RAND Study Indicates Retail Health Clinics Can Provide Comparable Care

Although the entry of retail health clinics into health care during the past few years has generated concern among more established providers, a recently released RAND Corp. study published in the Sept. 1 issue of Annals of Internal Medicine indicates that the cost and quality of health care provided by retail health clinics may be comparable to that provided in more traditional health care settings.

The authors of the study, "Comparing Costs and Quality of Care at Retail Clinics With That of Other Medical Settings for 3 Common Illnesses," note that "retail clinics have been the subject of controversy since the first ones opened in 2000." Many physicians have had concerns about the quality of care patients would receive in a retail setting, as well as about the cost and delivery of preventive care. However, researchers found that retail health clinics provided services at a lower cost than alternative settings, with similar or, in the case of emergency departments, better quality care and with no adverse effect on the delivery of preventive care.

The study compared the medical care patients received at retail clinics with the care received in physician offices, urgent care centers and emergency departments for three acute conditions -- otitis media, pharyngitis and urinary tract infection.

Lead author Ateev Mehrotra, M.D., M.P.H., is an assistant professor at the University of Pittsburgh School of Medicine, a board-certified internist and pediatrician, and a policy analyst at RAND. In an interview with AAFP News Now, he put the study in perspective.

"I don't think anyone should interpret this study to say that a complex patient with heart failure, diabetes and peripheral vascular disease could be equally managed in a retail clinic -- of course not," said Mehrotra. "The study is not at all doing that."

What the study does imply is that contrary to the concerns of some health care stakeholders, "retail clinics are unlikely to be dangerous for patients," he said.

Researchers for the study examined claims data from 2005 and 2006 for enrollees in HealthPartners, a large Minnesota health plan that has provided coverage for its enrollees at retail clinics for more than five years.

Mehrotra and his team looked at 2,100 episodes of care for the three chosen conditions in retail health clinics and matched that care to 15,170 episodes of care provided in other settings, based on age, sex, comorbid conditions and income.

According to the researchers, the comparative cost of care across all three acute conditions was

The difference in overall costs primarily was driven by the cost for evaluation and management, or E/M, visits, said the study authors.

Mehrotra said expenses in retail clinics were less than those of physician practices because most clinics are located in existing stores, have little or no overhead, and are staffed by lower-paid nurse practitioners.

"I think the retail clinics are just asking for less money; it's as straightforward as that," said Mehrotra.

But AAFP President Ted Epperly, M.D., of Boise, Idaho, suspects other factors could be at play, including that primary care physicians usually have higher E/M codes. Retail clinics typically see patients who are young and generally healthy and who have a single medical problem, said Epperly in an interview with AAFP News Now.

Many patients who visit primary care physician offices, however, have multiple chronic conditions, said Epperly. "For instance, my patients may come to see me with a pharyngitis or an otitis media, but they also have complex problems that include diabetes, hypertension, hypercholesteremia and depression. If we even talk about their diabetes management or their depression or I give them a Beck Depression Inventory just to see how they're doing, my E/M coding goes up from a level 2 to potentially a level 3 or a level 4."

As physicians well know, the level of the visit raises the cost of the visit.

Mehrotra pointed out that a sensitivity analysis conducted by the RAND study researchers to control for more complex care did not find that complexity resulted in the cost difference.

Epperly also noted that the RAND study made calculations based on health plan reimbursement rates. However, there's a wide price range between the wholesale and retail rates consumers pay, he said. "If an uninsured patient goes to the retail health clinic, he's paying the full retail cost as opposed to the wholesale cost the clinic may have agreed to with an insurance carrier," as was the case in the study.

Mehrotra said that medical care provided in a physician's office could deliver added value beyond what is available to a patient seen in a retail clinic. For example, there are benefits based on the trust between physicians and their patients or the merits of the continuity of care generally found in a primary care setting.

Those are open questions "out there for policy debate," said Mehrotra.

According to Epperly, retail health clinics are a niche market. "I think there is a place for retail health clinics -- for instance, for people who don't have a primary care physician or who are on the road traveling and have a symptom-limited urgent medical problem," he said. In those situations, retail clinics provide people with a convenient, accessible source of health care, "as opposed to an urgent care center where the costs are going to be greater or an emergency room where they're going to be five times greater."

However, Epperly made it clear that retail clinics should never replace the patient-centered medical home. Retail clinics must take responsibility for transmitting a patient's personal health information back to the patient's personal physician "whether it's in the same city or five states away where the patient was on vacation when he needed health care," said Epperly.

Mehrotra and the other researchers acknowledged that the study did not address how the expansion of retail health clinics might worsen the fragmentation of health care or the already suboptimal communication among health care professionals or between physicians and their patients.

The authors did conclude that "from a societal perspective, it might lead to a better allocation of health care resources if more patients with a mild illness go to a retail clinic."

Epperly emphasized that retail clinics "are symptom-limited and do not have the scope of practice to be able to simultaneously handle the complexity of multiple chronic diseases."

He cautioned that retail clinics should not expand their scope of practice beyond their original design; namely, to provide convenient, accessible health care to patients with symptom-limited acute problems.