Quick, low cost care attracts customers to retail clinics

Nurse and busy mom-on-the-go Georgette Oosting, 31, doesn't get sick often, but when she does, you won't find her in the doctor's office. Instead, the Angie's List member of Midland Park, N.J., goes to MinuteClinic in CVS/pharmacy — one of about 450 MinuteClinics and 1,200 total retail health care clinics in more than 30 states nationwide that treat minor illnesses and injuries.

She's gone there for everything from strep throat to a urinary tract infection. "It's fast, easy and they're open the weird hours we can go," says Oosting, whose husband Rudi recently got a flu shot at the clinic. The couple's $30 copay is the same whether they visit a clinic, urgent care center or family doctor's office.

As the health care market broadens, people seeking medical treatment are increasingly more likely to have these three options, and the ER, close at hand. While 87 percent of respondents to an online Angie's List poll say they go to the doctor's office most often when health issues arise — "to ensure I get top-notch care," says member Teri Pote of Alexandria, Va. — 28 percent, including Pote, say they've visited a retail clinic.

Growth in the retail clinic sector has slowed in recent years, with some clinics shuttered. But the industry that took root in 2000 looks poised for another wave of expansion that could redefine its role in primary care.

Apart from convenience, many consumers choose retail clinics, primarily operated by CVS/pharmacy and Walgreens, because of cost. According to a 2009 study published in the Annals of Internal Medicine and led by Dr. Ateev Mehrotra, a researcher with RAND Corp., retail clinics treated three common conditions — sore throat, earache and urinary tract infection — for substantially lower average costs than urgent care centers, primary care providers or emergency rooms.

The costs reflect differences in plan reimbursement levels, which account for everything from doctors' salaries compared with nurse practitioners and physician assistants who generally staff retail clinics, to expensive diagnostic equipment. "Our main goal in the ER is to rule out life-threatening emergencies," says Dr. Anthony Cardillo, an emergency physician at highly rated Glendale Adventist Medical Center in Glendale, Calif. "That can lead to exhaustive work-ups."

Besides a lower sticker price upfront, which is attractive to those without insurance and millions more with high deductible plans, retail clinics are increasingly covered by insurers. Copays vary but are often comparable to other primary care settings, typically $10 to $30; a copay for the emergency department can range from $50 to $200 — an attempt to dissuade people from going to the ER for non-emergency problems, says Dr. Bruce Hochstadt of New York-based human resources and benefits consulting firm Mercer.

There are other reasons retail clinics are forecasting increased traffic. Because of an insurance mandate in the new health care law, about 32 million more people are expected to get health insurance by 2014. "There's going to be more demand [and at least initially] the same number of docs," Mehrotra says. That's expected to push people to alternative care settings.

Mehrotra's research also shows that retail clinics are comparable to urgent care centers and physicians' offices on measures of quality and fare better than emergency departments. His team reached these conclusions after examining 14 quality indicators, such as what kind of tests were ordered and what drugs were prescribed. They determined that one in five visits to a doctor and one in 10 to an ER could be handled by a retail clinic.

Beyond just treating ear infections and other common ailments, many retail clinics are now expanding their offerings to include injections for osteoporosis; diabetes monitoring, including blood glucose checks; and other chronic disease management. Hospital systems are moving to open convenient care clinics inside Walmart stores in smaller and larger markets. Rural areas represent a new frontier for the sector where options for primary care are often limited, says Tom Charland, an analyst who heads the Shoreview, Minn.,-based consulting and research firm Merchant Medicine.

"It's almost like the retail clinics are going to come out of the closet and say 'We're willing to be your medical home,'" Charland says. He believes they'll stop short of offering all services a primary care doctor would, in part, because their business model is built around speedy service — the top reason respondents to our poll say they go to retail clinics.

Still, some patients are already treating the clinics as an adjunct medical home in place of the family doctor. About 40 percent of those who visit retail clinics don't have a primary care doctor, according to Tine Hansen-Turton, executive director of the Convenient Care Association, a trade organization.

This concerns physician groups that say medical problems could be missed without an ongoing relationship with a primary care provider, or if patients regularly bypass the doctor's office in favor of a retail clinic. "You put a lot pressure on the patient to determine what level of care they need," says Dr. Roland A. Goertz, president of the American Academy of Family Physicians.

Georgette goes to an ob-gyn annually, but neither she nor Rudi has a family doctor. "Sometimes I wish we had a regular doctor who really knew us," Georgette says, but she doesn't see it as a pressing need. "I guess when we're old and need lots of medicine, we'll go."

MinuteClinic practitioners give patients who don't have a primary care doctor a list of doctors in their area accepting new patients. Practitioners provide the doctors of those who do with a visit summary. "We're not trying to displace the primary care provider, but really be complementary," says Paulette Thabault, chief nurse practitioner officer for MinuteClinic, which is headquartered in Woonsocket, R.I.

Still, member Lisa Kearns of Monroe, N.C., says it's worth paying her plan's higher $30 copay to go to a retail clinic or urgent care center versus $15 to see a primary care doctor. Given long waits for primary care physicians in the past, she's taken a particularly stark position: "Unless it were something serious like H1N1, I would never go to a regular doctor's office."

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Quickhealth in San Mateo is great! It is located at 9 West 41st Ave. at El Camino Real in San Mateo. I have gone there when I needed a TB test for preschool teaching, when I needed primary care and didn't have health insurance etc.

I am a nurse of 39 years experience. I have been a Professional Paramedic, and have taught in a medical school as a full time Advanced Cardiac Life Support Instructor for 5 of those years. I have spent 20 years part time and full time in an emergency department, and my last ten years have been as a Nurse Practitioner after taking 5 years part time to obtain my Masters Degree as an Adult Care ARNP. The organized medical community has tried to expose the nurse practitioner (NP) as dysfunctional for many years. That all ended when the American Medical Association fostered a research program which was to once and for all confirm that the nurse practitioner could not replace the primary care physician as the gate keeper to medicine's specialties. Prior to this research there were about 47 similar research programs that were conducted on a much smaller scale. Of these programs at least 40 had already indicated that the statistics were in the nurse practitioner's favor. This was to be the definitive study. When the results came back the AMA was not going to publish them, until they were forced to by the American Nurses Association who threatened a lawsuit. The results can be found in the January 2000 issue of the Journal of the American Medical Association (JAMA). It was an overwhelming vindication of the concept that the nurse practitioner was able to function in this role, and over the last ten years many physicians have brought on these physician extenders to make their practice more functional, and more profitable. The AMA has stopped its previous antithesis to the NP and brought them in with open arms. They can now prescribe even schedule drugs in all but 2 of the 50 united states. During those ten years the NP now has to be Nationally Certified, and their competence is even more assured then it was when this research was conducted. There is no assurance that an individual NP will be as competent as you might want them to be, but the mechanism of their education and certification is in conjunction with the physician you might depend on blindly, only to find that he too is relatively incompetent. Statistics hold that about 10 percent of physicians are incompetent, even if they have not been removed from the role. I have seen both. Twenty percent of NP's never go on to practice as they seem to have difficulty making the transition from nurse to physician extender. This is why a independent organization like Angie's List has finally made the choice of physician's and NP's less of a guessing game and more of a science. If you have had trouble with either of these two entities I would suggest you express it here, as that privilege is now yours.

Most doctors are not in on the weekend,I get a recorded message to call back on Monday,if you are sick and need care you have 2 choices,emergency room or retail clinic...emergency room for me is 125.00 co pay.

As an NP in a retail clinic (having also worked in primary care and in a local ER), I feel the quality of care I give at my retail clinic is solid and evidence-based - the same way it was when I worked in other settings. I do have to disagree with other comments on here: a protocol for treatment does exist, but we're encouraged to use our own clinical judgment as well. And we *do* have medical directors available for consultation by phone. There are limitations on the conditions we're allowed to treat as some conditions (headache, for example) could be "just" a headache, or the could by just a symptom of something much, much more serious. We are encouraged to send patients either to their primary care provider, urgent care, or the ER depending on the situation if the patient's condition (or just their clinical presentation) are outside our scope of practice. In fact, we'll make the phone call to the patient's primary care office to arrange an appointment, or call to let urgent care or the ER know to expect our patient. I'd say I call 911 about once a week as people do definitely come to us for conditions that need emergency treatment. (And if a patient doesn't have a primary care provider, we always give them a list of care providers in the area that are accepting new patients - every patient *does* need a medical home. If a patient already has a PCP we fax that PCP's office a copy of the patient's chart from their visit so the PCP is aware of the care the patient sought and received.) Also, we get no bonus or incentive for sending prescriptions to one pharmacy or another - it's entirely the patient choice, although in the interest of saving a patient money, if their prescription is on a $4 list or a free list at a different pharmacy than the one they usually go do, I'll inform them of that fact - but they still get to go wherever they want. We provide a service to our patients and most leave very satisfied with their care. We're not meant to replace a PCP, but we have no control over patients' decisions on whether they see us or their own provider. Hope this helps to clear things up a bit.

As an NP in a retail clinic and also a busy urgent care/family practice. I see top quality, patient centered care in both locations. Emergencies occur in both practices and our guidelines are the same for both, call 911. I am so fortunate to work for such incredibly professional, top quality practices.

Traveling a lot, I like "clinics." However, at one to simply get a bandage changed, they inflated the exam, charging me over $350 for a $25 procedure. Buyer Beware.

There are pluses and minuses for using Retail clinics. First, the qualifications of the people staffing it and diagnosing patients. Second, you more often than not get what you pay for. Third, I can't think of a single MD that would be supportive of this concept. Why? Always boils down to money in the end. Money to pay for overhead, malpractice ins, staffing, supplies, billing etc etc. I think Urgent or Prompt Cares are safer and more appropriate than Retail locations that do not have an MD immediately available. I am an RN myself and I don't consider myself to be "dumb" but you would be surprised at the number of true emergency situations arrive on the doorstep of an Urgent Care - magnify that by a Retail clinic in a CVS or Walgreens or wherever else such places pop up. Don't ever forget non MDs are simply following their established "protocols" and nothing else. People rarely "fit" into such a neat tidy category. There is something to be said for having an MD look at the whole picture including medication interactions and the like. Your next Retail store trip could well end up costing you $$ out of pocket as you find yourself having to go to see an MD or an ER. MDs are admittedly per their intensive training lose their social/interactive skills. They carry massive debt from their education let alone any specialty certs they may have. If you feel your reg MD treats you like a number and only has 5 min or so of face time with you, time to look around for someone else. If you live in a large city, there's plenty of choice. If you want real top-of-the-line service and can afford it, look into a Concierge practice.

I had a bad experience at a care clinic in Walgreens. The nurse practitioner took my blood pressure with my arm dangling down and with the cuff over a long sleeved sweater and then alarmed me by saying it was way too high and I would have to go to the emergency room. At the ER I was informed that my B P was slightly elevated but nowhere near the stroke caategory. I was given an antibiotic for bronchitis and sinus infection. It cost quite a bit more at the ER on top os the fact that the Walgreens was a couple of blocks as compared to miles for the ER.

The advantage of a primary care doctor is that he/she gets to know you after a few visits. The retail clinics, however, are good for routine care such as for ear infections or tetanus shots.

I am a nurse practitioner who works in a retail clinic. I have practiced in a private primary care setting as well as community care setting. So I have some background when I discuss what retail clinics can do and not do. What I like about the retail clinic setting is that the patient can be treated for a common illness with no waiting or very little time waiting. The quality of service is just as good as any in private primary care setting. Our clinics are certified by the same national accrediting agency that inspects hospitals and other clinics for safety, efficiency, confidentiality as well as quality. We have quality control measures in house to ensure quality care to our patients. Retail clinics are a new avenue for people to attain convenient quality healthcare at reasonable prices. We accept most major insurances. When someone does not have insurance, our basic fees are quite affordable. I can give you story after story about patients who say we are as good if not better than their primary care doctor but that would be perceived as being biased. I would encourage anyone to visit a retail clinic and find out what we can offer to someone who needs medical care.

I understand the savings you can get my going to a retail clinic, but I think many of us don't have one close at hand, even in major metropolitan areas. Too bad there are not more around.

Thanks for that link, Greg. It confirms my earlier research, that there are no 'close at hand' clinics anywhere near me. I got a flier from my health insurance company, urging me to consider low-cost retail clinics. I live in Hayward, CA, a city of 150,000 with no retail clinic. I would have to drive on the freeway several cities down to get to the closest one.

I have found that I receive more thorough care at the local Zoomcare clinic, over a regular physician. I went there for my physical, and a cough that I had, and they gave me the full workup. Very convenient, cheaper, and paperless at that. My regular doctor always hurried through, ready to get on to the next appointment. I never felt actually cared for when I left.

What about continuity of care? These clinics do not know you as a patient, only a diagnosis.

I agree that the fast clinics are filling a niche, but I have several serious concerns about them. As a healthcare provider myself, I see many patients come back to us for care after misdiagnosis or (more often) undertreatment at one of the various minute clinics. It is clear to me the providers at those clinics are following algorithms and protocols, and not always good clinical judgment. I have nothing against NPs and PAs (I am a PA myself!), but good medicine does not go by a cookbook; it takes into account multiple factors for each patient, even for something as "simple" as a sore throat or urinary tract infection. And clearly, those based at pharmacies are under pressure to NEVER use anything but generic medications. I try my best at all times to do the same, but if the best thing for a patient is a non-generic, I will find a way for them to get what they really need. As for "faster"- I have heard more than a few stories of people being told that the wait at one of those clinics is 2-3 hours. A provider, no matter how fast, can only see one patient at a time. Every system has its limits. This was an imbalanced article, in my opinion. In my primary care practice, we can get a sick patient in for an acute problem within 24 hours, and almost always, the very same day they call. I completely agree that using these clinics for "simple" problems is much better than going to the ER. but there are more "cons" to this trend than you explored in your article.

As a primary care pediatrician we spent 7-10 years in training pay office overheads and high malpractice stay late at work and answer our own calls at no charge, Why anyone would go to a walk in clinic to see a PA or nurse practitioner with no physician back up is totally scary to me. Let alone the vested interest they have in prescribing -where this is not always in the best interest of the patient. We are open longer hours - take calls day and night and attempt to give excellent care. We feel totally undermined by these clinics and tell our patients /parents the same. this is not progress

The experiences I have had with "Urgent Care" clinics was not all positive. There is something to be said for continuity of care in that your regular GP or NP or whomever you normally sees, knows you personally, and knows your history whereas this is like getting a 5-minute health assessment, not always enough to know what is actually going on. I have seen a lot of guesswork diagnosis and free-flowing antibiotics to give this a resounding thumbs up. I have a strong medical background myself and I am very proactive on care, but sometimes your doctor does know best.

Michael Schroeder wrote: "As the health care market broadens, people seeking medical treatment are increasingly more likely to have these three options, and the ER, close at hand. " We agree emphatically - but finding those "close at hand" options with conventional search tools, like Google, Yahoo! or Bing, can be difficult. That's why we created Healthcare 311 -- http://www.healthcare311.com, a free clinics locator utility.

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