One of the many forces changing the landscape of the American healthcare today is the retail health clinic. Located in pharmacies and discount stores and sporting catchy slogans such as "You're Sick, We're Quick," in-store clinics are quickly sprouting throughout the country, providing a fast and convenient way for patients to obtain medical care.

But while patients are giving high marks to facilities such as Minute Clinic—which boasts a 93% satisfaction rating among its clients—many primary care physicians are understandably skeptical about this new mode of healthcare delivery, while others worry about the long-term implications to their profession.

Could this new phenomenon offer some solutions that will enhance rather than pose a threat to the future of primary care?

Retailing Healthcare
The idea behind in-store clinics was born out of the realization that, as Americans are being asked to pay more out of pocket for medical care, they will begin to approach these purchases with more of a shopper's eye. Proponents believe that these clinics can help reduce the inappropriate use of emergency departments for basic services. And for the uninsured and underinsured, retail clinics offer an alternative way to access primary care services.

Mary Kate Scott, author of "Health Care in the Express Lane: The Emergence of Retail Clinics," commissioned by the California HealthCare Foundation, says the number of such clinics is projected to grow from 330 today to 1500 by the end of 2008.

"Retail clinics have been around for about 5 or 6 years, but it's really only been in the last 12 to 18 months that they've gotten significant traction," Ms Scott, CEO of Scott & Company, a healthcare consulting firm, and adjunct professor at the University of Southern California's Marshall School of Business, tells IMWR.

Unlike the "doc-in-the-box" concept that was popular in the 1980s, which "in essence almost replicated a primary care physician's office," Ms Scott says, the retail clinic is much smaller, "it is almost always serviced by the nurse practitioner, and the economics are very different."

The 2 kinds of in-store health clinics are independently run clinics and healthcare-provider–affiliated. The top 4 independent operators are Minute Clinic, RediClinic, Take Care Health Systems, and The Little Clinic. The largest healthcare–provider affiliated clinics are Aurora QuickCare, AtlantiCare, Sutter Express Care, and Memorial Health System's MedPoint Express (see Table at www.imwr.com).

Founded in 2000, Minute Clinic has become the largest provider of retail-based healthcare in the United States and is the first to achieve accreditation from the Joint Commission on Accreditation of Healthcare Organizations.

Should You Worry?
Minute Clinic Chief Medical Officer Jim Woodburn, MD, MS, tells IMWR that, "We in no way are trying to replace primary care. We have, by our definition and by our physical facility, no way that we can care for patients in primary care."

So, if retail clinics are not trying to replace primary care, what do they provide? "We're here to provide an adjunct to care when patients can't get in to see their doctor or don't have a doctor," Dr Woodburn says. "We're no different from an emergency room or an urgent-care facility."

Retail clinics typically provide treatment for minor conditions (eg, pharyngitis; bronchitis; and ear, eye, sinus, and bladder infections), administer vaccinations, and perform screening tests. Most are staffed by a nurse practitioner or a physician assistant. Visits take approximately 15 minutes, and patients with significant or unusual concerns are referred to outside physicians. Prices are posted on menu boards and range from $49 to $150. Many insurance companies now cover visits to these clinics, with the same copay as an office visit. Some physicians have expressed concerns about continuity of care, especially among patients with chronic conditions.

Dr Woodburn stresses that Minute Clinic supports the idea of a medical home in several ways, such as by asking every patient who their doctor is and providing a list of local doctors to patients who do not have one. "We say to them, ‘We think it is important for you to have a medical home…because we will care for you today, but everybody needs to have someone who can take care of them for tomorrow and for the future."

As for continuity of care, Ms Scott explains that one of the first things retail clinics do when they enter a new market is to try to establish a good relationship with local primary care physicians.

And many clinics incorporated electronic patient records from the get-go. This has allowed them to put safeguards in place (such as tracking repeat visits) that trigger an alert if a serious medical condition is suspected. "Let's say you visit a Minute Clinic or RediClinic 4 times in 1 year with strep throat. They immediately say, ‘There may be something much more serious here, and you need to go see a primary care physician. You are no longer a candidate for this retail clinic,'" Ms Scott says.

Discussing concerns about quality and fragmentation of care, Richard Bohmer, MD, MPH, senior lecturer in business administration at Harvard Business School, writes that "these drawbacks have thus far remained theoretical" (N Engl J Med. 2007; 356:765-768).

Dr Bohmer points out that retail clinics have "worked to maintain good relationships with local primary care practitioners, some have software that searches for patterns of repeated presentations, and the strict reliance on evidence-based protocols should prevent overservicing."

Wave of the Future?
Are retail clinics the wave of the future? "Absolutely. Without doubt there are going to be thousands, and with that it's critical for [physicians] to adapt to it," Dr Woodburn says emphatically.

"I believe…primary care physicians are going to do what they're best at, which is complex, chronic, longitudinal care focused around chronic disease and behavior-change counseling. Physicians are overtrained to take care of simple, uncomplicated conjunctivitis, and as a result of that overtraining, they're too expensive," he says.

Over the past 6 months, he has seen a positive change in the way primary care physicians are responding. Retail clinics are working to be seen by primary care physicians as an opportunity, not a threat, Dr Woodburn adds. "The biggest thing is communicating who we are and what we do.…So if you don't like us, at least you know what you don't like for specific reasons."

He outlines ways for physicians to take advantage of the services these clinics offer. "If you want to close your office at 5 pm, but you want to please your patient base, then, if it's after hours, and it's a urinary tract infection, send it to us. We'll bounce them right back. Use us as an outlet."

Physicians who are looking to build their practice can also benefit. "We can refer patients who don't have an attached medical home, and we're happy to do that. And if you treat them right, and the patients are pleased with the referral, that makes us look good and builds your practice," he reasons.

Wake-Up Call
In their current form, observes Dr Bohmer, "It is unlikely that [in-store clinics] will usurp the core business of primary care practitioners."

However, Ms Scott says, "This is a good wake-up call for physicians. Someone came along and said, ‘We're going to offer something that's going to resonate with consumers.' And it's been a long time since a physician has either had the opportunity or the inclination to say, ‘What will resonate with my patients?'"

While retail clinics are not a "big force" yet, she notes, primary care physicians need to recognize that these clinics represent new, smart patients who are making choices about their basic healthcare needs.

Dr Woodburn concurs. "What if you can walk right in to your CVS store that has a Minute Clinic, and 90% of the time you're seen immediately. You park 20 feet away. You walk right in. If you need an antibiotic, you can go wherever you wish. But it's sure convenient—you're in and out in 30 minutes or less. That just feels right. That is the gap we are there to fill," he says.

ONLINE EXTRA
Most Patients Satisfied with Retail Health Clinics
The number of retail clinics has grown over the past 2 years, and a recent survey suggests that about 5% of US adults have visited these types of clinics. At a time when many patients are concerned about the costs and quality of healthcare, the majority of those who have used in-store clinics say that they are satisfied with the quality of care, cost, and convenience of these clinics (Table).

An online survey conducted by Harris Interactive between March 20 and 22, 2007 for The Wall Street Journal Online's Health Industry Edition included a national crosssection of 2441 US adults (aged ≥18 years).

Some 44% of those who use in-store health clinics had done so to receive a vaccination, while 33% received treatment for a common medical condition, like an ear infection, cold, strep throat, skin rash, or sinus infection. Retail clinics are being used by both insured and uninsured patients. About 1 in 5 individuals (22%) was uninsured, and about 4 in 10 (42%) were reimbursed by a health insurer for some or all of the fees they paid.

The percentage of individuals that has used retail clinics has not grown significantly (7% in 2005 vs 5% in 2007), but patients' concerns about these clinics have declined. Compared with 2 years ago, surveyed adults were less concerned about the qualifications of the staff (71% in 2005 vs 64% in 2007) or their ability to accurately diagnose serious medical problems (75% in 2005 vs 68% in 2007). Most of those who use these clinics say they are very or somewhat satisfied with all of the following: quality of care (90%), having qualified staff to provide care (85%), cost (80%), and convenience (83%).