Health for Sale as Retail Clinics Expand in California

by Stephanie Stephens, California Healthline Regional Correspondent

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LOS ANGELES -- Consumers without a primary care doctor are increasingly visiting walk-in retail medical clinics for simple acute and preventive care, according to a new study.

Visits to retail clinics increased by fourfold nationwide from 2007 to 2009, according to a study released last week by the RAND Corporation. The retail health market appears to have "tapped into patients' needs," study authors said. Most care delivered by retail clinics was limited to common acute ailments -- such as upper respiratory or urinary tract infections -- as well as flu shots. The most common retail clinic patient was a young adult without a primary care physician.

In Los Angeles, CVS Caremark's walk-in medical clinic subsidiary, MinuteClinic, announced a new partnership with UCLA Health System last month. University physicians serve as medical directors for 11 clinics in the Los Angeles area staffed by nurse practitioners and physician assistants. The Los Angeles clinics -- all up and running -- specialize in family health care and wellness services. MinuteClinic launched its retail health business in 2000 and now operates 600 clinics nationwide. It accepts insurance, cash, checks and credit cards.

Considering the expected uptick in patient demand for primary care physicians as a result of the Affordable Care Act, the RAND study authors predict more business for retail clinics.

The County Health Rankings from the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute show just more than 11,000 primary care physicians for Los Angeles County's nearly 10 million residents.

That translates to 884 patients per primary care physician in Los Angeles County, slightly higher than the state average of 847 patients for each primary care doctor. California has more than twice as many primary care physicians per capita as the national average of 1,718 patients per PCP.

According to retail medical research and consulting firm Merchant Medicine, 1,363 retail clinics operate in 39 states. The company's CEO, Thomas Charland, counts 59 clinics in California, with very few in Southern California.

RiteAid has six Lindora Health Clinics in Los Angeles and Orange counties. The clinics are staffed with physicians and nurse practitioners, according to the company's website.  

According to Charland, Safeway is building more than 100 retail clinics in its California stores. "Based on one of the building permits we reviewed online, which listed the clinic at 399 square feet, we anticipate that retail clinics will open inside Safeway stores this fall," he wrote on his website.

"I have no idea how they will announce or how they will approach it -- maybe form an LLP or a medical corporation they operate themselves," Charland told California Healthline. "Their CEO [Steven Burd] is very progressive about health care for employees."

Safeway did not respond to requests for comment.

Getting Used to Retail Health

The cost of treatment in a retail setting generally is lower for consumers than it is in a freestanding clinic. Further, unlike freestanding clinics, patients seeking care at retail clinics generally do not need to make an appointment, and retail clinics are open on evenings and weekends.

"You can't walk into a retail store for something off the shelf -- you have to pay for it. And it's the same with health care," said Charland. Most clinics post a menu of services and prices in the clinics and online. That transparency is an attractive feature, according to some retail clinic proponents.  

"It's a very difficult business to make money at," Charland said. "It's highly seasonal, and most of the people who come to retail have illness that's upper respiratory in nature -- January, February and March."

Although some people associate retail clinics with a lower-income, uninsured demographic, Charland said that's usually not the case.

"You won't find retail clinics in poor areas or the inner city," he said. The typical customer is a dual-income, upper-income, well-educated parent with kids living at home, according to Charland. More than half use health insurance.

"They tend to self-diagnose and understand that the condition they have isn't rocket science and can be treated quickly. That's good, since they may need to get to soccer practice or a parent meeting," Charland said.

A Team Approach

As health care professionals look to form new alliances, there's a place for retail, Charland said. "What is changing would have changed with or without ObamaCare, and that's the formation of accountable care organizations, narrow networks and essentially a focus on partnerships. What's going to change for retail clinics is their part in those and how they operate within a certain scope of service that fits exact specifications -- just as an urgent care does," Charland said.

Steven Green, president of the California Academy of Family Physicians, agreed, noting that clinics are but one more element of team-based care or the patient-centered medical home.

"One concern I have with retail clinics is when people come for treatment of an acute problem. It's certainly convenient, and I can see why it's attractive," Green said. "It's also a lost opportunity, for had the patient seen a regular family physician, that doctor may have checked to see if they were due for preventive screens -- colon or cervical cancer, mammogram -- while looking at the bigger picture."

Clinics present both a challenge and opportunity for family physicians, he said, since patients need access to care delivery at the community level, and providers need access to patients' health records to stay on top of preventive care needs.

"Some fragmentation is seen now, as a nurse practitioner may not really know the full history," he said. "It's far preferable to a person going to the emergency room for a non-serious illness, though. They're better served in a retail clinic."

Practicing More Medicine

"The demographic spectrum of retail clinics will broaden, and we'll see boarder acceptance of nurse practitioners as providers," said Charland.

Nurse practitioners welcome new opportunities, said Beth Haney of Yorba Linda, president of the California Association for Nurse Practitioners.

"Nurse practitioners are well positioned to do more, especially with the influx of millions of patients in California's health care system in the next 24 months," she said. "If the scope of problems and illnesses that come into a clinic are expanded to more chronic care or complex cases, NPs handle those every day in their own practices."

The American College of Nurse Practitioners defines NPs as registered nurses who are prepared, through advanced education and clinical training, to provide a wide range of preventive and acute health care services to individuals of all ages.

In California, NPs work with a doctor and under a document known as "standardized procedures," Haney said. "Those delineate what we can and can't do."

A patient's thorough health history is incrementally important, and an NP would still obtain that. "We're very cognizant and refer as needed," she said.

The RAND study found that fewer than 1% of visits to retail clinics through 2009 were for chronic disease care.

As long as retail clinics aren't the only source of patient care, and aren't a substitute for primary care, they're a potentially positive development for the health care system in general, said Dylan Roby, director of the Health Economics and Evaluation Research Program at the UCLA Center for Health Policy Research.

"If it's a serious situation, a nurse practitioner can refer someone to an urgent care clinic or request they see their primary care physician for a follow-up," he said.

Consumer advocates agree there is a place for retail clinics in California's health system.

"It would be better if someone went to a place that had their medical records and was able to put the issue in the context of their medical history," said Anthony Wright, executive director of Health Access California.

"Retail clinics have the same oversight and regulations as any other form of health care. They're not the ultimate solution to issues in our health care system and are not a replacement for having coverage or for access to a primary care doctor. They do fill a gap but may be more of a 'Band-Aid' for the broader issues."


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