Expect Retail Health Clinics to Expand Scope of Practice

One of the nation's leading retail health clinics, Take Care Health Systems, recently informed the AAFP that it would not renew its commitment to the Academy's list of Desired Attributes of Retail Health Clinics. The action fueled AAFP's already heightened concerns about retail health clinics expanding their scope of practice beyond the treatment of simple acute health concerns.

AAFP News Now turned to California-based health care consultant and author Mary Kate Scott for insight into how and why retail health clinics are expanding and how that will likely affect family physicians. Scott, an adjunct professor at the University of Southern California's Marshall School of Business in Los Angeles, began researching the industry in 2005. The California Healthcare Foundation commissioned Scott to write two white papers on retail health clinics. The second of those reports, Health Care in the Express Lane: Retail Clinics Go Mainstream, (35-page PDF; About PDFs) was published in 2007.

Q: How has the retail health landscape changed in the past six to 12 months?

A: Retail health clinics have undergone incredible and rapid expansion. Retailer-owned is far and away the (business model followed by the) majority of the clinics, but the interesting growth in the market is with the health care provider/operator. These are hospital and health care systems that are entering this retail health clinic market.

Q: Are retail clinics expanding their scope of practice?

A: I think there is a significant move by the majority of operators to increase their scope. In part, it's driven by the new owners, but it's also driven by the fact that the consumer is more familiar with a retail clinic. The consumer has indicated very strong satisfaction with the retail clinics. That satisfaction leads operators to say, "Let's start to expand that scope and the service offering." The retail clinic operators are going to maintain their brand promise of immediate care delivered in a convenient way by a health care professional. Do I think that retail clinics are going to become medical homes? No, I don't.

Q: What kinds of new services are clinics offering consumers?

A: You can see the expansion with things like camp physicals, screenings and preventive care. Consumers need a health care provider; they want something done quickly, simply and conveniently. That core brand promise is now being applied to a whole new range of services, including injections, vaccinations and weight loss counseling. Consumers have indicated that for these common concerns, they prefer a nurse practitioner. The consumer has proven to be pretty smart about knowing when to see a doctor versus a nurse practitioner. Less than 4 percent of consumers who show up at a retail clinic are there inappropriately.

Q: Should the quality and safety of health care delivered in a retail clinic setting by a nurse practitioner be of concern?

A: No, I don't think so. Clinics use highly trained nurse practitioners, and these providers stay well within their scope of practice. Departments of health at the state level regulate this scope, including the prescribing authority. Some states, faced with an acute shortage of physicians, high health care costs and high emergency department use, are even expanding nurse practitioners' scope of practice.

Q: Are states putting enough emphasis on quality and safety as they make those regulatory decisions?

A: I think they are. If you look at the scope of practice that a nurse practitioner can deliver, the clinics really don't use the nurse practitioners to their full extent.

Q: Are family physicians' business concerns about retail health clinics valid?

A: Anyone who runs a business, as a physician does, is appropriately concerned when competitors come into their market with an offer that the consumer finds compelling and interesting. Forward-thinking physicians are starting to understand how they can effectively have their patients utilize these retail health clinics, and they're finding their patients are not leaving their practices. The patient says, "Yes, you're still my family doctor, you're still my core medical home, but this is a way for me to get simple after- hours care." However, the industry faces a challenge if these clinics continue to add services and the consumer continues to accept them.

Q: Is this type of market fragmentation unique to the health care industry?

A: This has happened in just about every industry. By providing just a small set of services and doing it again and again, you actually can bring down the cost and increase the quality. Take Jiffy Lube and Midas. Jiffy Lube said, "All we're going to do is change oil," and Midas said, "All we're going to do is brakes." And someone came along and said, "We won't charge you what a mechanic charges, because we're going to use a technician, not a mechanic." And slowly they've expanded their services.

Q: What role does the cost of health care play in consumers' embrace of retail health clinics?

A: Consumers are being forced to shoulder more of the cost, and as consumers are forced to pay, they become inquisitive about what they're being charged. So you have a consumer interested in what's being charged, and then that consumer is given a proposition to get very good care that's appropriate in terms of time, cost, place and provider. The consumer is choosing that alternative.

Q: If retail health clinics siphon off the easy and quick patients, can family physicians survive financially by treating only the more complex and time-consuming patients?

A: Retail clinics are stimulating this really important debate. As we get the right care at the right time with the right provider, what's the right cost? Let's solve the real problem; physicians should be paid more for complex patients, and patients requiring a lower level of service should be charged less. When you really stop and look at it, retail clinics are taking away something that maybe physicians shouldn't be doing. They don't undergo seven years of training (between medical school and residency) to treat strep throat.

Q: What other challenges from competitors will family physicians likely face in the future?

A: If the doctor feels threatened now, wait five years when we'll have even more Internet access, more health care information, a greater set of services at retail health clinics and a greater array of very different health care providers. I think physicians can only expect to see more competition. As physicians see this, they should be concerned, and they should ask themselves, "What keeps my patients coming to my practice? What makes my practice relevant?" I think most consumers see tremendous value in their doctor and the medical home. Physicians need to make sure this value is transparent to the consumer and increases over time.