This year's “Fast 50,” Fast Company magazine's annual compilation of “people, technology, ideas and trends that will shape how we work and live over the 10 years ahead,” includes one name that family physicians should note. Listed along with Bill Clinton (for his global warming work) and Bill Gates (for his investments in India) is Michael C. Howe of MinuteClinic, picked for his efforts to shape how you and your patients will work and live in the years ahead.
MinuteClinic, which was co-founded by a family physician,1 is the largest of a growing number of retail clinics, the health centers popping up in CVS stores, Targets, Wal-Marts and many other high-traffic retail outlets in metropolitan areas around the country. Patients with acute illnesses can enter these retail clinics without an appointment to see a nurse practitioner or a physician assistant, be diagnosed in a matter of minutes, and head back out the door, stopping by the in-store pharmacy to fill a prescription if needed. If the problem requires a physician, patients are referred to their primary care physicians. If they do not have one, the nurse practitioner refers them to one off the clinic's referral list.
While these clinics lack the personal nature of seeing a family physician who knows your complete medical history, their appeal is their convenience and affordability. The clinics are usually open in the evening and on weekends, and their prices are relatively low – and posted on menu-type boards for all to see.
If you practice in a metropolitan area and haven't seen one of these clinics yet, the odds are you won't have to wait long. Since being appointed CEO in June 2005, Howe has pushed a rapid expansion of MinuteClinic from 22 clinics in two states to 81 clinics in 10 states. With that fast-food growth mentality (Howe was previously Arby's CEO), MinuteClinic has assumed the most visible role in the growth of retail health clinics. But it's not the only company trying to grab Americans by their sore throats and simultaneously causing family physicians to wonder if and how they should react.
Here they come
Fast Company could have just as easily highlighted Hal Rosenbluth, who sold his Rosenbluth International travel company to American Express in 2003 and today is chairman of the board for Take Care Health Systems retail clinics. Or it could have singled out Steve Case, who stepped down as AOL Time Warner chairman in 2003 and last year founded Revolution Health Group. Revolution's October 2005 investment in InterFit Health is driving the expansion of that company's RediClinic retail clinic division.
InterFit plans to open 75 additional Redi-Clinics this year, the majority of them inside Wal-Mart stores. MinuteClinic plans to be operating 300 clinics by the end of 2006. Take Care is the most ambitious, gunning for 1,400 clinics by the end of 2008. Joining these three chains in the field of retail clinics are at least nine (the field is changing too quickly to know for sure) smaller companies with similar business models (see “The world of retail clinics”).
From the retail side, Wal-Mart CEO Lee Scott announced in February that his company would open 50 more in-store retail health clinics this year. And if those 50 show promise, well, Wal-Mart isn't known for doing things on a small scale.
“Whether you like it or not, this train is big, it's well out of the station and there's no way it's going to stop,” said Jim Woodburn, MD, the chief medical officer for MinuteClinic, about the retail clinic industry.
While the well-financed companies might be the engine out front, the passengers buying the tickets are a powerful mix of patients and payers.
A poll conducted last October by Public Opinion Strategies indicated that patients seem open to the idea of retail health clinics. Of the 800 adults polled, 59 percent said they would be likely to use a retail health clinic.
And an online poll of 2,245 adults done last October for the Wall Street Journal by Harris Interactive indicated that 7 percent had used a retail clinic's services.2 When asked about the experience, the majority were very satisfied or somewhat satisfied with key aspects:
Convenience (92 percent satisfied);
Quality of care (89 percent satisfied);
Staff's qualifications (88 percent satisfied);
Cost (80 percent satisfied).
Of the other 93 percent of those polled who had not been to a retail clinic, 41 percent said they were very likely or somewhat likely to use a retail clinic if they or someone in their family needed basic medical services like a flu shot, a strep-throat test or a sports physical. Thirty-two percent said they were not very likely to use a retail clinic in that situation, and 27 percent said it was not at all likely.
Of everyone polled, 75 percent said they would be worried that serious medical problems might be misdiagnosed at a retail health clinic.
Nonetheless, one person who has been watching the trend closely predicts patients will appreciate having the option of visiting the clinics.
“I'm seeing kind of a newfound energy from patients around choice,” said Tom Charland, executive director of the National Association for Ambulatory Care, who previously worked as a MinuteClinic senior vice president. “I'm reluctant to call it power; I don't think it's quite there yet. But in the United States, apart from the health care industry, consumers exhibit a fair amount of power as purchasers, as consumers. They enjoy that and practice that without ever thinking about it in every industry I can think of – with the exception of health care. I think that is starting to happen in health care with the trend toward cost shifting.”
That cost shift, in which employers pass on the higher costs of health insurance by asking workers to pay more health insurance premiums and costlier co-payments and deductibles, is also helping to push retail clinics. More and more insurance companies are contracting with retail clinics, allowing patients to pay just their co-pay when they use a retail clinic. In some cases, employers are encouraging their employees to use retail clinics by waiving the co-pay entirely if they do.
“Between those two elements – the patient element and the payer element – and the fact that the employers are behind it, I don't think this is something that the physicians are going to stop,” Charland said.
|Aurora Quick Care
|13 sites, 1 state
|Aurora Pharmacy, Piggly Wiggly
|Considering additional locations.
|The nurse is in.
|1 site, 1 state
|9 additional clinics in the next year.
|The Little Clinic
|Convenient neighborhood medical care.
|8 sites, 3 states
|50 new clinics in 2006, signed agreement with Publix.
|Time, sensitive care.
|1 clinic, 1 state
|2 more clinics in 2006 in Bashas' Supermarkets.
|We'll help you get well soon.
|2 sites, 1 state
|Rapid medical care.
|2 sites, 1 state
|Scott's Food, shopping mall
|Clinicians Consulting played a role in opening both and intends to help Indiana physicians start their own retail clinics.
|www.medspot.net, www.healthspotclinics.com, www.cliniciansconsulting.com
|You're sick. We're quick.
|81 clinics, 10 states
|Bartell Drugs, Cub Foods, CVS, Target
|300 clinics total by the end of 2006.
|On the spot relief.
|3 sites, 1 state
|ACME Fresh Market, Ritzman's Pharmacy
|Opening a clinic this month in Buehler's. Plans for a total of 15 clinics within the next year. In talks with Discount Drug Mart and Giant Eagle.
|Get well. Stay well … Fast!
|11 clinics, 4 states
|Duane Reade, H-E-B, Wal-Mart
|Plans to open 75 more clinics in 2006. The majority will be in Wal-Marts.
|Great care. Fast and fair.
|12 clinics, 1 state
|10 stand-alone clinics; 2 located in Wal-Marts
|Plans to open 2 more clinics this summer, 1 free-standing and 1 in a Wal-Mart.
|Take Care Health Systems
|We're here to take care of you.
|16 clinics, 3 states
|Osco Drug, Rite Aid
|1,400 clinics by the end of 2008. Contract in place with Brooks Eckerd Pharmacy.
|Prompt & professional medical care.
|3 sites, 1 state
|12 clinics total by end of 2006. Has identified more than 50 Longs stores that are candidates for a clinic.
In late 2005, the AAFP Board of Directors began sizing up the major retail clinics. After studying the issue, AAFP's leaders decided the best approach was to try to shape the emerging retail clinics in a way that could benefit patients by trying to improve patient safety and ensure some level of quality in the care provided by the retail clinics.
To that end, in December the AAFP Board of Directors released a list of desired attributes for retail health clinics. The desired attributes cover scope of service, evidence-based medicine, team-based approach, referrals and electronic health records (EHRs). They are meant as a guide to the retail clinics themselves and as an aid for family physicians trying to decide how to deal with the new retail clinic across the street.
To ensure that the retail clinics are familiar with the desired attributes, the AAFP Board of Directors formed the Retail Medicine Workgroup, which meets weekly and is chaired by AAFP President-elect Rick Kellerman, MD. In recent months, the group has met with executives from the three largest retail clinic chains, MinuteClinic, Revolution (RediClinic) and Take Care.
These face-to-face talks start with the list of desired attributes and go from there. They've led to hearty endorsements of the AAFP's effort to define what it takes to be a “desired” retail clinic.
“We support that,” said MinuteClinic's Woodburn. “We're looking forward to working with the AAFP to take it to a deeper level – to define it, measure it, commit to it. We'll do all of those things.”
A statement from Take Care indicated that the company “wholeheartedly supports” the AAFP's list of desired attributes.
“We cannot say enough about the AAFP's commitment to understanding this emerging care model and their efforts to contribute to shaping quality and accessibility within this delivery system,” Peter Miller, Take Care president and CEO, said in the statement.
Another issue that has come up in these talks that could benefit family medicine is the possibility that AAFP-produced patient-education materials would be available in some of the clinics. Some of the retail clinics have expressed an interest in that idea, and talks are continuing.
AAFP'S DESIRED ATTRIBUTES OF RETAIL HEALTH CLINICS
Since this article was published in May 2006, the AAFP's Board of Directors has continued to amend the Academy's desired attributes of retail health clinics.
In accordance with the principles of the Future of Family Medicine report and the evolving model of care by family physicians, the AAFP has identified the following attributes that are important to the patient care offered by retail health clinics. It is the individual physician's choice whether or not to work cooperatively with a retail clinic operation, using the following attributes as a guide in decision-making.
Scope of service – Retail clinics must have a well-defined and limited scope of clinical services.
Evidence-based medicine – Clinical services and treatment must be evidence-based and quality improvement-oriented.
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.
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.”
Electronic health records (EHRs) – 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.
A taste of competition
The AAFP recently completed focus groups with its members on the issue of retail clinics. Most participants seemed pragmatic about the development, though that can be a tough attitude to maintain when a retail clinic actually opens in your town. Pennie Marchetti, MD, who runs a solo family practice in Stow, Ohio, had to confront the issue when a QuickClinic opened in a nearby grocery store.
“I admit when I first noticed the clinic, I felt threatened,” Marchetti said. “But on further reflection, I don't expect to see any difference in my patient flow because the grocery store has a nurse practitioner in it. I don't feel threatened by the urgent care centers that are already here, and the retail clinics seem like even less competition since they're set up to strictly ‘treat and street.’”
In the Nashville area, family physician Steve Samudrala, MD, has seen a difference. Samudrala estimates that one of his clinics, located down the road from two MinuteClinics, might be seeing up to 10 fewer patients per day. But Samudrala doesn't have anything bad to say about the retail clinics.
“Competition is a great thing,” he said. “It makes all of us stronger.”
David C. Thorson, MD, the medical director of a large group of family physicians in the Minneapolis-St. Paul area, knows about competition with retail clinics. He has been dealing with MinuteClinics since 2000, when he felt his first twinge of concern.
“We were worried because we feel that those are our patients,” Thorson said. “We take pride in providing care from cradle to grave, if you will, and trying to be available to our patients.”
If those patients aren't seeing their family physician regularly for the smaller problems, Thorson feels, then the bigger problems might go undetected.
“I think most family physicians would say their patients' ticket into our office is not as important as what we find once they are in our office,” Thorson said. “I'm afraid that there are people who would otherwise be having preventive care organized for them who aren't getting it because they are not going to a person who's looking at that.”
AAFP President Larry Fields, MD, agrees that the ideal world would be one in which every patient visited their family physician for every health issue. But the reality is that retail health clinics are going to become a part of the care routine for at least some of your patients.
“Some of the retail clinics will probably succeed,” Fields said. “Some will fail. It depends on their business model and how well they do what they say they're going to do.”
He insists that retail clinics need to stick to a limited scope of services.
“These clinics have no place in complicated diagnoses or treatment,” Fields said. “They have no place in providing follow-up care, even if it's for the same problem that the patient presented to them with initially. It is incumbent upon them to communicate with the patient's family doctor exactly what they did for the patient in a very expeditious manner.”
Leaders at the retail clinics are quick to say that they don't want to move into the role of a primary care provider.
“We want to refer people back to their primary care physician for their comprehensive care needs,” said Regina Baime, MD, Take Care Health Systems' chief medical officer. “And for those people who see us who do not have a primary care physician, we see ourselves as an entry point into the system.”
MinuteClinic's Woodburn agrees.
“We're never going to be a replacement,” Woodburn said. “We will refer people to family doctors. We'll work with family medicine and family physicians. We want to work together.”
They also want to make money, and their ability to make it off basic acute services traditionally offered by family physicians is a sign that all is not well in family medicine.
“Let's face it,” Fredric V. Christian, MD, immediate past president of the Rhode Island Medical Society, wrote in January.3 “Minute-Clinic has exposed an Achilles' heel of office-based practice. There is an access problem. If there were not, care options such as Minute-Clinic or similar counterparts would not be venturing in for-profit medicine.”
Sandra Kinsey, the general manager of InterFit Health's RediClinic division, suggests that retail clinics are part of a solution to patients' access problem – and a couple of longtime health care headaches.
“We are taking care of an underrepresented portion – over 50 percent of our current customers are uninsured,” Kinsey said. “We are helping to fill a gap. We're seeing a very large percentage of people on the weekends, so that in turn is reducing the call that physicians are having to take. It's also relieving some of the burden on the emergency rooms.”
Kinsey also suggests that as family physicians become familiar with the work done by the retail clinics, they might want to refer their patients with simple problems to retail clinics to focus their time on chronically ill patients. Of course, not all family physicians want to cede those quick encounters.
“Most doctors look upon those things as (A) enjoyable, because they're quick and give us a chance to meet an otherwise healthy person, and (B) those are catch-up times, to a certain extent. Those are the things that add to your day.” Thorson said. “If you talk to doctors who have a lot of midlevel practitioners in their clinics, they'll often say, ‘I don't get to see any of those simple, easy things anymore because the midlevels see all of those.’ It changes the style of their practice.”
How will all of this affect the average family physician, for whom acute problems constitute almost 50 percent of patient visits during a typical week?4 In the coming years, many will have to decide whether to compete or cooperate with the retail clinics when they come to town.
“We've done both,” Thorson said. “I think you have to compete in areas where you can compete, and collaborate in those areas where you can't.”
Here are some options for working cooperatively with retail clinics.
Get on the referral lists. If you're accepting new patients, and a retail clinic has opened or is about to open nearby, contact them directly and ask to have your name added to their referral list. Fields advises making sure the retail clinic demonstrates a commitment to the AAFP's desired attributes. “If these clinics operate the way they're supposed to, they should be referring patients who need a physician to our members or making sure established patients go back and see our members,” Fields said.
For MinuteClinic, Woodburn said getting on the company's referral list is as simple as e-mailing him directly at firstname.lastname@example.org. A Take Care spokeswoman advised either navigating the company's Web site to contact them or calling 866-825-3227. InterFit Health partners with major health systems when it enters a new market with RediClinics, so its referral list is limited to physicians in those health systems. (And if you're a part of one of those major health systems, don't be surprised when you're told, “You're now working in cooperation with the new retail clinics in town.”)
Explore becoming a clinic's supervising physician. Most retail clinics contract with local physicians to be the supervising physicians who the on-site nurse practitioners can call if needed. Sometimes, the supervising physicians work as independent contractors. Sometimes, if the retail clinics have partnered with a major health system, the supervising physicians are drawn from that pool. Sometimes, it comes down to connections.
“We use our nurse practitioners, who say, ‘I worked with Dr. Jones, and I like Dr. Jones. He might be interested. I'll talk to him,’” MinuteClinic's Woodburn said. As for the pay, Woodburn said, “It's a fair-market rate established through tough negotiations and a lot of conversations.”
The number of supervising physicians varies from state to state, depending on the laws. In one state, a physician might be allowed to supervise an entire group of clinics. In another, the physician might be limited to supervising a handful of nurse practitioners, meaning there would be more opportunities for supervisory roles there.
Here are some suggested ways to make your practice more competitive from your patients' point of view.
Revisit the Future of Family Medicine project's New Model. “This might be an opportunity to take to heart the lessons of the Future of Family Medicine project, which said that one of the main things patients wanted out of their physician was convenience. That's what these clinic provide,” Fields said. “While we've known for a few years now that patients want that, I'm not sure how widely that's actually been implemented.”
Specifically, the Future of Family Medicine report, published in 2004, recommended “elimination, to the extent possible, of barriers to access by patients through implementation of open-access scheduling, expanded office hours and additional, convenient options for communication between patients and practice staff.”5 (See “The New Model of Family Medicine: What's In It for You,” FPM, May 2005.)
Spread the word. If the Future of Family Medicine report sounds like it's describing your practice already, then make sure your patients know how well you match up against the convenience offered at retail clinics. And if you make any changes in the future, let them know that, too.
The retail clinics are advertising on television and radio. If you have the budget, that's something to consider. But many family physicians do not have the financial means to do so. If not, newsletters, telephone answering messages and signs in your clinics are good ways to get the word out to your patients. (See “‘You Should See My Doctor’: Cost-Effective Marketing Ideas for Your Practice,” FPM, January 2002.)
Write letters to patients who visit a retail health clinic. Most of the retail health clinics incorporate EHRs, one of the AAFP's desired attributes. This allows them to process patients quickly and to generate some record of the encounter. In Minnesota, MinuteClinic has received positive marks for its willingness to send these records to patients' physicians. From a clinical standpoint, this allows physicians to have a patient chart with fewer gaps. But it also lets you know which patients have been using a retail clinic and gives you an opening to touch base with that patient by sending a letter.
Thorson recommends something along these lines: “We see you were recently seen at a retail health clinic. We hope everything is going fine. We just wanted to remind you that we do offer office hours from ____ a.m. to ____ p.m. We'd like you to remember that we are available.”
Keep your nurse practitioners happy. Some AAFP members have expressed concern that retail clinics might come into town and steal their nurse practitioners. Eva A. Meyers, FNP, president of the California Association of Nurse Practitioners Region 17, said that although most nurse practitioners are not likely to bolt as soon as a retail clinic starts recruiting, some are likely to give the retail clinics a long look. Meyers will be presenting an overview on retail clinics at the American Academy of Nurse Practitioners' annual conference next month in Grapevine, Texas.
“Most nurse practitioners are very happy in a family practice setting,” Meyers said. “At the same time, if they're looking for more independent practice or possibly more autonomy, a retail clinic could be an option.”
If you are concerned by the prospect of losing your nurse practitioners, you might want to examine what you're offering them in salary, benefits and work-life balance. That way, you'll be prepared to counter any talent raid launched by the retail clinics. (See “What Motivates Staff?” FPM, November/December 2004.)
Be innovative. Charland talked to members of the National Association for Ambulatory Care (NAFAC) before a conference on retail clinics that NAFAC organized last month in Las Vegas. He was impressed by the proactive stance many of them were taking.
“I'm seeing innovation even before these clinics come into the market,” Charland said.
Thorson's group is piloting a strategy to offer free generic drugs. For example, if a patient comes in to one of their clinics with an ear infection, they'll go home with the appropriate generic drug for their entire treatment course. The clinics absorb the generic drug cost because they feel it's a valuable selling point for them.
“We purchase it and give it away as a value-added service,” Thorson said. “We can say: ‘If you come here it's one stop. You don't have to have two co-pays – one for the visit and one for the drug.’” (See “Innovation in Practice: 6 Ways to Harness the Power of Your Ideas,” FPM, June 2005.)
Buy your own clinic. There's no patent on the retail health-care concept, but there is a price tag. Costs for buying your own retail clinic vary, of course, based on location and other market factors. In Ohio, the start-up costs for a QuickClinic franchise begin with a $30,000 franchise fee. If that venture doesn't appeal to you, perhaps you could consider adding an after-hours clinic to your practice as a way to offer more convenient care to your patients. (See “Creating a Successful After-Hours Clinic,” FPM, January 2004.)
The years ahead
The retail clinic business is so new that individual companies have been able, so far, to basically pick a major market on the map and move in. But as quickly as the retail health market is growing, those companies are sure to start bumping up against one another. At that point, competition or consolidation is inevitable. Either way, the industry will evolve, always with the goal of attracting more patients.
Of course, retail clinics are already bumping up against potentially their biggest competitor: primary care physicians. If you feel that your patients might be attracted to these retail health clinics to the detriment of your practice, now is the time for you to evolve and start thinking about how you can improve your access and your appeal to patients. If this trend seems like too much to think about, remember: Your patients already are.