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Retail Clinics and Drugstore Medicine Christine K. Cassel, MD

E ASY ACCESS TO MEDICAL CLINICS IN RETAIL SETTINGS is gaining momentum in the United States. While criticized in some quarters, these clinics are success- ful as measured by patient satisfaction and quality

scores. Retail clinics hold potential for a uniquely US solu- tion to the problem of access to primary care. Although ques- tions remain about their future, evidence suggests that re- tail clinics may have an important role in US health care.

Primary Care and the Current Health Care System Among the most important issues facing health care today are access to care, cost of care, and coordination of care. The first issue, access to care, has multiple features. If there is not full implementation of the Affordable Care Act, the num- ber of uninsured patients in the United States who cannot afford care will increase.1 In addition, the health care de- livery system is generally unable to provide patients access to timely information and to prompt clinician attention to problems in a timely and efficient manner. The shortage of primary care physicians in the United States has made ac- cess worse as many primary care physician panels are full, and few physicians offer open access scheduling. Some health problems are neglected while other health problems are treated in emergency departments or other high-cost set- tings where care is not personalized and is extremely ex- pensive—especially for simple problems. For a working per- son with a sudden onset of a febrile illness, the retail clinic provides a solution: that person can be seen quickly the day the problem arises and most often is able to receive a simple and straightforward evaluation and treatment or recom- mendation to seek specialist care if indicated.

Second, cost of care is a major concern of employers, fed- eral and state governments, and, most important, patients and consumers. The individual described above could get easy and timely access to care in a retail medical clinic and, if insured, would pay a small deductible or co-payment; if uninsured, the visit would be less than $100 and the pric- ing would be transparent. In contrast, the same minor prob- lem could cost hundreds of dollars for an emergency de- partment visit.

The third major challenge facing the US health care sys- tem is care coordination, especially for the large number of

patients with multiple chronic conditions, increasing as the population ages. These patients often receive care from mul- tiple specialists, with different recordkeeping systems, and few of those specialists interact in an ongoing way with the patient’s other physicians and clinicians in rehabilitation or nursing. Lack of coordination is thought to cost the health care system billions of dollars.2 To date this has not been a major area of expertise or availability of retail clinics but, as they consider a role in chronic care, it is coming into fo- cus. Indeed, chronic care plans are an increasingly impor- tant priority for retail health clinics.

For instance, an elderly woman with multiple chronic con- ditions, including diabetes and congestive heart failure, is not the type of patient usually thought of as ideal for re- ceiving care in a retail clinic. But with good communica- tion between multiple specialists, convenient access in eve- nings and on weekends, and familiarity with local community resources, the retail clinic potentially could be an impor- tant component of coordination of care aimed at reducing disease exacerbations, unnecessary hospitalizations, and ad- verse drug interactions. If this vision were realized, the re- tail clinic phenomenon could be transformative for a vast number of patients in the United States.

What Are Retail Clinics Doing and What Do They Promise? Retail clinics have existed in some form for more than a de- cade, but led by several retail pharmacy corporations, the number of clinics increased from about 200 in late 2006 to nearly 1200 by 2009.3 However, at that point, the rapid growth stopped as grocers, pharmacies, and mass merchan- disers sought to find the right model that would make the clinics reasonably profitable. While the current models vary, the clinics mainly are located in high-traffic retail stores, in- volve 1 or 2 mid-level practitioners (nurse practitioners or physician assistants), and have a limited scope of services defined by widely accepted treatment guidelines for acute illnesses.

Other elements of retail clinics demonstrate awareness of the needs of the health care system. Many have ex- tended hours and are open on weekends, have embraced

Author Affiliations: American Board of Internal Medicine, Philadelphia, Pennsyl- vania. Corresponding Author: Christine K. Cassel, MD, American Board of Internal Medi- cine, 510 Walnut St, Ste 1700, Philadelphia, PA 19106 ([email protected]).

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electronic medical records, and refer patients to a primary care physician if they do not have one. Recently, several ma- jor retail clinic chains have again increased the numbers of clinics—the per-clinic growth in patients seen for the or- ganizations has been greater than 20% per year, suggesting unmet demand.4 Today there are nearly 1400 retail clinics, with at least one company planning to build to 1000 clin- ics over 3 years.

The retail clinics have also attempted to evaluate quality of care. Research done by third parties has suggested that clin- ics provide equal-quality care and lower costs than other set- tings.5 Reported patient satisfaction is high.6 Some clinics are accredited by organizations like the Joint Commission and feature important innovations, such as 10% of charts being peer reviewed and 100% of patients being telephoned within 48 hours of being seen—common-sense steps that most primary care practices have not adopted. Effective decision sup- port and management tools appear to provide the right sig- nals about when to seek physician consultation.

Although there is a shortage of primary care physicians in the United States, less recognized is the importance of other health professionals as part of an effective team of care. The retail clinic is a site where first-line roles for advanced practice nurses and pharmacists have already been shown to be effective in managing acute uncomplicated condi- tions. Pharmacists’ skills are underutilized if they are lim- ited to their role in filling prescriptions—the so-called behind- the-counter functions. In effective teamwork approaches to chronic illness, exemplified by many models of geriatric care,7

the pharmacist is an active part of the health care team—in both the inpatient and outpatient settings. In a retail clinic with a pharmacy, clinical expertise is expanded by access to the pharmacist and the pharmacy database available in that setting. This same team, with active physician involve- ment, could provide the nidus for better management of more complex chronic illnesses.

A persistent question about the retail clinic phenom- enon is lack of integration with the rest of health care. With the primary care medical home seen as a promising solu- tion for better and lower-cost care, some see the patient at the retail clinic as homeless. The retail clinics are address- ing this in several ways. First, they maintain relationships with primary care practices and refer patients to them; this is important because up to 50% of patients seen cannot iden- tify a primary care clinician. Second, for patients who do have primary care physicians, most retail clinics fax or e-mail messages to the patient’s physician immediately after the visit. Third, several of the larger chains are now developing re- lationships with medical homes or accountable care orga- nizations, promoting integration through electronic medi- cal record communication. In this setting, the retail clinics become a virtual part of the medical home.

To meet their potential, retail clinics will need to ensure diagnostic and management capabilities, which requires elec- tronic support, accessible specialty expertise, and effective

teamwork to ensure appropriate “triage” of patients with complicated medical problems. Some critics are concerned about potential conflicts of interest in embedding clinical care in a commercial context in close proximity to a phar- macy where selling prescriptions and over-the-counter drugs is a major business line. These conflicts are inherent in many aspects of health care delivery. They can and should be man- aged by transparency, oversight, and payment incentives that reward value rather than volume.

The Future Role of the Retail Clinic What would it take for the retail clinic to have a greater role as an access point and coordinator of care in the frag- mented US health care system? First, the exchange of health information among medical specialists, hospitals, and per- haps accountable care organizations with the retail clinic will be critical. In this era of increasing aspirations for health information exchange this ought to be possible—and ap- pears to be beginning to take shape. Second, retail clinics need to become more ubiquitous. Almost every person in the United States could have a health care practitioner within just a few miles. If that practitioner could have access to that patient’s information through health information technol- ogy connectivity, full information about every patient could be available at every encounter to every relevant clinician.8

There are challenges, but this is happening already. The question is whether this phenomenon will grow and flour- ish in the ways described here or whether 20th-century at- titudes about physician and hospital dominance in health care will prevent market-based solutions to the health care access and cost crisis. This model is a challenge to medical and hospital leadership, as well as to leaders in the retail health clinic industry, as they pursue the potential oppor- tunities and benefits for the American people. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

REFERENCES

1. US Department of Commerce. Income, Poverty and Health Insurance Cover- age in the United States: 2010. Washington, DC: US Bureau of the Census; 2011. http://www.census.gov/prod/2011pubs/p60-239.pdf. Accessed May 1, 2012. 2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 3. Merchant Medicine website. http://www.merchantmedicine.com/home.cfm. Accessed May 1, 2012. 4. Ashwood JS, Reid RO, Setodji CM, Weber E, Gaynor M, Mehrotra A. Trends in retail clinic use among the commercially insured. Am J Manag Care. 2011; 17(11):e443-e448. 5. Mehrotra A, Liu H, Adams JL, et al. Comparing costs and quality of care at re- tail clinics with that of other medical settings for 3 common illnesses. Ann Intern Med. 2009;151(5):321-328. 6. Ahmed A, Fincham JE. Physician office vs retail clinic: patient preferences in care seeking for minor illnesses. Ann Fam Med. 2010;8(2):117-123. 7. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpa- tient medical care: a systematic review. Arch Intern Med. 2006;166(9):955- 964. 8. President’s Council of Advisors on Science and Technology. Report to the Presi- dent: Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward. Washington, DC: Executive Office of the President; 2010. Health Information Technology Report. http://www .whitehouse.gov/sites/default/files/microsites/ostp/pcast-health-it-report.pdf. Ac- cessed May 1, 2012.

VIEWPOINT

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