years old, female from dual income families in the mid- to upper-income range with children in the home.

“We ask every patient that comes in if they have a primary care provider and what their name is,” she says, “and over 50 percent of the people that come to us do not have primary care providers. Over 50 percent of the people we treat don’t have health insurance, so if you don’t have health care insurance, you most likely don’t have a primary care physician.”

One of the aspects of retail health clinics that has piqued the suspicion of many physicians is their prevalence in retailers with pharmacies. Kinsey is quick to point out that there is no relationship between RediClinic and its host retailers except that of a landlord and a tenant. “We are strictly a leased business inside of our retailers, so there is no sharing of sales or royalties or profitability.” Convenience is key. “Our business model is focused on taking care of the customer and the patient, and many of them are short on time. … What’s more convenient than seeing the nurse practitioner and having the pharmacy be 10 steps across the hallway and getting your prescription filled right away so that you can get home and start feeling better?”

Convenience is good but does it come at the cost of continuity of care? Kinsey says the people at RediClinic are just as concerned about continuity of care as the physician community. She says they work to include their patients’ primary care physicians in the treatment they offer and they have policies in place to prevent people from using their clinics as a medical home. Anyone visiting a RediClinic more than three times in six months is referred to a primary care physician. Patients are also referred when they experience failed treatments or if they return with worsened symptoms.

Patients receive a printed summary of their visit that they can take to their primary care physician and they can have RediClinic supply a complete printed copy of their record to their physician. They also get a receipt they can submit to their insurance provider for possible reimbursement.

“We are not a substitute for somebody’s primary care physician,” Kinsey says. “We are a supplement to the whole health care system, being able to provide people services when they cannot get into their primary care physician in the time in which they feel it’s necessary.”

AAFP has taken a practical approach to dealing with the clinics, says AAFP President-elect Rick Kellerman, M.D., of Wichita, Kan., who chairs a workgroup formed to look into the clinics. After meeting with some of the most well-developed clinics, the group drew up a list of desired attributes that an “ideal” retail heath clinic should have. The AAFP Board of Directors approved the list of desired attributes late last year and as they were reported in AAFP News Now, they say retail clinics should have:

• a well-defined and limited scope of clinical services;
• clinical services and treatment plans that are evidence-based and quality improvement-oriented;
• formal connections with physician practices in the community, preferably with family medicine practices, to provide continuity of care. Other health professionals should operate only in accordance with state and local regulations and should be part of a care team operating under physician supervision;
• codified systems for referring patients to physicians when patients’ symptoms exceed the clinics’ scope of services;
• use of electronic health record systems — preferably, systems that are compatible with the continuity-of-care record supported by the AAFP ­— that can communicate patients’ information with the family physicians’ offices.

Kellerman says MinuteClinic and Take Care have essentially adopted these attributes, adding that the workgroup plans to meet with the backers of InterFit and RediClinic in April. “The reason MinuteClinic and Take Care have really narrowed down what they want to do is because that’s frankly where they see the profit,” he says. “They think that extending scope of practice will increase their risk and may not be financially viable for them.”

AAFP has received a lot of negative feedback for meeting with the clinics, but Kellerman says that fighting them or ignoring them won’t stop them. “The Kansas City experience on this kind of taught us a lesson, I think,” he says. Take Care entered the Kansas City market last fall and they immediately called a meeting of the family physicians in the area. Kellerman says only a few showed up and those who did were not interested in partnering with the clinics in any way. “So what did Take Care do? They said, ‘Well if we can’t work with the family docs, we’ll find someone else to supervise us.’ So now there is this group of emergency physicians who are supervising the nine Take Care retail clinics in Kansas City.”

He suggests that if you learn that a retail clinic is opening in your community, meet with the people opening the clinic and find out what their goals are. “You don’t have to work with them but at least try to understand what’s going on in the community,” he says. “When I talk like this I feel like I’m talking in favor of retail clinics. I can tell you down deep, I don’t like them. On the other hand, my realistic side says it doesn’t matter what you feel.”

Kellerman says physicians should pay attention to what has driven the development of these clinics: the desire for convenience and immediate access. “I think it’s telling family physicians — and it came out of the [Future of Family Medicine] task force, that we need to put ourselves in the shoes of our patients.” Open-access scheduling, electronic and telephonic consultation, extended hours, group visits and other practice redesign recommendations were suggested in the final FOFM report as ways to change what has been a physician-centered delivery system to one that is patient-centered.

“I think we’re all going to have to look at our practices, look at our communities and try to accommodate the needs of the public, many of whom work. We’re probably late in doing this if anything.”

Whitehouse’s Melissa Gerdes has developed an innovative way to meet her patients’ desire for convenience. She calls it QuickSick™ and it allows established patients suffering mostly from upper respiratory problems to get in and out of the clinic in 15 to 20 minutes over the lunch hour. By only allowing a narrow scope of conditions to be scheduled, Gerdes and her staff can streamline the encounter so that she only needs to spend 5 minutes with each patient. That’s 12 slots over lunch. “The patients really love them.”

She recently chaired a meeting of her physician group to make plans for what they’re going to do if a retail clinic comes to town. “There was a lot of concern that at these remote sites you don’t have access to the testing or [that the providers could] break out of that retail mindset if you need to deal with a bigger problem.”

Once in a while, a QuickSick visit goes awry, she says, like the time a patient came in for strep throat and rode out in an ambulance. Gerdes noticed the patient had an arrhythmia and discovered she was suffering from congestive heart failure. “We had to put her on medicines and start an IV and do all this stuff for her to save her life,” she says. “You know, in my office I can do that. … But out at Wal-Mart, you’re sitting there wringing your hands until the ambulance gets there.”

Advocates of retail clinics tout their ability to clear physicians’ dockets of low-acuity patients, freeing physicians to manage the more difficult cases. Michael Howe, chief executive officer of MinuteClinic recently told the publication Health Executive, “If we can take these minor, acute, episodic ailments that are within the focused, disciplined scope of practice we’ve chosen to pursue out of the ER and the primary-care environment, it will free them up to focus on trauma and chronic disease management.”

That’s just what one of TAFP’s past presidents is afraid of. Justin Bartos, M.D., of Keller, Texas, says that in the current managed care environment, chronic disease management just doesn’t pay. “A quick urgent visit may capture almost as much revenue as a chronic care visit but require much less physician time,” he says. In effect, the low acuity cases act to subsidize the amount of disease management in a family medicine practice. He says the “partial-care clinics,” as he calls them, are part of a trend in medicine to “try and address the more optimal lines of business rather than provide a more comprehensive practice of medicine.”

Roland Goertz, M.D., M.B.A., chair of AAFP’s Commission on Governmental Advocacy, says the traditional financial model in most family medicine clinics holds that to be a successful practice, you need a combination of relatively easy medical care situations mixed with complicated medical care situations. “If the family physician only sees the most complicated patients, the payment model is not in your favor. … You’re not going to see 25 to 30 patients a day, it’s just not possible.”

While Goertz agrees that the advent of retail health clinics raises several concerns, he doesn’t think they will be a threat to family medicine in the long run. “As physicians we might abhor the concept because it threatens some of us, but in reality we need to pay attention to what it says to us and then we need to make some adjustments in my opinion to how we approach our patients. Honestly I don’t think any good practicing, patient-attentive doctor is going to be harmed by them.”

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AAFP’s desired attributes of retail health clinics

1. Scope of Service — Retail clinics must have a well-defined and limited scope of clinical services
2. Evidence-based Medicine — Clinical services and treatment must be evidence-based and quality-improvement oriented
3. Team-based Approach — The clinic should have a formal connection with physician practices in the local community, preferably with family physicians, to provide continuity of care. Other health professionals, such as nurse practitioners, may only operate in accordance with state and local regulations. Ideally, other health professionals should be part of a “team-based” approach, with physician supervision, as prescribed by the Future of Family Medicine report
4. Referrals — The clinic must have a referral system to physician practices or to other entities appropriate to the patient’s symptoms beyond the clinic’s scope of work. The clinic should encourage all patients to have a “medical home”
5. Electronic Health Records — The clinic should include an EHR system sufficient to gather and communicate the patient’s information with the family physician’s office, preferably one that is compatible with the Continuity of Care Record supported by AAFP and others

Source: American Academy of Family Physicians, www.aafp.org.