Retail Clinics Fall Short in Relieving Crowded EDs

December 09, 2016 01:17 pm Sheri Porter

Health care policy wonks and others looking to curb expensive hospital emergency department (ED) utilization for nonemergency care have, for more than a decade, entertained the possibility that retail clinics could serve as a viable alternative for patients seeking immediate care.

However, new research( published in Annals of Emergency Medicine appears to effectively quash that hope.

"I don't think retail clinics are solving this problem of (people with) low-acuity conditions going to emergency departments," said corresponding author and RAND Corp. policy researcher Grant Martsolf, Ph.D., M.P.H., R.N., in an interview with AAFP News. "Retail clinics don't seem to be fulfilling this promise we hoped for.

"So what is their role going forward? How do retail clinics fit in with the broader primary care system and the broader health care system?"

Story Highlights
  • New research in the Annals of Emergency Medicine shows that retail clinics have not curbed patients' use of hospital emergency departments for nonemergency care.
  • The number of retail clinics nationwide grew from 130 in 2006 to nearly 1,400 in 2012.
  • The AAFP has been monitoring retail clinic activity for many years, updating its retail clinic policy in 2014 and developing a set of desirable characteristics for retail clinics that were made public in July 2015.

These latest research findings double down on results of another study published in March in Health Affairs, which concluded that retail clinics contribute to the cost of care.

Regardless, there's no doubt that the number of retail clinics has increased dramatically since they first popped onto the health care landscape in the year 2000, setting up shop in drug stores, grocery stores and other large retail venues.

This recent study noted that the number of retail clinics grew from 130 in 2006 to nearly 1,400 in 2012, the most recent year for which statistics were gathered for this study.

"One-third of the urban population in the United States lives within a 10-minute drive of a retail clinic," wrote the authors. Furthermore, "Up to 13.7 percent of all ED visits are for low-acuity conditions that in theory could be treated in retail clinics, where the cost of care is significantly lower than (that for) an ED visit."

Study Methods, Research Highlights

Authors of the study, titled "Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits," retrieved data from 2,053 EDs in 23 states from 2007 to 2012.

They examined the association between retail clinic penetration and the rate of ED visits for 11 low-acuity conditions: allergic rhinitis, bronchitis, conjunctivitis, other eye conditions, influenza, otitis externa, otitis media, pharyngitis, upper respiratory infections/sinusitis, urinary tract infections and viral infections.

AAFP Timeline on Retail Clinic Policy

The AAFP has been monitoring retail clinic activity -- and its effect on family physician practices -- for many years.

Here's a chronology of the AAFP's policy actions:

  • In 2005, the AAFP created its first official retail clinic policy when the clinics grew from a curiosity to a rapidly spreading phenomenon.
  • In 2010, the AAFP revised its policy to oppose the expansion of scope announced by some retail clinics to include the diagnosis and management of chronic medical conditions.
  • In 2014, the AAFP Congress of Delegates adopted a resolution that articulated the Academy's policy on how retail clinics could successfully participate in the health care market.
  • In July 2015, the AAFP developed a set of characteristics(1 page PDF) designed to guide discussions between the AAFP and retail clinics about how to collaborate for the good of patients.

Those characteristics include employing supervising physicians, supporting the patient-physician relationship by referring patients back to primary care and utilizing electronic health records to transfer a patient's medical records to his or her primary care physician.

Researchers measured clinic penetration as the percentage of each ED catchment area that overlapped with the 10-minute drive radius of a retail clinic.

Martsolf and his research team found that in 2007, there was an average of 3,286 visits per ED for low-acuity conditions -- a rate of 133 per 1,000 total ED visits. As the number of retail clinics surged during the ensuing years, nonemergency visits to the ED did not drop, as some observers had expected.

"Across all ED visits, increased retail clinic penetration was not associated with a change in low-acuity ED visits," said the authors, although they did note a statistically relevant reduction in nonemergency ED visits paid for by private insurance.

Private insurance was the only payer category for which both the number and rate of low-acuity ED visits decreased during the study period, said the authors. Specifically, private insurers paid for 1,235 low-acuity ED visits in 2007 versus 950 in 2012 -- a rate of 119 per 1,000 total ED visits in 2007 versus 108 per 1,000 visits in 2012.

The authors further noted that Medicaid patients accounted for the highest rates of nonemergency ED visits; however, they pointed out that only about 60 percent of retail clinics accept Medicaid, whereas 97 percent accept private insurance and 93 percent take Medicare.

These findings go hand in hand with the fact that many retail clinics "open in communities with higher incomes and higher rates of private insurance such as outer-ring suburbs and not in low-income, inner-city areas."

Authors also suggested that older patients with Medicare coverage likely had comorbidities and potentially more complications, and therefore purposely chose to go to an ED rather than a retail clinic.

Martsolf offered another hypothesis that applies to consumers who would never dream of going to the ED for a minor problem but who wouldn't hesitate to access a new neighborhood retail clinic looking for peace of mind regarding a mildly sick child.

"We think a lot of this (activity) is 'additive care' -- folks who were going to go to the ED are still going to the ED, and folks who are going to the retail clinic would not have gone to the ED anyway," explained Martsolf.

"There's a group of people who, for whatever reason, choose the ED as their place when it's after hours and they need care," and retail clinics have not changed their utilization habits, he added.

Family Medicine Perspective

Martsolf said retail clinics initially gained a foothold when they were seen as responding to a perceived "hole in the market" that sometimes left anxious patients with few care alternatives.

That was a decade ago, when most primary care offices closed at 5 p.m., offered no access on weekends and might say the next available appointment was three weeks out.

But family physicians took on that challenge. According to the AAFP's current policy on retail clinics, "the overwhelming majority of family physicians offer same-day scheduling in their practice." Furthermore, the AAFP calculates that about half of all FPs have implemented extended hours as a service to patients who want to be seen by their primary care physician.

That said, the old model persists in some areas, said Martsolf, and the real question for family physicians when it comes to retail clinics is how they work with the clinics to overcome issues around continuity of care and care coordination.

"What happens when your patients can't get in to see you for a cough or cold and they go to a retail clinic and you never see that chart -- you never see the care that happened there?" said Martsolf.

Still, he added, what's important for family physicians is that these clinics don't seem to be solving the access problems that continue to send patients to the ED for low-acuity care.

"Are retail clinics still responding to deficits in the primary care system, and if so, how do family doctors both address those deficits and also work with retail clinics? Because some of their patients are going to be seen there," Martsolf noted.

Related AAFP News Coverage
AAFP Board Takes Tough Stand on Retail Clinics