Portal de Periódicos da CAPES

Retail Clinics: A Shift From Episodic Acute Care to Partners in Coordinated Care

2015; Elsevier BV; Volume: 129; Issue: 2 Linguagem: Inglês

10.1016/j.amjmed.2015.08.019

1555-7162

James E. Dalen,

Patient Satisfaction in Healthcare

The first retail clinic, offering care for common acute medical conditions, opened in a grocery store in Minneapolis in 2000.1Spetz J. Parente S.T. Town R.J. et al.Scope-of-practice laws for nurse practitioners limit cost savings that can be achieved in retail clinics.Health Aff (Milwood). 2013; 32: 1977-1984Crossref PubMed Scopus (54) Google Scholar By 2015 there were 1900 retail clinics in the United States.2Iglehart J.K. The expansion of retail clinics—corporate titans vs. organized medicine.N Engl J Med. 2015; 373: 301-303Crossref PubMed Scopus (11) Google Scholar Some have estimated that there will be 3000 retail clinics located in drug stores, grocery stores, and “big box” businesses in 2016.3Robert Wood Johnson Foundation. Growing retail clinic industry employs, empowers nurse practitioners. Available at: www.rwjf.org/en/library/articles-and-news/2015/02/growing-retail-clinic-industry-employs–;empowers-nurse-practitio.html. Accessed August 10, 2014.Google Scholar The majority are operated by 2 drug store chains: CVS (MinuteClinics) and Walgreens (Take Care Clinics).4Rudavsky R. Pollack C.E. Mehrotra A. The geographic distribution, ownership, prices, and scope of practice at retail clinics.Ann Intern Med. 2009; 151: 315-320Crossref PubMed Scopus (74) Google Scholar Retail clinics are responding to a market failure in the United States: the lack of a rapid, convenient access for patients with minor medical problems, especially at night, and on weekends. They are designed to treat a limited number of common acute conditions. Upper respiratory infections (rhino sinusitis, pharyngitis, and ear infections) account for 61% of visits, and vaccinations or preventive examinations 22%.5Weinick R.M. Burns R.M. Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics.Health Aff (Milwood). 2010; 29: 1630-1636Crossref PubMed Scopus (318) Google Scholar The top 10 diagnoses account for 90% of all visits.6Mehrotra A. Wang M.C. Lave J.R. et al.Retail clinics, primary care physicians, and emergency departments: A comparison of patients' visits.Health Aff (Milwood). 2008; 27: 1272-1282Crossref PubMed Scopus (131) Google Scholar Each of these conditions has widely accepted treatment guidelines, and they do not require follow-up visits. Treatment is by nurse practitioners or physician assistants. Patients with conditions that fall outside their scope of practice (less than 5% of visits) of care are referred to a physician office or an emergency room.6Mehrotra A. Wang M.C. Lave J.R. et al.Retail clinics, primary care physicians, and emergency departments: A comparison of patients' visits.Health Aff (Milwood). 2008; 27: 1272-1282Crossref PubMed Scopus (131) Google Scholar The patients tend to be young (aged 18-44 years6Mehrotra A. Wang M.C. Lave J.R. et al.Retail clinics, primary care physicians, and emergency departments: A comparison of patients' visits.Health Aff (Milwood). 2008; 27: 1272-1282Crossref PubMed Scopus (131) Google Scholar), more women than men,6Mehrotra A. Wang M.C. Lave J.R. et al.Retail clinics, primary care physicians, and emergency departments: A comparison of patients' visits.Health Aff (Milwood). 2008; 27: 1272-1282Crossref PubMed Scopus (131) Google Scholar and 20%-30% are uninsured.5Weinick R.M. Burns R.M. Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics.Health Aff (Milwood). 2010; 29: 1630-1636Crossref PubMed Scopus (318) Google Scholar, 7Mehrotra A. Lave J.R. Visits to retail clinics grew fourfold from 2007 to 2009, although their share of visits remains low.Health Aff (Milwood). 2012; 31: 2123-2129Crossref PubMed Scopus (57) Google Scholar Thirty percent to 60% do not have a primary care physician.6Mehrotra A. Wang M.C. Lave J.R. et al.Retail clinics, primary care physicians, and emergency departments: A comparison of patients' visits.Health Aff (Milwood). 2008; 27: 1272-1282Crossref PubMed Scopus (131) Google Scholar, 7Mehrotra A. Lave J.R. Visits to retail clinics grew fourfold from 2007 to 2009, although their share of visits remains low.Health Aff (Milwood). 2012; 31: 2123-2129Crossref PubMed Scopus (57) Google Scholar, 8Laws M. Scott M.K. The emergence of retail-based clinics in the United States: Early observations.Health Aff (Milwood). 2008; 27: 1293-1298Crossref PubMed Scopus (43) Google Scholar, 9Cassel C. Retail clinics and drugstore medicine.JAMA. 2012; 307: 2151-2152Crossref PubMed Scopus (27) Google Scholar The number one reason is convenience. Appointments are not needed; one does not have to miss work or school. These clinics are easily accessible and are open after hours and on weekends. The American Academy of Family Physicians (AAFP) reports that family practice physicians offer convenient care.10American Academy of PediatricsAAP principles concerning retail-based clinics.Pediatrics. 2014; 133: e794-e797Crossref PubMed Scopus (14) Google Scholar The American Academy of Pediatrics (AAP) encourages all AAP members to provide accessible hours and locations as part of a medical home.11American Academy of Family Practice. Retail clinics. Available at: www.aafp.org/about/policies/all/retail-clinics.html. Accessed August 10, 2014.Google Scholar Despite these observations by the family physicians (AAFP) and pediatricians (AAP), nearly half of all visits to retail clinics are made when physicians' offices are closed.7Mehrotra A. Lave J.R. Visits to retail clinics grew fourfold from 2007 to 2009, although their share of visits remains low.Health Aff (Milwood). 2012; 31: 2123-2129Crossref PubMed Scopus (57) Google Scholar One third of the US population lives within a 10-minute drive of a retail clinic.3Robert Wood Johnson Foundation. Growing retail clinic industry employs, empowers nurse practitioners. Available at: www.rwjf.org/en/library/articles-and-news/2015/02/growing-retail-clinic-industry-employs–;empowers-nurse-practitio.html. Accessed August 10, 2014.Google Scholar Most clinics offer free parking. Prescriptions can be filled on site. The charges are transparent, easy to understand, and cheaper than other providers. Medicare, Medicaid, and private insurance are accepted. Patient satisfaction is as high as 90%.8Laws M. Scott M.K. The emergence of retail-based clinics in the United States: Early observations.Health Aff (Milwood). 2008; 27: 1293-1298Crossref PubMed Scopus (43) Google Scholar The AAP10American Academy of PediatricsAAP principles concerning retail-based clinics.Pediatrics. 2014; 133: e794-e797Crossref PubMed Scopus (14) Google Scholar and the American Academy of Family Practice11American Academy of Family Practice. Retail clinics. Available at: www.aafp.org/about/policies/all/retail-clinics.html. Accessed August 10, 2014.Google Scholar have expressed concerns that these clinics provide lower quality of care. The AAP has formally opposed retail clinic care for children.10American Academy of PediatricsAAP principles concerning retail-based clinics.Pediatrics. 2014; 133: e794-e797Crossref PubMed Scopus (14) Google Scholar There is no evidence that care by nurse practitioners is of low quality. Many studies have documented the clinical performance of nurse practitioners.12Chang J.E. Brundage S.C. Chokshi D.A. Convenient ambulatory care—promise, pitfalls, and policy.N Engl J Med. 2015; 373: 382-387Crossref PubMed Scopus (27) Google Scholar, 13Iglehart J.K. Expanding the role of advanced nurse practitioners—risks and rewards.N Engl J Med. 2013; 368: 1935-1941Crossref PubMed Scopus (97) Google Scholar Mehrotra et al14Mehrotra A. Hangsheng L. Adams J.L. et al.Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses.Ann Intern Med. 2009; 151: 321-328Crossref PubMed Scopus (212) Google Scholar compared the care for 3 common conditions (otitis media, pharyngitis, and urinary tract infections) in retail clinics, physician offices, urgent care, and emergency departments. They examined 14 quality indicators. There were no differences in quality among these 4 sources of care. The most frequent criticism is that retail clinics fragment care, interrupt continuity of care, and lack coordination with the rest of health care.11American Academy of Family Practice. Retail clinics. Available at: www.aafp.org/about/policies/all/retail-clinics.html. Accessed August 10, 2014.Google Scholar, 15Pollack C.E. Gidengil C. Mehrotra A. The growth of retail clinics and the medical home: Two trends in concert or in conflict?.Health Aff (Milwood). 2010; 29: 998-1003Crossref PubMed Scopus (31) Google Scholar, 16Garbutt J.M. Mandrell K.M. Allen M. et al.Parents' experiences with pediatric care at retail clinics.JAMA Pediatr. 2013; 167: 845-850Crossref PubMed Scopus (16) Google Scholar As noted, 30%-60% of retail clinic patients do not have a primary care provider,6Mehrotra A. Wang M.C. Lave J.R. et al.Retail clinics, primary care physicians, and emergency departments: A comparison of patients' visits.Health Aff (Milwood). 2008; 27: 1272-1282Crossref PubMed Scopus (131) Google Scholar, 7Mehrotra A. Lave J.R. Visits to retail clinics grew fourfold from 2007 to 2009, although their share of visits remains low.Health Aff (Milwood). 2012; 31: 2123-2129Crossref PubMed Scopus (57) Google Scholar, 8Laws M. Scott M.K. The emergence of retail-based clinics in the United States: Early observations.Health Aff (Milwood). 2008; 27: 1293-1298Crossref PubMed Scopus (43) Google Scholar, 9Cassel C. Retail clinics and drugstore medicine.JAMA. 2012; 307: 2151-2152Crossref PubMed Scopus (27) Google Scholar making coordination of care problematic. Some clinics have effective relationships with local primary care providers. Electronic medical records permit transmission of records to a patient's primary care provider if the patient agrees. An increasing number of retail clinics have developed affiliations with hospitals or health care systems. These affiliations vary considerably; some are true partnerships where the clinic staff may be employees of the health system. Physicians at the health care system may have oversight of care at the retail clinic. The clinic and the health care system may share the medical record. Some affiliations are much less comprehensive. The affiliation of retail clinics with health care systems has led to a much wider scope of practice at some retail clinics. Many now care for and manage patients with chronic conditions, such as hypertension, diabetes, and asthma, with oversight by physicians at the health care system. In this model the retail clinic can become an extension of medical homes, by providing ongoing care at convenient sites outside the hospital. CVS—which has 1000 retail clinics (MinuteClinics) in 31 states in 201517McCluskey PD, Luna T. Walk-in clinics force big medicine to rethink. Available at: www.bostonglobe.com/business/2015/08/07/walk-clinics-are-forcing-big-medicine-rethink-retail-health-care/DUdP4usrTuVA2AIiJJfUHJ/story.html. Accessed August 10, 2014.Google Scholar —has affiliations with more than 50 health care organizations, including the Cleveland Clinic,18Monegain B. Cleveland clinic partners with minute clinic, links EMRs. Healthcare IT News, February 13, 2009Google Scholar, 19PRNewswire. MinuteClinic forms clinical collaboration with Cleveland Clinic Florida. Available at: www.prnewswire.com/news-releases/minuteclinic-forms-clinical-collaboration-with-cleveland-clinic-florida-123543574.html. Accessed August 12, 2015.Google Scholar the Henry Ford Health System,20Henry Ford Health System. CVS Caremark MinuteClinic and HFHS announce clinical affiliation. Available at: www.henryford.com/body.cfm?id=46335&;action=detail&ref=1421. Accessed August 10, 2014.Google Scholar and more recently Kaiser Permanente.21Lauer G. Kaiser-Target partnership another step in retailization of health care. California Healthline, November 24, 2014Google Scholar The Cleveland Clinic has had partnerships with multiple CVS Minute Clinics since 2009.18Monegain B. Cleveland clinic partners with minute clinic, links EMRs. Healthcare IT News, February 13, 2009Google Scholar In 2011, Cleveland Clinic Florida began collaboration with 12 CVS Minute Clinics.19PRNewswire. MinuteClinic forms clinical collaboration with Cleveland Clinic Florida. Available at: www.prnewswire.com/news-releases/minuteclinic-forms-clinical-collaboration-with-cleveland-clinic-florida-123543574.html. Accessed August 12, 2015.Google Scholar The clinics are staffed by MinuteClinic nurse practitioners; Cleveland Clinic family practitioners provide clinical consultation. Medical records are integrated. These clinics manage patients with chronic conditions, as well as treating acute medical problems. The CVS affiliation with Henry Ford began in 2011.20Henry Ford Health System. CVS Caremark MinuteClinic and HFHS announce clinical affiliation. Available at: www.henryford.com/body.cfm?id=46335&;action=detail&ref=1421. Accessed August 10, 2014.Google Scholar Henry Ford provides 5 medical directors for 10 MinuteClinics in southeast Michigan. Nurse practitioners can consult Henry Ford physicians. Medical records will be merged. Ford refers patients to MinuteClinics for after-hours care. The clinics with Ford physician oversight will manage certain chronic diseases. Walgreens had 400 “Take Care” acute care retail clinics in 20 states in 2013.22Stempniak M. Retail clinics: Threat or opportunity?. Health and Health Networks, October 1, 2013Google Scholar Walgreens leases space in their facility to a clinic operator—usually a health system. They are staffed by nurse practitioners or physician assistants and treat patients with acute conditions. Recently Walgreens has aligned with health systems, including the Ochsner Health system in New Orleans and the Community Health Network in Indianapolis. These affiliations will allow an expansion of the clinic's scope of practice to include management of chronic diseases. It also will facilitate scheduling of follow-up appointments, consults, and tests at their affiliated institutions.22Stempniak M. Retail clinics: Threat or opportunity?. Health and Health Networks, October 1, 2013Google Scholar Walmart has 100 retail clinics (Clinic at Walmart) across the country, mostly in rural areas. The clinics are leased and operated by health systems. They offer acute care, with a limited scope of services. They encourage patients to get continuing care elsewhere.23Abrams R. In ambitious bid, Walmart seeks foothold in primary care services. Available at: http://www.nytimes.com/2014/08/08/business/in-ambitious-bid-walmart-seeks-foothold-in-primary-care-services.html?_r=0. Accessed August 10, 2014.Google Scholar Walmart recently opened 5 primary care clinics (Walmart Care Clinics) in South Carolina and Texas. Walmart owns and controls these clinics. Walmart sets the scope of services.21Lauer G. Kaiser-Target partnership another step in retailization of health care. California Healthline, November 24, 2014Google Scholar These clinics offer chronic disease management. Quadmed (which has experience in operating employer on-site clinics) is joining with Walmart to help staff and run these clinics.21Lauer G. Kaiser-Target partnership another step in retailization of health care. California Healthline, November 24, 2014Google Scholar Each primary care clinic has a supervisory physician who oversees compliance and prescription orders at 1 or 2 clinics, but they do not treat patients. These clinics charge $40 per visit; employees/dependents who are covered by Walmart insurance will pay $4 per visit. These Walmart primary care clinics are not affiliated with a health care organization. If these clinics are successful, Walmart will offer many more, especially in rural locations where physicians are scarce.23Abrams R. In ambitious bid, Walmart seeks foothold in primary care services. Available at: http://www.nytimes.com/2014/08/08/business/in-ambitious-bid-walmart-seeks-foothold-in-primary-care-services.html?_r=0. Accessed August 10, 2014.Google Scholar Kaiser Permanente has recently opened multifunctional clinics inside Target stores in Southern California.21Lauer G. Kaiser-Target partnership another step in retailization of health care. California Healthline, November 24, 2014Google Scholar The clinics are staffed by Kaiser nurse practitioners and are overseen by Kaiser physicians. Laboratory tests will be available on site. The nurse practitioners and patients can consult Kaiser physicians via telemedicine. Electronic health records and video conferencing facilitate specialty consults. The scope of practice at these clinics includes pediatrics, gynecology services, chronic conditions, and all the usual acute care and vaccination services.21Lauer G. Kaiser-Target partnership another step in retailization of health care. California Healthline, November 24, 2014Google Scholar The clinics are open 70 hours per week; services are available to members and nonmembers of Kaiser, and the average charge to nonmembers is $75 per visit. Target is selling its clinic business to CVS, so these clinics will become CVS Minute Clinics.24News Observer. Target selling pharmacy, clinic businesses to CVS health. Available at: www.newsobserver.com/news/business/article24394669.html. Accessed August 10, 2014.Google Scholar These new collaborations such as with Henry Ford and Kaiser Permanente have a dramatic impact on the role of retail clinics. Many are shifting from offering episodic acute care to becoming an integral part of health care systems offering continuing coordinated care. Patients in the health system benefit by receiving some of their coordinated care from the health care organization at a retail clinic close to their home at their convenience. The retail clinic has shifted from contributing to fragmentation of care to the possibility of becoming partners with medical homes to offer coordinated care.