assignment

The Health Care Industry

By: Susan Ladika

Pub. Date: March 27, 2020 Access Date: November 10, 2022

Source URL: https://library.cqpress.com/cqresearcher/cqresrre2020032700

©2022 CQ Press, An Imprint of SAGE Publishing. All Rights Reserved. CQ Press is a registered trademark of Congressional Quarterly Inc.

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Table of Contents

Introduction

Overview

Background

Current Situation

Outlook

Pro/Con

Chronology

Short Features

Bibliography

The Next Step

Contacts

Footnotes

About the Author

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Page 2 of 19 The Health Care Industry CQ Researcher

A CVS in San Ramon, Calif., offers free sanitizing wipes for shoppers during the coronavirus pandemic. In some stores, CVS operates HealthHUBS that provide services such as treatment for coughs or help managing chronic conditions, part of an effort to expand health care options. (Getty Images/Smith Collection/Gado/Contributor)

Introduction Amid the tumult and disruption caused by the global coronavirus pandemic, a physician shortage and rising health care costs, providers and insurers have been focusing on new ways to make care more accessible to consumers. Changes include placing health clinics in retail stores where consumers can get primary care services, find help managing chronic conditions or even take a yoga class. Providers also are turning to telehealth — offering care via computer, phone or mobile device. Mergers and partnerships among retailers, insurers and providers are driving some of the changes as the health care industry struggles to bring down the high costs of care in the United States. The coronavirus pandemic is also boosting telehealth. But some experts worry about the quality of care offered by these new services. They warn that retail clinics and telehealth can undercut patients' relationships with primary care doctors. Yet given the physician shortage, other experts say retail clinics and telehealth have a vital role to play.

Overview When Rosita Rodriguez came to a CVS drugstore in Spring, Texas, last year looking for pain medication, she met with the “care concierge,” Jesse Gonzalez. He helped the 68-year-old select medication, then told Rodriguez she could get her glucose level checked at the store and join free yoga classes.

“I did yoga, and it was such a joy,” said Rodriguez, who now regularly visits the store. “Whenever I need something, I see Jesse. He's there for me.”

The store in the Houston suburb is one of CVs' new HealthHUBs, where customers can receive primary care services including flu shots and treatment of coughs, get help managing chronic conditions such as diabetes and participate in health and wellness classes. The new clinics were spurred by CVs' $69 billion acquisition of health insurer Aetna in 2018.

National Guard soldiers set up a triage tent on March 19 in the parking lot of the Adventist HealthCare White Oak Medical Center in Silver Spring, Md., in preparation for an expected onslaught of coronavirus patients. The pandemic has brought a renewed focus on the U.S. health care system and how to improve it. (Getty Images/Drew Angerer)

The HealthHUBs are part of a growing trend to put health care more directly in the hands of consumers. That might mean visiting a drugstore or big-box store for health care, or consulting with a physician by phone, mobile device or computer. The landscape also is shifting as health insurers and care providers put a greater emphasis on “well care,” aimed at keeping consumers healthy, rather than just providing treatment when someone is ill. Besides seeking to keep people healthy longer, insurers and providers say they want to make health care more accessible and to lower sky-high medical costs.

“Consumer-centric health care coordination could be a way to essentially transform care delivery,” says Sonal Kathuria, managing director in the health practice of the consultancy Accenture.

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But some experts say these changes could reduce the quality of care without necessarily lowering costs. The reason, they say, is that visits to clinics can result in less continuity of care, as one health care provider may not be aware of the care a patient has already received.

The information patients share with health care providers, and the treatment they receive, “needs to get integrated somewhere into an individual's health record,” says Dr. Ken Abrams, managing director and life sciences and health care national physician leader at the global consulting firm Deloitte. “If you ignore it, there are more opportunities for error.”

Health care is a huge business in the United States. Spending on all health care climbed to $3.6 trillion, or more than $11,000 per person, in 2018 — a 4.6 percent increase from 2017, according to the Centers for Medicare & Medicaid Services (CMS), the federal agency that supervises those two programs. (Medicare primarily provides health insurance to those age 65 and older; Medicaid offers coverage to lower-income adults.)

Health care spending made up 17.7 percent of U.S. gross domestic product (GDP) in 2018, far higher than that of 10 other high-income countries, such as Germany and the United Kingdom. A study by the Commonwealth Fund, a foundation that promotes a high-performing health care system, found that in 2016, the world's other wealthy countries spent an average of 11.5 percent of GDP on health care.

One reason for the disparity is that the cost of medical care is far greater in the United States than elsewhere. In 2017, the average price for heart bypass surgery in the United States was $78,000, more than twice the price in the United Kingdom and Switzerland, according to a study by the International Federation of Health Plans, which represents health insurance CEOs from around the world. Basic health care visits and medications are also much more expensive in the United States than in other countries.

“It is staggering how much [more expensive] the United States is,” said John Hargraves, director of data strategy for the Health Care Cost Institute, which collects claims data from several health insurance companies.

Costs are expected to keep rising as Baby Boomers — the generation born between 1946 and 1964 — age. Total health care spending in the United States is projected to reach almost $6 trillion by 2027, and will account for 19.4 percent of GDP, according to the Centers for Medicare & Medicaid Services.

The aging population and growing demand for health care services come at a time when the U.S. physician shortage is projected to reach as many as 122,000 by 2032, including between 21,000 and 55,000 primary care physicians, according to the Association of American Medical Colleges.

These trends were already well established before the coronavirus pandemic, which is almost certain to increase the constraints and pressures on the U.S. health care system. As that system struggles to cope with the pandemic, it may be forced to rely even more on the new forms of health care delivery to relieve some of the strain.

What the pandemic's ultimate impact will be is “the million-dollar question,” says Dr. Ateev Mehrotra, an associate professor of health care policy at Harvard Medical School. “My sense is that it will drive a big bump longer term,” especially with telehealth.

Alternative Types of Care

Many experts across the health care spectrum hope that the increasing use of alternative care such as telehealth — consulting with providers by telephone or online — and retail clinics will improve access to care and help control health care costs.

“Consumers are demanding more and more access to care,” Abrams says, adding that retail clinics and telehealth are “very much consistent with our 24/7 culture.”

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At the same time, insurers who are involved in retail clinics hope to “sell not just diabetes medication, but diabetes management” and “change the behavior of those [patients] you're financially responsible for,” says Jeff Gourdji, a partner with the consultancy Prophet.

But not everyone is convinced these new models will become widely used.

“This is going to take a lot of cultural change for patients to feel that this is a reasonable option for them,” Mehrotra said. Patients may be willing to get a flu shot at a drugstore, but not to go there for help managing their diabetes, he said.

Nevertheless, studies show that “in general, people are pretty happy with the clinics” because of the quality of the care they receive, Mehrotra says.

Retail health clinics are not new, but their numbers have been growing and the scope of their services is expanding. In 2016, the United States had more than 2,000 retail clinics.

CVS acquired MinuteClinics, which provided basic services such as treatment for an ear infection or sore throat, in 2006, and the Walgreens and Walmart chains have similar retail clinics.

After a pilot program at three stores in the Houston area, CVS announced in 2019 it would roll out its HealthHUBs to 1,500 locations by the end of 2021.

“We have a sense of urgency about the need to bring real change to health care,” said Kevin Hourican, then-president of CVS Pharmacy, who cited the importance of creating “an entirely new consumer experience and [helping] people on their path to better health.”

Meanwhile, Walgreens and Humana began partnering on two senior-focused primary care clinics in the Kansas City, Mo., area in 2018 and last year announced plans to add two more in the Kansas City region and one in Anderson, S.C.

In September, Walmart added a health center to its superstore in Dallas, Ga., a suburb of Atlanta. Walmart Health offers primary care, X-rays, lab work, counseling, dental care, community health programs and health insurance education and enrollment. Services are available to anyone, regardless of whether they have health insurance. A primary care visit costs $40; an adult dental checkup and cleaning is $50. Counseling costs $1 per minute. Walmart has opened its first drive-thru coronavirus testing centers in the Chicago area, and other retailers are expected to follow suit.

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Another growing alternative is telehealth. (See Short Feature.) These services are typically offered by a direct-to-consumer telemedicine provider, such as Teladoc Health or MDLIVE, or through a major health system, such as the Cleveland Clinic, a medical center in Ohio.

Because of the coronavirus pandemic, experts are promoting telehealth as a way to help diagnose COVID-19, and to keep patients with other ailments out of doctors' waiting rooms. Several health insurers, including Humana and Aetna, are temporarily charging no co-payments for all consultations done via telemedicine, and the Trump administration is expanding access to telemedicine in Medicare.

“The use of telemedicine is going to be critical for management of this pandemic,” said Dr. Stephen Parodi, executive vice president of external affairs, communications and brand for the Permanente Foundation, the national leadership and consulting organization for Kaiser Permanente, a major West Coast health system.

A 2019 survey by data company J.D. Power found about 10 percent of consumers had used telehealth to consult with a health care provider in the previous 12 months. Hospitals also are increasingly using telehealth.

Critics worry about the quality of care offered by telehealth providers and retail clinics. Mehrotra, who has conducted more than a dozen studies on telehealth services, says that quality of care “varies from company to company.”

While retail clinics and telehealth can provide immediate care, “primary care tends to perform better” over the long term because of the continuity of care to patients, says Shawn Martin, senior vice president of advocacy, practice advancement and policy for the American Academy of Family Physicians, based in Leawood, Kan. The question with these alternate-delivery models is “how to incorporate them into the primary care system,” he says.

Dr. Mark J. Werner, director of clinical consulting for the Chartis Group, a Chicago-based health care consulting firm, said retail clinics do not necessarily provide quality care or reduce costs. “None of the research has shown… these approaches to delivering care has meaningfully addressed cost,” Werner said.

The pandemic also is complicating things for retail clinics. Many of the clinics, according to public health experts, lack essential safety protocols and protective equipment. Experts fear they are becoming prime locations for the coronavirus to spread among patients and the doctors and nurses treating them.

While CVS says its new HealthHUBs are outperforming a control group of its traditional stores in terms of sales and new customers, Walgreens is shuttering its company-run clinics because of challenges in becoming profitable.

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A doctor (foreground) consults with a patient through videoconferencing. Experts hope telehealth will improve access to health care while helping to control costs. (Getty Images/BSIP/Universal Images Group/Contributor)

Many of the changes in the industry are tied to mergers and partnerships between health insurers and health care providers, both of which want to lower costs and increase profitability. Insurers Cigna and Health Care Service Corp., the parent company of five Blue Cross and Blue Shield plans, have invested millions in telehealth provider MDLIVE.

Another change is the rising number of insured following passage of the Patient Protection and Affordable Care Act (ACA) in 2010: About 90 percent of Americans now have health insurance, up from 82 percent in 2010.

The two remaining Democratic presidential candidates differ on what should happen to the U.S. health insurance system. Sen. Bernie Sanders of Vermont calls for a government-run single-payer system that he calls Medicare for All. Former Vice President Joe Biden calls for strengthening the ACA by adding a so-called public option, government-sponsored coverage that would provide an alternative to private insurers. How health insurance might be transformed if a Democrat wins the White House in November is anyone's guess.

Background Rise of Urgent Care Centers

From the turn of the 20th century until recently, Americans received medical care from two main providers: doctors and hospitals.

“Before, you went to a doctor's office or the ER. Neither of those is sufficient,” Deloitte's Abrams says.

The first urgent care centers were created in the 1970s, offering patients the opportunity to receive medical care without having to make an appointment, and providing care when most doctor's offices were closed or when treatment was needed promptly but did not merit a trip to the emergency room.

Since then, the number of urgent care centers has risen from 6,400 in 2014 to more than 9,200 in June 2019. Those figures do not include clinics located inside retail stores.

A family physician and a businessman started the first retail health clinics, known as QuickMedx, in the Minneapolis area in 2000. They accepted only cash payment and treated a handful of medical conditions, such as strep throat and flu. The clinics were designed to be a more affordable alternative to urgent care centers.

The name was changed to MinuteClinic in 2003. In 2006, MinuteClinic outlets began to be located at CVS stores, and CVS then acquired MinuteClinic. As of 2017, the company had more than 1,100 retail clinics in CVS and Target stores.

Walmart, Walgreens and other retailers also began to open clinics inside their stores in the 2000s.

Nurses, nurse practitioners and physician's assistants primarily staff these clinics. To compete with the clinics, some major hospital systems have placed health clinics inside retailers, such as a partnership between Walgreens and the not-for-profit health system TriHealth, which operates seven clinics at Walgreens stores in the Cincinnati area.

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Patients wait in a hallway at Grady Memorial Hospital's emergency department in Atlanta in July 2006. Urgent care centers were created in the 1970s to help reduce the workload at overcrowded hospitals. (Getty Images/Jonathan Torgovnik)

Telehealth also grew as the use of the internet and cellphones spread in the early 21st century. Teladoc, which says it is the country's oldest and largest telehealth provider, was founded in 2002 and began serving patients in 2005. Consumers can reach a physician through their mobile device, computer or phone.

For the first nine months of 2019, Teladoc reported it had almost 3 million virtual visits, a 64 percent increase from the first nine months of 2018, and virtual visits for mental health care were rapidly expanding.

Generally, patients go online or call in to consult with a telehealth provider. They discuss the patient's symptoms and, if needed, a prescription is placed at the patient's pharmacy. A patient may be told to go to the emergency room, or to consult with a local physician for follow-up care.

Along with easy access to care, virtual visits tend to be much cheaper than in-person ones. A study by the RAND Corp., a California-based think tank, in 2017 found telehealth visits cost about $79, compared with $146 for in-person visits. But the study also said that access to telemedicine generated new demand for health care, so it did not necessarily produce cost savings.

Demand for medical care has increased in the past decade for a variety of reasons. One is that the ACA, which Congress passed in 2010, has increased insurance coverage by providing subsidies in the form of tax credits for households whose incomes are between 100 percent and 400 percent of the federal poverty level. Subsidies in 2020 are available for individuals who earn up to $49,960 and for families of four who earn up to $103,000. The ACA also expanded Medicaid to include all those whose incomes are below 138 percent of the federal poverty level, although not all states have widened their Medicaid coverage.

Arthur Barrett (left) of New York City signs up for health insurance coverage in March 2014, made available through the Affordable Care Act. The law has helped cut the uninsured rate in the United States. (Getty Images/Andrew Burton)

In addition, the ACA supported health care delivery methods aimed at reducing the cost of care.

The law has faced numerous legal challenges over the years. In 2012, the U.S. Supreme Court upheld the law's constitutionality, ruling that the individual mandate, which required all Americans to obtain health insurance or pay a financial penalty, was authorized under Congress' power to levy taxes. The following year Americans started signing up for coverage on the federal and state health exchanges created under the law, and ACA coverage began in 2014.

In 2015, the U.S. Supreme Court ruled the federal government could provide subsidies to residents in states that did not establish their own exchanges. Two years later, congressional Republicans with the support of President Trump tried to repeal the ACA, but the measure did not pass in the Senate.

Current Situation Legal Challenges

Despite the fact that millions of Americans have gained health insurance coverage since 2010, the ACA's future remains uncertain.

With Congress' passage of the 2017 Tax Cuts and Jobs Act, the tax penalty for failing to purchase health insurance was eliminated. A group of states, led by Texas, filed suit in 2018, arguing the ACA is unconstitutional without the tax penalty. A federal District judge in Texas agreed.

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In December, the Fifth Circuit Court of Appeals in New Orleans ruled the individual mandate was unconstitutional, but it sent the case back to the District judge in Texas to determine whether other parts of the law also are unconstitutional, as the judge had ruled.

“It's really hard for me to believe that courts and the Supreme Court won't find a way to create severability of various provisions of the law,” in which other parts of the law can stand even if one part, such as the individual mandate, is void, says Martin of the American Academy of Family Physicians.

Seventeen Democratic-led states, the District of Columbia and the Democratic-controlled U.S. House of Representatives are fighting to preserve the law, and the Supreme Court in early March agreed to review the appellate court's decision. The case likely will be heard in the fall.

“As Texas and the Trump administration fight to disrupt our health care system and the coverage that millions of people rely upon, we look forward to making our case in defense of the ACA. American lives depend upon it,” said California Attorney General Xavier Becerra, who is leading the Democrats' defense of the ACA.

Texas Attorney General Ken Paxton, a Republican, expressed confidence the Republican challenge will prevail. “The federal government cannot order private citizens to purchase subpar insurance that they don't want, and I look forward to finally settling the matter before the U.S. Supreme Court,” he said.

The Wellness Campaign

Some health care providers and health insurers are putting an increasing focus on wellness.

“So much of what influences your health outcomes is outside the clinic,” says Dr. Dora Hughes, associate research professor of health policy and management at George Washington University. During the Obama administration, she worked as a counselor for Health and Human Services Secretary Kathleen Sebelius.

These factors include income level and whether individuals have safe housing and access to healthy food and transportation.

At Northwest Permanente, a medical group based in Portland, Ore., patient navigators have been added to the staff to help determine whether patients need extra assistance, such as locating secure housing or financial aid. “They are there to help address the social and nonmedical needs of our members by building trusting relationships with patients, helping them to connect with resources in their communities, and to activate individual patients' care plans,” said Dr. Imelda Dacones, the health system's president and CEO.

A teleconsultation takes place in February between medical staff at Wuhan Union Hospital, located in the city where the coronavirus first appeared late last year, and Guangzhou Medical University in Guangzhou, China. The pandemic is spurring questions about next steps for the health care industry. (Getty Images/Xinhua/Xiao Yijiu)

The ACA, meanwhile, seeks to improve care and lower costs by rewarding doctors and hospitals for producing good health outcomes rather than focusing on a large volume of patients.

The Centers for Medicare & Medicaid Services, for example, is now allowing Medicare Advantage plans to provide extra services to members with chronic conditions to improve their health and quality of life. (Medicare Advantage provides Medicare benefits through a private insurer.) As a result, some insurers are working with ride-sharing companies such as Uber or Lyft to offer free rides to medical appointments, or with Papa, which provides companionship from “grandkids on demand.”

“The ACA has helped to drive these partnerships,” Hughes says. And even if the ACA is overturned, “the private sector has embraced the newer models of care. The old days of practicing medicine are over.”

Mergers and Partnerships

CVs' acquisition of Aetna is fueling its retail clinic effort. In November, CVS Chief Executive Officer Larry Merlo said the HealthHUBs were generating new customers and sales after the first eight months.

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“Without the Aetna tie, I think the clinic strategy is very, very difficult,” said Todd Huseby, a partner with the consultancy Kearney. Retail clinics “have not been all that profitable, and utilization is not as high as they would want it to be.”

“I see a number of upsides for patients,” said Hughes. “Managing a chronic disease … is hard work. To have CVS and their broad community footprint available, to have providers that you can see at nights and on the weekends, to be able to get your bloodwork done when you want — I mean, that could be hugely beneficial for patients.”

On the other hand, Walgreens announced in October that it was shutting about 150 of its retail clinics. Analysts say the small clinics the company has operated have struggled to make money, and competition from telehealth is increasing. Walgreens will continue to maintain more than 200 clinics that are run by local health care providers.

Local health systems are taking part in these ventures as “a byproduct of competition. They see patients go to CVS and it hurts utilization” of other health care providers, says the American Academy of Family Physicians' Martin. “There's a lot of incentive to keep people in your system.”

In other cases, major health systems are partnering with retailers to offer telehealth services to customers. One such partnership involves BayCare, based in Clearwater, Fla., and Publix, Florida's largest grocery store chain, which now has telehealth kiosks in some locations. Consumers can consult with a BayCare physician, and then get their prescriptions filled at Publix.

Beacon Health Options, a behavioral health company based in Boston, in 2018 opened a mental health care clinic inside a Walmart in Carrollton, Texas. People can make an appointment or just walk in to see a licensed mental health care professional. Counselors deal with such issues as depression, anxiety or grief. The initial assessment costs $140, and clients then pay $110 per session. For those who do not have insurance or cannot afford the fees, payment is based on a sliding scale.

Outlook 2020 Election

Several major uncertainties surround the health care industry, according to experts: The coronavirus pandemic, the legal fate of the ACA, the outcome of the November presidential election and how widely retail clinics and telehealth will be utilized.

The ACA's future “is so fraught with intense partisanship, it's hard to know what's going to happen,” Deloitte's Abrams says.

Democratic presidential contender Sanders calls for the creation of Medicare for All, a single-payer national health insurance system that would provide health care coverage to everyone in the United States while eliminating most private insurance. Sanders says his plan would mean no premiums, no deductibles, no co-payments, no surprise bills and no provider networks.

But it is unclear how Sanders would pay for his plan. In an interview with CBS, Sanders said “nobody knows” how much his plan would cost and it's “impossible to predict” because of the many variables involved in the plan's implementation.

Meanwhile, Democratic front-runner Biden is calling for a public health insurance option for everyone, similar to Medicare, as well as increasing access to tax credits to reduce the cost of private health insurance and expanding access to Medicaid.

President Trump in February released his proposed fiscal 2021 budget, which includes about $1 trillion in cuts to Medicaid and to premium subsidies for the ACA over a decade. It lacked details on his vision for the future of health care, and analysts say Congress is unlikely to approve the budget.

Another open question is whether retail clinics and telehealth will become widely used by consumers, particularly those who are older.

A survey by the data science consultancy Civis Analytics found 18 percent of respondents had sought care at a retail clinic in the previous year. About 35 percent of those who went to a clinic had gone to CVS, while more than 30 percent had to gone to Walgreens for care.

Those between the ages of 18 and 49 were most likely to have visited a retail clinic. Almost 30 percent of people in that age group had visited one. They were least used by those between the ages of 50 and 64, at about 18 percent.

The J.D. Power survey of telehealth usage found 13 percent of 18- to 24-year-olds have used telehealth services, compared with 5 percent of those ages 65 and older. Experts say the coronavirus is giving a further boost to telehealth. At a White House meeting with President Trump in March, health insurers said they would pay for the virtual visits for people who may have coronavirus to improve access to care for their customers.

“I don't think it's a matter of if virtual health will become mainstream. It's a matter of when,” Abrams says.

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Pro/Con Can telehealth help address the nation's primary care shortage?

Pro J. Nwando Olayiwola, MD Chair and Professor, Department of Family Medicine, Ohio State University College of Medicine. Written for CQ Researcher, March 2020

The United States is experiencing increasing demand for primary care services. This is due in part to people living longer, healthier lives, resulting in a larger aging population than in previous generations.

Meanwhile, medical schools are challenged to keep up with the growing need for primary care physicians. According to the Association of American Medical Colleges, the shortage of primary care physicians to care for the adult population will reach at least 20,000 by 2030.

A number of medical schools have tried different strategies to increase the supply of primary care physicians, such as shortening the length of medical school or increasing class sizes, but they still do not see enough people choosing to specialize in primary care to meet the demand. At the same time, it's becoming harder to find physicians willing to practice in certain rural, urban and underserved communities.

Telehealth can improve access to both primary and specialty care. To prevent bottlenecks, primary care physicians with full patient schedules can reserve in-office visits for patients who need them the most, while caring for patients with certain non-emergency conditions via telehealth.

A lot of the demand for telehealth is also being driven by patients who are becoming tech savvy consumers. For example, consumers do not have to go to an airport to purchase an airline ticket or to a movie theater to see a movie — these experiences are much more personalized than in the medical field.

Health care, on the other hand, is not always reflective of what patients experience as consumers elsewhere. I have patients who ask, “Can you just email this to me? Do I have to come in?” Often, these patients are trying to emulate what they are experiencing in other areas of their lives.

Telehealth doesn't necessarily solve all the problems with health care access. There are still situations in which doctors need to see patients in person. And not everyone wants to receive health care via telehealth. You have to be very respectful of that. Patients should be able to access care in the manner they prefer, and we should always make sure these choices are available.

Con R. Shawn Martin Senior Vice President, Advocacy, Practice Advancement & Policy, American Academy of Family Physicians. Written for CQ Researcher, March 2020

To understand the limitations of telehealth, we need to differentiate between “primary care” and “primary care services.”

The American Academy of Family Physicians defines primary care as “care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom or health concern (the ‘undifferentiated’ patient) not limited by problem origin (biological, behavioral or social), organ system or diagnosis.’ This definition is grounded in the four C's of primary care — first contact, comprehensive, continuous and coordinated.

In our health care system, patients have frequent opportunities to seek and receive primary care services from a variety of sources: telemedicine, retail clinics, work-site clinics or urgent care centers. While each of these delivery sites provides patients with “primary care services,” they do not provide primary care. Again, it is important to distinguish between first contact, comprehensive, continuous and coordinated primary care and the delivery of primary care services.

As delivery and payment models continue their progression away from dealing with specific illnesses to comprehensive care focusing on patients' “wellness,” there likely will be an emphasis on the implementation of technologies that expand connectivity between patients and their family physician and primary care team. I do not subscribe to the “technology is going to replace primary care” mantra that is promoted by some. However, I do think technology will alter primary care significantly, creating opportunities for greater connectivity and a more expansive scope of practice for family physicians.

We know from literature that a longitudinal relationship with a primary care physician is the one thing that demonstrably improves health for individuals and populations and most appropriately manages resources, including financial. This is why patients need and deserve longitudinal primary care, not simply primary care services. Patients may utilize, from time to time, primary care services from convenient sources of care such as telemedicine or a retail clinic, but these services are not comprehensive primary care.

As our health care delivery system continues to evolve, there is little question that patients will seek alternative ways to receive primary care that more closely align with their health care needs and lifestyle. Primary care physicians need to incorporate these alternatives into their practices and care team so that all patients can access and experience the proven value of comprehensive, continuous and coordinated primary care.

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Page 11 of 19 The Health Care Industry CQ Researcher

Chronology 1965–1997 Major changes to U.S. health care system are made or attempted.

1965 Democratic President Lyndon B. Johnson signs legislation creating Medicare, providing health insurance to those ages 65 and older, and Medicaid, insuring low-income adults.

1970s Emergency room physicians create the first urgent care centers in various locations.

1993 Newly elected Democratic President Bill Clinton releases plan to overhaul the U.S. health care system. The proposal calls for universal coverage and government control of costs and premiums, with insurers competing to provide coverage. The following year, it dies in the Senate due to lack of support.

1997 Congress approves the Children's Health Insurance Program, providing coverage for children in families who earn too much to qualify for Medicaid but too little to afford private insurance.

2000–2006 New ways of providing convenient health care emerge.

2000 QuickMedx opens the first retail health care clinics in Minnesota to treat a handful of conditions. The name is changed to MinuteClinic in 2003.

2002 A former NASA flight surgeon and an entrepreneur found Teladoc Health to provide telehealth — health care treatment via computer, phone or mobile device — for minor medical emergencies. It begins treating patients three years later.

2003 The Veterans Health Administration begins using telehealth to coordinate care for veterans with chronic conditions.

2006 The drugstore chain CVS acquires MinuteClinics. CVS had already been placing the clinics in its stores.

2010-Present Affordable Care Act takes effect and is beset by legal challenges.

2010 Democratic President Barack Obama signs the Patient Protection and Affordable Care Act (ACA), designed to increase the number of insured by subsidizing insurance for lower-income households; expanding Medicaid; and supporting care models that lower costs.

2012 U.S. Supreme Court upholds the ACA's constitutionality but rules against mandatory Medicaid expansion.

2014 Consumers begin receiving ACA coverage on state and federal health exchanges and about 8 million Americans sign up. … Some states start expanding Medicaid.

2015 Supreme Court rules federal subsidies could be provided to residents in states that did not establish ACA exchanges.

2016 American Medical Association recommends all students in medical schools and residency programs receive training to provide care via telehealth.

2017 Congressional Republicans unsuccessfully attempt to repeal the ACA. … Congress eliminates the ACA's tax penalty under the individual mandate, which requires people to purchase insurance.

2018 In Texas v. United States, 20 Republican-led states sue the federal government, contending that without the individual mandate's tax penalty the ACA is unconstitutional. A federal District judge in Texas rules the entire law is unconstitutional, but the ACA's defenders appeal. … CVS acquires health insurer Aetna for $69 billion and announces pilot program to launch care clinics, known as HealthHUBs, at several Houston-area locations. … Retailer Walgreens and insurer Humana agree to open senior-focused primary care clinics in the Kansas City, Mo., area.

2019 Fifth Circuit Court of Appeals in New Orleans rules individual mandate is unconstitutional, sends the case back to the District judge for further review on whether the entire ACA is invalid.

2020 A group of Democratic-led states and members of the House of Representatives ask the Supreme Court to fast-track a decision on the ACA's validity. The court at first declines; it later agrees to hear the case. … President Trump unveils proposed budget for fiscal 2021, which would cut health care spending and Medicaid by $1 trillion over 10 years (February).

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Short Features

Telehealth Is Gaining in Popularity

“It has really gotten to the point we can do this in a reliable, effective manner.”

When Minerva Granger gets sick, she reaches for the telephone — not to book an appointment at her doctor's office, but to connect directly with a physician through the telehealth company Teladoc Health.

“If anything comes up during the year, I'd call Teladoc,” says the 54-year-old paralegal in Tampa, Fla., who has used the direct-to-consumer telehealth provider about 20 times in the past two years. Patients can consult with a physician by phone, computer or mobile device.

The benefits are many, says Granger, who has recurrent bronchitis. She can talk with a doctor within a few minutes, rather than waiting a few days to see her primary care physician, and if she needs a prescription, Teladoc calls her pharmacy. A co-pay is $50, compared with $98 for a doctor's visit. And Granger says she is “not exposed to all the other sick people sitting in the doctor's office.” Instead, she has called Teladoc “right from my desk at work.”

At a telemedicine center in Sioux Falls, S.D., in October, physicians working for Avera Health consult with emergency rooms at rural hospitals in 30 states. (Getty Images/The Washington Post/Michael S. Williamson)

Telehealth for minor medical emergencies, primary care and mental health care is a growing segment of the health care landscape. And as the coronavirus pandemic spreads, telehealth is gaining even more attention in the United States as a way to help diagnose and treat the disease, and to provide care for patients with other ailments so they do not have to visit doctors' offices.

At Rush University Medical Center in Chicago, doctors are using telehealth to help screen potential coronavirus cases. In one instance, a man who had recently traveled abroad called the virtual care line and said he had had a fever and cough the previous week, but was feeling fine.

“He said all the right buzzwords: cough, fever, fatigue,” said emergency room physician Meeta Shah, who referred the man to the Chicago Health Department.

“This is a kind of turning point for virtual health,” Shah said. “We're actually seeing how it can be used in a public health crisis.

Telehealth provider Teladoc Health reported a 50 percent jump in patient visits for the week ending March 13, compared with the previous week. Requests for virtual visits rose to as many as 15,000 per day and about 100,000 for the week.

“We are seeing more patients and more of those patients are experiencing upper respiratory issues,” said Dr. Lew Levy, chief medical officer for Teladoc Health. “As we saw during the flu epidemic of 2018, a community's health care system can become overwhelmed and virtual care can help provide needed relief.”

A 2018 study in the Journal of the American Medical Association (JAMA) examined insurance claims data from 2005 to 2017 for privately insured and Medicare Advantage members for an unnamed private health plan. (Medicare Advantage provides benefits for Medicare, the federal program that covers those ages 65 and older, through a private insurer.)

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Page 13 of 19 The Health Care Industry CQ Researcher

During that time, members made nearly 385,000 visits using telemedicine, and usage jumped from 0.02 visits per 1,000 members in 2005 to 6.57 visits per 1,000 members in 2017, according to the study, led by Dr. Michael Barnett, an assistant professor of health policy and management at Harvard University. Usage for primary care surged in 2016 and 2017, just as primary care and psychiatric services have been in short supply.

The shortage is particularly acute in rural areas. As of March, 80 million Americans lived in federally designated “health professional shortage areas” that lack primary care services, more than 60 percent of them in rural areas, according to a federal study. More than 14,000 primary care practitioners and 6,000 mental health care providers are needed to address the shortfall in rural and other areas, the study found.

And the shortages are expected to worsen. The United States is expected to have a shortage of 21,000 to 55,000 primary care physicians by 2032, and a shortfall of 6,000 to 15,600 psychiatrists and other mental health providers by 2025, according to the Association of American Medical Colleges.

Using telehealth is “a way of utilizing what resources we have,” says Mei Kwong, executive director of the Center for Connected Health Policy, a nonprofit that seeks to integrate telehealth into the health care system. With today's improved technology and connectivity, she adds, “it has really gotten to the point we can do this in a reliable, effective manner.”

But not everyone is sold on telehealth, particularly when it comes from direct-to-consumer companies rather than a patient's own physician.

Two studies found that telemedicine providers were more likely to prescribe medications without taking time to determine whether the drugs were actually needed. “Outpatient respiratory tract infections rarely warrant antibiotics, although they are frequently prescribed,” the researchers wrote. “Because patients often expect to receive antibiotics, physicians may believe that explaining why they are unnecessary is more time-consuming than simply prescribing them.”

A major proponent of telemedicine is the U.S. Department of Veterans Affairs (VA), and more than 900,000 military veterans used telehealth services in fiscal 2019, a 17 percent increase over the previous year.

For those who live in areas where internet connectivity may be unreliable, the VA is piloting a program that allows veterans to use telehealth from locations such as Veterans of Foreign Wars and American Legion posts, as well as Walmart stores.

“We want every veteran to have a choice to schedule an in-person, telephone or video visit with their providers depending on their preferences for health care delivery,” VA Secretary Robert Wilkie said.

— Susan Ladika

[1] Reed Abelson, “Doctors and Patients Turn to Telemedicine in the Coronavirus Outbreak,” The New York Times, March 11, 2020, https://tinyurl.com/swnvnh4.

[2] “Teladoc Health Sees Daily Virtual Medical Visits Up 50% in Past Week,” Teladoc Health, March 13, 2020, https://tinyurl.com/vgb48ea.

[3] Michael L. Barnett et al., “Trends in Telemedicine Use in a Large Commercially Insured Population, 2005–2017,” JAMA, Nov. 27, 2018, https://tinyurl.com/rzxvfu5.

[4] “Shortage Areas,” U.S. Health Resources and Services Administration, March 20, 2020, https://tinyurl.com/y7rrjquj.

[5] “New Findings Confirm Predictions on Physician Shortage,” Association of American Medical Colleges, April 23, 2019, https://tinyurl.com/qv2d72d; Stacy Weiner, “Addressing the escalating psychiatrist shortage,” Association of American Medical Colleges, Feb. 12, 2018, https://tinyurl.com/snxtjsv.

[6] Eric Wicklund, “Is Convenience a Problem for Direct-to-Consumer Telehealth Programs,” mHealthIntelligence, Oct. 2, 2018, https://tinyurl.com/rckbg7y.

[7] “VA reports significant increase in Veteran use of telehealth services,” news release, U.S. Department of Veterans Affairs, Nov. 22, 2019, https://tinyurl.com/t2gbg39.

Bibliography Books

Makary, Marty , The Price We Pay: What Broke American Health Care — and How to Fix It , Bloomsbury Publishing, 2019. A surgeon at Johns Hopkins Hospital contends that hospital financial practices are damaging the doctor-patient relationship, and he talks to patients to see how medical costs have affected them.

Topol, Eric , The Patient Will See You Now , Basic Books, 2016. The chair of innovative medicine at Scripps Research in California says technology — particularly telemedicine and the digitization of medical data — will give patients more control over their health care.

Articles

Giambruno, Stephanie, and A. Pawlowski , “Mental health clinic opens inside a Walmart in Texas,” Today, Nov. 28, 2018, https://tinyurl.com/vbp3n9o. A Boston company offers therapy and other mental health services at a clinic in a Texas Walmart store.

Ibarra, Ana B. , “Are Virtual Doctor Visits Really Cost-Effective? Not So Much, Study Says,” Kaiser Health News, March 7, 2017, https://tinyurl.com/sz8tlz4. A study finds virtual health care does not necessarily reduce health care costs because patients seek care for conditions they might otherwise have treated on their own.

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Page 14 of 19 The Health Care Industry CQ Researcher

Japsen, Bruce , “Walgreens And Humana Expand Senior Clinic Venture To More Markets,” Forbes, July 30, 2019, https://tinyurl.com/qsp6dsw. A drugstore chain and a health insurer announce plans to establish more primary care clinics for senior citizens.

Kodjak, Alison , “CVS Looks To Make Its Drugstores A Destination For Health Care,” NPR, Feb. 21, 2019, https://tinyurl.com/r82uchu. CVS aims to change how health care is delivered by setting up HealthHUBs at some of its drugstores to handle primary care, management of chronic conditions, wellness classes and other services.

Liptak, Adam, and Abby Goodnough , “Supreme Court to Hear Obamacare Appeal,” The New York Times, March 2, 2020, https://tinyurl.com/tan7xdc. The Supreme Court agrees to hear a case challenging the constitutionality of the Affordable Care Act, the 2010 law that overhauled the federal approach to health insurance.

Mann Jackson, Nancy , “Screening for social determinants,” Medical Economics, Feb. 21, 2020, https://tinyurl.com/ws7lzaa. A health system looks at the medical symptoms of a teenager and also the social factors that might be influencing her health.

Wallace, Elizabeth , “How Biden's and Sanders' Healthcare Plans Measure Up,” Healthline, March 2, 2020, https://tinyurl.com/u45p67h. Industry experts examine the health care proposals of the two remaining Democratic presidential candidates.

Wicklund, Eric , “Is Convenience a Problem for Direct-to-Consumer Telehealth Programs,” mHealthIntelligence, Oct. 2, 2018, https://tinyurl.com/rckbg7y. Studies show health care providers working for direct-to-consumer telehealth services may be overprescribing antibiotics.

Reports and Studies

“Understanding Retail Clinic Patients,” Civis Analytics, 2018, https://tinyurl.com/tucaf5p. A study by a data software company examines who uses retail clinics, what treatments are sought and the level of patient satisfaction.

Barnett, Michael L. , et al., “Trends in Telemedicine Use in a Large Commercially Insured Population, 2005–2017,” Journal of the American Medical Association, Nov. 27, 2018, https://tinyurl.com/rzxvfu5 In a study led by an assistant professor of health policy and management at Harvard University, researchers look at the jump in usage of telehealth for primary and mental health care at a large insurance company.

Garfield, Rachel, Kendal Orgera and Anthony Damico , “The Uninsured and the ACA: A Primer — Key Facts About Health Insurance and the Uninsured Amidst Changes to the Affordable Care Act,” Kaiser Family Foundation, Jan. 25, 2019, https://tinyurl.com/yxak8r8s. Researchers explore how health insurance coverage has changed since the major provisions of the Affordable Care Act took effect in 2014.

Papanicolas, Irene, Liana R. Woskie and Ashish Jha , “Health Care Spending in the United States and Other High-Income Countries,” The Commonwealth Fund, March 13, 2018, https://tinyurl.com/y5tyopsy. Researchers at the Commonwealth Fund, a foundation that studies health care, find much more is spent on health care services and administration in the United States than abroad.

The Next Step Health Care Spending

Coombs, Bertha , “Health care stocks see worst week in two decades,” CNBC, Feb. 29, 2020, https://tinyurl.com/r283cga. Health insurance and hospital stocks tumbled as it became clear insurers would pay higher costs because of the coronavirus pandemic.

McCall, Rosie , “The U.S. Wastes 25 Percent of Its Healthcare Spending, With Up to $935 Billion Lost Every Year,” Newsweek, Oct. 7, 2019, https://tinyurl.com/y3asl8m9. Nearly a trillion dollars in health care spending in the United States is lost each year to, among other things, administrative complexity, billing and coding waste, according to a study by the insurer Humana.

Morse, Susan , “Healthcare spending is higher over 5 years, mostly due to a rise in prices, says new report,” Healthcare Finance, Feb. 14, 2020, https://tinyurl.com/y75ttfwe. Annual health care spending per person for those with employer-sponsored insurance rose more than 18 percent between 2014 and 2018.

Physician Shortage

“Facing Doctor Shortage, California Eyes More Authority for Nurse Practitioners,” Times of San Diego, Feb. 16, 2020, https://tinyurl.com/vhg9h9r. The California Legislature is considering allowing nurses who receive additional training and certification to work independently of doctors.

“UH Considers Expanding Medical School to Maui Amid Doctor Shortage,” Maui Now, Feb. 23, 2020, https://tinyurl.com/uzbtf6h/. The University of Hawaii is asking state lawmakers to approve an expansion of the medical school to the island of Maui, where some patients are forced to wait six months to see a doctor.

Sterman, Joce, and Alex Brauer , “A nationwide doctor shortage is looming. Rural areas will the hardest hit,” ABC7 WJLA News, Oct. 31, 2019, https://tinyurl.com/wvoupd3. A representative from the Association of American Medical Colleges says the worsening doctor shortages in the United States are, in part, the result of population growth, aging and a cap on congressional funding that covers the residency training doctors need.

Retail Clinics

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Page 15 of 19 The Health Care Industry CQ Researcher

Galvin, Gaby , “Study: More Walk-In Clinics, Fewer ER Visits,” U.S. News & World Report, Dec. 18, 2019, https://tinyurl.com/t8xgujo. After a retail clinic opens, people living nearby are less likely to visit the emergency room for less serious illnesses, such as the flu, according to three economists.

Meyersohn, Nathaniel , “Welcome to Walmart. Your doctor will see you now,” CNN Business, March 4, 2020, https://tinyurl.com/v6tcbne. After opening two stand-alone health clinics in Georgia, Walmart might take the concept national, possibly changing the way millions of Americans receive health care.

Numerof, Rita , “Walgreens Closes Nearly 160 Walk-In Clinics — What It Means for Retail Healthcare,” Forbes, Nov. 22, 2019, https://tinyurl.com/vd2yggf. Walgreens' decision to close many of its retail clinics does not mean these clinics are a bad idea, according to a health care consultant.

Telemedicine

Ducharme, Jamie , “The Coronavirus Outbreak Could Finally Make Telemedicine Mainstream in the U.S.,” Time, March 3, 2020, https://tinyurl.com/t22sbca. Telemedicine has been slow to gain popularity in the United States due to regulation and lack of awareness, but the coronavirus could change that, medical experts say.

Matter, Jacqueline , “The Next Decade of Healthcare: Telemedicine,” ABC 7 WWSB, Feb. 13, 2020, https://tinyurl.com/qovky7h. Almost 75 percent of all urgent care, doctor and emergency room visits could be conducted through videoconferencing or over the phone, according to the American Medical Association.

Walsh, Kathy , “Consumers Worried About Coronoavirus Are Turning to Telemedicine,” CBSN Denver, March 9, 2020, https://tinyurl.com/udpq62o/. In Denver, more patients are using telemedicine after the coronavirus outbreak began, and recent federal legislation lifted restrictions on Medicare so more seniors could use telehealth.

Contacts American Academy of Family Physicians 11400 Tomahawk Creek Parkway, Leawood, KS 66211 800-274-2237 aafp.org Organization representing nearly 135,000 family physicians and medical students that lobbies the government, negotiates with insurers and educates patients on behalf of its members.

American Telemedicine Association 901 N. Glebe Road, Suite 850, Arlington, VA 22203 703-373-9600 americantelemed.org Association of health care providers, health insurers and technology companies that use or promote telehealth — video, computer, phone or mobile devices — to communicate with patients.

America's Health Insurance Plans 601 Pennsylvania Ave., N.W., South Building, Suite 500, Washington, DC 20004 202-778-3200 ahip.org Trade association that represents health insurance companies.

Center for Connected Health Policy 2520 Venture Oaks Way, Suite 180, Sacramento, CA 95833 877-707-7172 cchpca.org Nonprofit that seeks to integrate telehealth into the health care system. As the federally designated National Telehealth Policy Resource Center, it also provides technical assistance to a dozen federally funded regional Telehealth Resource Centers, as well as to state and federal policymakers, health care providers and the public.

Centers for Medicare & Medicaid Services 7500 Security Blvd., Baltimore, MD 21244 877-267-2323 cms.gov Federal agency that oversees Medicare, Medicaid, the Children's Health Insurance Program and the federal and state health insurance marketplaces.

Convenient Care Association 1413 Florence Drive, Gwynedd Valley, PA 19437 610-656-1213 ccaclinics.org Trade association representing heath care systems and companies that provide health care at retail locations.

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Page 16 of 19 The Health Care Industry CQ Researcher

RAND Corp. PO Box 2138, 1776 Main St., Santa Monica, CA 90407-2138 310-393-0411 rand.org Research organization that works to develop solutions to public policy issues.

Footnotes [1] Alison Kodjak, “CVS Looks To Make Its Drugstores A Destination For Health Care,” NPR, Feb. 21, 2019, https://tinyurl.com/r82uchu.

[2] “National Health Expenditures 2018 Highlights,” Centers for Medicare & Medicaid Services, Dec. 27, 2019, https://tinyurl.com/rjj463g.

[3] Ibid.; Irene Papanicolas, Liana R. Woskie and Ashish Jha, “Health Care Spending in the United States and Other High-Income Countries,” The Commonwealth Fund, March 13, 2018, https://tinyurl.com/y5tyopsy.

[4] Tom Sackville, “iFHP Comparative Price Report Issued,” news release, International Federation of Health Plans, Dec. 18, 2019, https://tinyurl.com/rl26zum; Margot Sanger-Katz, “In the U.S., an Angioplasty Costs $32,000. Elsewhere, Maybe $6,400,” The New York Times, Dec. 27, 2019, https://tinyurl.com/wmdoxz9.

[5] Sanger-Katz, ibid.

[6] “NHE Fact Sheet,” Centers for Medicare & Medicaid Services, Dec. 5, 2019, https://tinyurl.com/yx3t7d2v.

[7] “New Findings Confirm Predictions on Physician Shortage,” Association of American Medical Colleges, April 23, 2019, https://tinyurl.com/qv2d72d.

[8] Susan Ladika, “Dr. Drugstore Will See You Now,” Managed Care, Nov. 6, 2019, https://tinyurl.com/qpf3j42.

[9] “CVS announces further expansion into health care services,” The Associated Press, STAT, June 4, 2019, https://tinyurl.com/vvfss9g.

[10] “Retail Health Clinics: Part Of The New Front-Door To Healthcare,” Oliver Wyman, 2016, https://tinyurl.com/tbfvsgs.

[11] Chris Mills Rodrigo, “CVS debuts expanded health care options in Houston stores,” The Hill, Feb. 13, 2019, https://tinyurl.com/qthrjua; Caroline Humer, “CVS to expand health hubs to 1,500 stores by end of 2021,” Reuters, June 4, 2019, https://tinyurl.com/qqfjn6b.

[12] Bruce Japsen, “Walgreens And Humana Expand Senior Clinic Venture To More Markets,” Forbes, July 30, 2019, https://tinyurl.com/qsp6dsw.

[13] Paige Minemyer, “An inside look at Walmart's new health clinic,” FierceHealthcare, Oct. 29, 2019, https://tinyurl.com/umpu4uh; “In Dallas, Georgia, Walmart Unveils Enhanced Store Experience and First-Ever Walmart Health Center,” Walmart, Sept. 13, 2019, https://tinyurl.com/y4262l7r; and Hayley Peterson, “Walmart just opened its first drive-thru coronavirus testing sites. Here's what they look like,” Business Insider, March 22, 2020, https://tinyurl.com/rgj2btm.

[14] Susan Ladika, “Health Insurers Offer Free Telemed to Curb Coronavirus Spread,” Health Payer Specialist, March 13, 2020, https://tinyurl.com/regdese; Stephanie Armour and John D. McKinnon, “Telemedicine Gets a Boost From Coronavirus Pandemic,” The Wall Street Journal, March 17, 2020, https://tinyurl.com/uyocgqh.

[15] Reed Abelson, “Doctors and Patients Turn to Telemedicine in the Coronavirus Outbreak,” The New York Times, March 11, 2020, https://tinyurl.com/swnvnh4.

[16] Heather Landi, “Only 1 in 10 Patients Use Telehealth as Lack of Awareness Hinders Adoption, J.D. Power Survey Finds,” FierceHealthcare, July 31, 2019, https://tinyurl.com/rf464hl.

[17] Reed Abelson and Julie Cresswell, “The Disappearing Doctor: How Mega-Mergers Are Changing the Business of Medical Care,” The New York Times, April 7, 2018, https://tinyurl.com/yd4tv4zw.

[18] John Woodrow Cox, “Fearful doctors and nurses at walk-in clinics have a message for patients: Stay away,” The Washington Post, March 20, 2020, https://tinyurl.com/s63qhlp.

[19] Bruce Japsen, “CVS Profits Rise As Health Hubs Open,” Forbes, Nov. 6, 2019, https://tinyurl.com/rufr7kx; Tom Murphy, “Walgreens to shutter in-store clinics, add Jenny Craig sites,” ABC News, Oct. 28, 2019, https://tinyurl.com/vhgnkb8.

[20] Bruce Japsen, “Cigna And Blue Cross Plans Buy Stake In Telehealth's MD Live,” Forbes, Aug. 1, 2018, https://tinyurl.com/v8yjnqz.

[21] Papanicolas, Woskie and Jha, op. cit.; Rachel Garfield, Kendal Orgera and Anthony Damico, “The Uninsured and the ACA: A Primer — Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act,” Kaiser Family Foundation, Jan. 25, 2019, https://tinyurl.com/yxak8r8s.

[22] Dylan Scott, “The Real Differences Between the 2020 Democrats' Health Care Plans, Explained,” Vox, Dec. 19, 2019, https://tinyurl.com/vprgnr9.

[23] Rod Brouhard, “The Evolution of Urgent Care Centers,” Verywell Health, Jan. 19, 2020, https://tinyurl.com/vhbs4gj.

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Page 17 of 19 The Health Care Industry CQ Researcher

[24] “The Essential Role of the Urgent Care Center in Population Health,” Urgent Care Association, November 2019, https://tinyurl.com/sw32pr9.

[25] “History,” CVS Pharmacy, https://tinyurl.com/vwpufg9.

[26] Milt Freudenheim, “Wal-Mart Will Expand In-Store Medical Clinics,” The New York Times, Feb. 7, 2008, https://tinyurl.com/y7yckkjc.

[27] Heidi Godman, “Retail Health Clinics: The Pros and Cons,” Harvard Medical School, Jan. 15, 2016, https://tinyurl.com/t8ty3l3.

[28] “TriHealth to Operate Retail Health Clinics in Cincinnati Area Walgreens Stores,” news release, TriHealth, Oct. 28, 2019, https://tinyurl.com/wdszjpn.

[29] “10 things to know about Teladoc,” Becker's Hospital Review, Feb. 14, 2017, https://tinyurl.com/sjm2pge.

[30] Heather Landi, “Teladoc reports Q3 Revenue up 24%, boosted by strong growth in mental health virtual visits,” FierceHealthcare, Oct. 31, 2019, https://tinyurl.com/uda9cnt.

[31] Ana B. Ibarra, “Are Virtual Doctor Visits Really Cost-Effective? Not So Much, Study Says,” Kaiser Health News, March 7, 2017, https://tinyurl.com/sz8tlz4.

[32] “Affordable Care Act (ACA)” U.S. Centers for Medicare & Medicaid Services, https://tinyurl.com/gmv2dmb; Louise Norris, “Will you receive an Obamacare Premium Subsidy?” HealthInsurance.Org, Jan. 25, 2020, https://tinyurl.com/hw4db4a.

[33] “Affordable Care Act,” ibid.

[34] Kimberly Amadeo, “Obamacare Timeline: Health Coverage and the Insurance Marketplace,” The Balance, March 13, 2019, https://tinyurl.com/wz59pcp.

[35] Shannon Muchmore and Samantha Liss, “Timeline of the Affordable Care Act — still under siege,” Healthcare Dive, Nov. 13, 2019, https://tinyurl.com/sqgpghu.

[36] Ibid.

[37] Nathaniel Weixel, “Appeals court strikes ObamaCare mandate, sends case back to lower court,” The Hill, Dec. 18, 2019, https://tinyurl.com/wrlg7e9.

[38] Katie Keith, “Continued Uncertainty As Fifth Circuit Strikes Mandate, Remands On Rest Of ACA,” Health Affairs, Dec. 19, 2019, https://tinyurl.com/souhhax; Susannah Luthi, “Supreme Court will hear major challenge to Obamacare,” Politico, March 3, 2020, https://tinyurl.com/yxyz29jc.

[39] Ibid.

[40] “Social Determinants of Health,” Office of Disease Prevention and Health Promotion, https://tinyurl.com/z32yfnv.

[41] Nancy Mann Jackson, “Screening for social determinants,” Medical Economics, Feb. 21, 2020, https://tinyurl.com/ws7lzaa.

[42] Juan Pablo Segura and Kelly Leggett, “This is why we need to accelerate value-based care,” Medical Economics, Nov. 13, 2017, https://tinyurl.com/wk35luf.

[43] Susan Ladika, “Florida Blue to Address Big MA Enrollee Cost Driver: Loneliness,” Health Payer Specialist, Jan. 3, 2020, https://tinyurl.com/u623f7v.

[44] Bruce Japsen, “CVS Profits Rise As Health Hubs Open,” Forbes, Nov. 6, 2019, https://tinyurl.com/rufr7kx.

[45] Ladika, “Dr. Drugstore Will See You Now,” op. cit.

[46] Kodjak, op. cit.

[47] Murphy, op. cit.

[48] Susan Ladika, “A Telehealth Hookup: Hospitals and Retailers,” Managed Care, July 31, 2018, https://tinyurl.com/usymqd6.

[49] Stephanie Giambruno and A. Pawlowski, “Mental health clinic opens inside a Walmart in Texas,” Today, Nov. 28, 2018, https://tinyurl.com/vbp3n9o.

[50] “Health Care as a Human Right — Medicare for All,” Sen. Bernie Sanders, https://tinyurl.com/groz64m.

[51] Peter Sullivan, “Sanders under increasing pressure on funding for “Medicare for All,'” The Hill, Jan. 29, 2020, https://tinyurl.com/tkwomvw.

[52] “Health Care,” JoeBiden.com, https://tinyurl.com/yxskr7lu.

[53] Margot Sanger-Katz, “In Trump's Budget, Big Health Care Cuts but Few Details,” The New York Times, Feb. 10, 2020, https://tinyurl.com/urp5ndj.

[54] “Understanding Retail Clinic Patients,” Civis Analytics, 2018, https://tinyurl.com/tucaf5p.

©2022 CQ Press, An Imprint of SAGE Publishing. All Rights Reserved.

Page 18 of 19 The Health Care Industry CQ Researcher

[55] Landi, op. cit.; Abelson, op. cit.

About the Author Susan Ladika is a freelance writer in Tampa, Fla., whose work has appeared in Managed Care magazine, Health Payer Specialist by the Financial Times, HR Magazine, Bankrate.com and CreditCards.com. She previously worked as a writer and editor for newspapers in the Southeast, including The Tampa Tribune. She also has reported from Europe for The Associated Press.

©2022 CQ Press, An Imprint of SAGE Publishing. All Rights Reserved.

Page 19 of 19 The Health Care Industry CQ Researcher