Plugging one crack in a health care system that is splintered with problems, retail health clinics – also known as convenient care clinics (CCCs) – are sprouting like mushrooms in malls, pharmacies, groceries and big-box stores all across the United States.

They are also squeezing into the list of health care provider options available to LIUNA members and their families, at least in some parts of the country. Yet, the rapid growth of the clinics, which are for-profit enterprises, raises caution among some health promotion advocates.

What is a CCC? 

Convenient care clinics are small storefronts or sections of larger commercial businesses that provide a menu of basic health services – at a price – to anyone who walks in for care.

In most cases, the clinics post their services and prices on a roster at each site. The information is also available online. Generally, services are basic, cost in the $40 to $60 range and, in many cases, are limited to adults. Examples include: sinus infections, strep throat (extra for a lab test), ear aches, pink eye, insect bites, poison ivy, lice, urinary and bladder infections, athlete’s foot, minor burns, wart removal, vaccinations, pregnancy testing, suture removal, vomiting and diarrhea, physicals, seasonal allergies, sunburn, abrasions and sprains.

The first retail clinic opened just seven years ago in Minneapolis. Today, about 400 operate nationwide, many in retail pharmacies such as Walgreens or CVS and others in groceries or big-box chains like Target. Some are stand-alone clinics in malls. The industry trade association – the Convenient Care Association (CCA) – estimates that 700 clinics will be operational by the end of 2007. By the end of 2008, that number will top 2000.

This explosive growth has attracted corporate buy-outs. In June, Walgreens bought Take Care Health Systems of Pennsylvania, keeping up with CVS which purchased Minneapolis-based MinuteClinic in 2006. Other chains, such as RediClinic, continue to operate independently.

Market Driven

According to analysts, CCC growth is fueled by cost and access problems in the nation’s larger health care system. Roughly 46 million Americans have no health insurance at all. They avoid health care until they absolutely need it; then they go to an emergency room where the cost is very high. For those with insurance, co-pays, deductibles and coverage gaps keep the overall cost high, and the limited office hours of primary care physicians sometimes make it difficult for working families to get care when they need it.

Retail clinics purport to solve both problems. On the one hand, they can be open as long as their local host facility, and evening and weekend hours are the norm. On the other hand, because of lower overhead, rates for the basic services they provide are less than a primary care physician and way less than the emergency room.

No appointment is required and the wait is often less than 15 minutes. As Fredric V. Christian, MD, former president of the Rhode Island Medical Society, wrote in 2006, “Let’s face it, [the retail clinic trend] has exposed an Achilles’ heel of office-based practice. There is an access problem. If there were not, care options such as MinuteClinic or similar counterparts would not be venturing in for-profit medicine.”

Part of the retail clinic business plan is a careful assessment of which services can be provided cheaply and profitably without the additional space, more elaborate equipment and staff of a doctor’s office. Already, the CCCs’ lower prices have attracted deals with major health insurers, including some which service LIUNA health and welfare plans.

Quality of Care Concerns

The danger in such deals, say health promotion advocates, is that they will lead patients into an even more pragmatic, catch-as-catch-can approach to their health. In New York – where one chain, RediClinic, recently signed an expansion deal with Reade Drug Stores – Dr. Jim Melius, LHSFNA’s Research Division Director and Administrator of the New York State Laborers’ Health and Safety Trust Fund says, “These clinics fill a role, but we should urge our members to have a primary care provider who knows their medical history and monitors their long-term condition and care.”

The American Association of Family Physicians (AAFP), whose members feel the pinch of CCC competition, expresses similar concerns but nevertheless is seeking avenues of collaboration with the new clinics. The AAFP has published a five-point list of “desired attributes” for retail clinics to guide its members in establishing clinic partnerships.

The CCA has developed its own set of quality and safety standards. These include:

  • Using electronic health records (EHRs) to ensure high-quality, efficient care.
  • Building relationships with traditional health care providers and hospitals and working toward the goal of using EHRs to share patient information to ensure continuity of care.
  • Encouraging patients to establish a relationship with a primary care provider and making appropriate referrals for follow-on care or care that is outside the scope of the clinic’s services.
  • Providing written instructions and educational materials to patients upon leaving the clinic.
  • Establishing emergency response procedures and developing relationships with local emergency response service providers to ensure necessary care for patients in emergency situations.
  • Monitoring quality on an ongoing basis including peer review, collaborating physician review, use of evidence-based guidelines, collecting aggregate data on selected quality and safety outcomes and collecting patient satisfaction data.

According to CCA Director Tine Hansen-Turton, most CCCs are staffed by nurse practitioners (NPs), who are authorized in 43 states to “practice independently or in remote collaboration with physicians.” In all states, NPs are authorized to write prescriptions and they can receive reimbursement for Medicare Part B services. For certification, most states require successful completion of a master’s program, but specific requirements vary by state. “Because of doctor shortages and the many problems of our health care system, most states have recognized the skills of nurse practitioners and physician assistants (PAs) and provided authorization for their delivery of services, without the need of direct physician supervision,” explains Hansen-Turton. However, she adds, “The lack of uniformity in the state ­­­definitions makes NPs vulnerable” to assertions by critics that the quality of care in retail clinics may be circumspect.

Adding to such concerns is the fact that patients, without scheduled appointments, are seen by whichever nurse or other health provider is on duty when they arrive. This may not be the same provider who checked them on their last visit, and he or she is unlikely to have access to the patient’s complete medical history. Actually, the situation is similar in emergency room visits. This suggests that the clinics – like ERs – may not be a good source of recurrent or continuing care.

Wary Support

An October 2005 online survey of 2,245 adults by the Wall Street Journal shows that the public has some ambivalence about the quality of care potential of retail clinics. Even in 2005, seven percent had used a retail clinic and were satisfied with the clinic’s convenience (92 percent), quality of care (89 percent), staff qualifications (88 percent) and cost (80 percent). Of the 93 percent who had not used a clinic, 41 percent said they were likely or somewhat likely to use one in the future. Yet, of everyone polled, 75 percent said they are worried that serious medical problems might be misdiagnosed at a clinic.

Like it or not, however, even discounting the CCC trend, the proportion of patients seeing non-physician providers is rising across the country. The AAFP reports that more NPs and PAs – independently or as part of a physician’s practice – provide primary care today than do family physicians. Projections indicate that the nation will have a shortage of 50,000 doctors by 2010 and 200,000 by 2020. The nation’s problems with the cost and accessibility of health care are mounting.

“We’re just starting to see retail clinics in our area, and the insurers are supporting them,” says Dennis Sarnowski, Administrator of the Laborers’ District Council of Western Pennsylvania Welfare Fund. Along with other LIUNA health and welfare fund administrators, he concedes that “they’re not yet well understood.” Whatever the quality and safety standards of the industry’s new trade association, the practice of incipient CCCs around the country may vary substantially. “As advocates for our members,” says Sarnowski, “we need to investigate their mission and philosophy, assess their treatment programs and then communicate any concerns to our members.”

Judging by CCA Director Hansen-Turton, clinic advocates welcome such investigation. Nevertheless, they say, the potential problem of misdiagnosis is overblown because the point of the clinics is neither the treatment of serious medical situations nor the provision of ongoing care. CCCs are more than willing to leave that to physicians while they focus on their menus of common, one-time, basic services offered at times and places convenient to working families. Effective, community-based referral systems and open lines of communication with local primary care providers also will help CCCs keep to their own niche while guiding patients toward a “medical home.” Moreover, as the CCCs acquire the capacity to access and augment electronic patient health records, the possibility of prescription mistakes due to allergies or drug conflicts will be further reduced.

Aetna, the insurer of the LIUNA staff health and welfare plan, already lists some CCCs among its provider options so Administrator Madonna N. Brennan has begun processing their fees. “These clinics fit a niche,” she says.   “If you’re on your way home from work and need to check a cough or sore throat, you can stop for a quick assessment without worrying about taking a sick day tomorrow to see your doctor. It’s cheaper than the emergency room and doesn’t run up against restrictions at the after-hours urgent care center. These clinics can also be useful if you have the sudden onset of a minor ailment while you’re traveling out-of-town.”

Judging by their accelerating growth in recent years, convenient care clinics appear to be here to stay.

[Steve Clark]