SAN DIEGO -- With millions of newly insured patients expected to tax an already short supply of primary care physicians, retail clinics may play a significant role in California's new health care landscape, according to health care experts.
The growth of retail clinics is fostering new partnerships and in some cases new forms of cooperation rather than -- or in addition to -- competition.
San Diego's Sharp HealthCare and MinuteClinic, the retail health care division of drug store chain CVS Caremark, have teamed up to expand primary care access around San Diego.
The move is partly in anticipation of full implementation of the Affordable Care Act on Jan. 1, 2014.
"The reason we have things like MinuteClinic coming up is that it's filling a need," said Steven Green, who is on the board of directors for Sharp Rees-Stealy, one of Sharp HealthCare's medical group affiliates. Green coordinates medical directors providing clinical oversight of the San Diego-based MinuteClinics. "Maintaining good access is always one of our challenges and a priority. There's no question if there is a big influx of patients there will be a challenge [to meet the need]," he said.
That challenge has begun to shift hospital and primary care perceptions of retail clinics from rivals to possible partners who can help extend the care continuum and manage patient volume. Benefits of arrangements like the one forged between Sharp and CVS, which was signed in April and scheduled to start this summer, cuts both ways, said Jill Dailey, a managing director with the consulting firm Accenture.
"As the retail clinics have expanded in terms of their geographic footprint, they want to drive up their volumes, and a great way to do that is to forge relationships with local hospital systems or with physician practices that might want to send patients for lower-acuity issues to the retail clinics," she said.
Dailey said some hospitals around the U.S. -- particularly those at or beyond capacity -- also are proactively looking to establish new relationships to better serve people who are newly insured because of the ACA, as well as to meet the needs of a growing aging population. "They're interested in looking at other models to move some of the lower-acuity, lower-reimbursement level services into a retail clinic," Dailey said.
San Diego's Medical Community Offers Reserved Support
Few health care professionals argue that increased access to care is a problem, but the relationship forged between these two health care giants has left some in the San Diego medical community a bit uneasy.
Theodore Mazer, communications director for the San Diego County Medical Society, said he's concerned about consumer awareness for retail clinic patients.
"Are they being properly educated that they have an option of where to go and that they're not being brought into a network that they are unwittingly participating in?" Mazer asked.
According to Nancy Gagliano, MinuteClinic's chief medical officer, the answer to that question is an unequivocal yes.
"Our affiliations are important, but we believe that we are an important component of access in the entire community and we make sure patients who come to see us who are not Sharp members get the exact same care and coordination back to their primary care physician. Anyone who comes to our practice with a primary care physician always gets a visit summary with patient approval," she said.
According to Gagliano, 50% of current MinuteClinic patients don't have a primary care physician. Upon leaving a clinic in San Diego, each unaffiliated patient will be given a list of doctors accepting new patients in the area regardless of the physician's affiliation. Sharp HealthCare providers, she said, will not get preferential treatment when it comes to referrals.
Mazer said there are also concerns about how this partnership plays into the debate taking place in California over the ability of non-physician clinicians to practice independently. A set of bills (SB 491, SB 492 and SB 493) authored by Sen. Ed Hernandez (D-West Covina) would expand the scope of practice for nurse practitioners, optometrists and pharmacists to address the physician shortage.
The bills were approved by the state Senate Business, Professions and Economic Development Committee and sent on to the Senate Appropriations Committee.
"There's a tremendous battle right now in the state of California over independent practice of non-physicians doing primary care medicine," Mazer said. "The Minute Clinics, the retail clinics in general, are lending more credence as a screen that says, well, we don't have a doctor here, we have nurse practitioners, and we practice primary care medicine. In California they're still doing that under the supervision of the physician. The fact that Sharp is giving sort of credence to this, I think they need to tread very carefully," Mazer said.
Both Green and Gagliano contend, however, that there's no veiled attempt to push the issue of independent practice by non-physicians.
Gagliano, who is a primary care physician by training, said she "and the rest of the organization are very committed to the primary care physician-led medical home model."
The fact is, she said, "one of the underlying problems is that there is a primary care shortage, and I think as a country we have to have solutions to make sure we have enough access for patients.
"Our model is to have nurse practitioners work within the extent of their license, and 100% to get the patient back to their primary care physicians."
Poised for Growth
Rapid growth is expected in retail health clinics located in pharmacies and retail chains. That was the conclusion of a recent report by Accenture that anticipates expansion at a rate of 25% to 30% per year between now and 2015, thereby doubling the number of retail clinics to a total of 2,868 nationwide.
Staffed by nurse practitioners and physician assistants, retail clinics offer expanded hours of operation compared with typical primary care physician' offices and can treat a range of health issues from strep throat to common infections, minor wounds, abrasions and joint sprains. They administer common vaccinations and screen for and monitor diabetes, high blood pressure and high cholesterol, among other conditions.
And patients appreciate what retail clinics have to offer. A 2012 study by the Santa Monica-based Rand Corporation found a fourfold increase in visits to retail clinics nationally between 2007 and 2009, largely due to their convenience, accessible hours and low cost, which averages about $78 per visit.
The rate of growth slowed in the following years, according to the Accenture report, but is expected to pick up once again. Dailey explains the temporary slowdown as a result of three primary factors:
- Friction with the provider community;
- Aneed to fine-tune retail clinic staffing models and uncertainty over the future:
- Impact of the Affordable Care Act in 2010 and 2011.
"There are a lot of people out there who either want the convenience [of a clinic] that they can easily get to in their own neighborhood or those without a doctor where a clinic like this will make it easier for them to get certain common conditions cared for," Green said.
The Accenture report predicted the growing number of retail health clinics would create $800 million savings annually in overall healthcare expenditures by 2015 and add capacity for 10.8 million patient visits per year nationally.
The expanded access and lower cost associated with care delivered at retail clinics has gotten the attention of insurers, too. Increasingly, health plans are including retail and other walk-in clinics in their networks.
More than 60 health insurers contract with CVS MinuteClinics in California. "Eighty five percent of the patients we see are seen under insurance," Gagliano said.
In addition, the company contracts with six Medicaid plans in Southern California. "We're committed to working with Medicaid in every state," Gagliano said, responding to concerns about access for the growing Medicaid population expected in California once the health reform law takes full effect.
Despite predictions, no one yet knows how health reform and the increase in the insured population will affect access to care. Policymakers, insurers, providers and consumers agree that with a rapidly changing health care environment everyone must be open to new models. Health care experts generally agree that retail clinics are among a number of alternatives for dealing with increased demand for primary care.
"Most physicians who just don't lambast the idea of retail clinics as encroachment would much rather see an organized means of dealing with those clinics and doing the right thing for the patient. I think they would be fine with that," Mazer said.