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Retail Healthcare Update: Disrupting Traditional Care by Focusing on Patient Needs

Matthew Driver

Authors:

Kush C. Gaur, M.D. Candidate 20201, Mona Sobhani, Ph.D1., and Leslie A. Saxon, M.D.1*

1 USC Center for Body Computing, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

Abstract

Entry of retailers into the healthcare space has grown in recent years, especially the prevalence of health clinics in retail stores. Although patients initially reported wariness in using and trusting retail health clinics, usage among patients has increased and they report satisfaction with the care received. Here, we discuss how patient satisfaction is likely attributable to how retail health clinics are built around patient needs and preferences, which include shorter wait times, transparent pricing, and convenience. This model of patient care has never been executed before. Attitudes toward retail health clinics from traditional care providers are also discussed.  Lastly, we review the key players in the retail health clinic space, their current offerings, and suggest potential future directions.

Keywords

Retail healthcare, Pharmacies, Digital health, Healthcare model, Public health,

Introduction

Over the past 18 years, the medical care delivered in clinics located in retail stores has matured, and the number of clinics providing care has expanded. These retail clinics, more broadly known as convenient care clinics, currently focus on simpler acute conditions and preventive care. Currently there are more than 2700 convenient care clinics operating in 44 states and Washington D.C., which have had more than 40 million patient visits to date 1. Financial analysts are bullish on the $1.4B market 2, with some projecting that $200 billion will flow from traditional medical venues into alternative ones like retail clinics and remote care 3. But who is using this type of healthcare, what does it look like, and has it been accepted by the medical community?

Consumers are becoming more familiar with the concept of retail healthcare and more open to receive healthcare services from non-traditional health providers, thereby stirring the growth of these retail health clinics. A recent survey reported that 70% of consumers are now familiar with retail health, and 79% of those found the experience the “same or better” than a traditional site. Those that are less likely to use the service are not yet comfortable or trusting of its services 3.

Acceptance by patients is likely due to retail clinics representing a healthcare delivery model focused and built around the needs of the patient as a consumer. These needs were outlined in a healthcare consumer report 4 which identified “personalized healthcare” as a top priority, including a partnered and engaged physician-patient relationship, with increased face-to-face time. Other priorities included economic transparency in coverage and care prices, convenience of care (defined as minimal wait times and same day appointments), and access to digitally-enabled tools and services such as mobile applications and telemedicine services. Retail health clinics address many of these consumer priorities that some traditional practices may not offer. They provide a bevy of benefits including locally-based and immediate care, lower and transparent costs, shorter wait times, and direct access to medications.

For a typical visit, patients can make a guaranteed same-day appointment with a nurse practitioner or physician assistant and receive a list of medical conditions treated by the clinic with a pre-designated treatment price. A typical visit lasts about 15 minutes, and patients are discharged with a treatment protocol and/or a prescription, and sometimes even guidance to seek further care at a traditional site. In addition to the easier, faster, and more transparent healthcare, the location of these health clinics within retail stores allows convenient access to health products and food, creating an all-in-one experience for the patient. These consumer-facing advantages have fueled growth 5 and satisfaction, with some patients rating the experience at retail health clinics better than traditional sites.

Who are those using these clinics? Multiple studies have found that most visits are from younger adults, between the ages of about 18 to 44 3,6, but that usage by older patients has also risen from 8% to 15% in recent years7. In addition, women use the clinics more than men. A study conducted by Blue Cross Blue Shield (“The Health of America Report – Retail Clinic Visits Increase Despite Use Lagging Among Individually Insured Americans,” 2017) on 60 million of its commercially-insured members found that young adults visit retail health clinics almost three times as much as older patients, and women use the clinics 72% more than men. Other heavy users of these clinics include minority families and families with children 9.

Only one-third of retail health consumers state they have a primary care physician, meaning about 60% don’t have a primary touchpoint for healthcare 5. And generally, regardless of consumer income, these patients are less likely to have insurance 10. It is important to note that these retail consumers without primary physicians would otherwise receive care in Emergency Departments (ED), urgent care centers, or not receive care at all 11.

Traditional care provider attitudes toward retail health clinics

Since their inception, retail health clinics have received pushback from traditional providers and physician organizations, including The American Academy of Family Physicians (AAFP), American Medical Association (AMA), American College of Physicians (ACP), and the American Academy of Pediatrics (AAP). Although the pushback seems to be slightly retreating, there is still wariness that retail clinics cause fragmentation of care and hinder the concept of longitudinal and coordinated care delivery. The AAFP 12 and ACP 13 oppose expansion of services provided by retail health clinics beyond minor acute illnesses, and oppose their management of chronic medical conditions. The AMA 14 expressed similar views in their 2017 Delegate Report 15. They believe retail health clinics should help patients locate a primary care physician, use a structured referral system, coordinate information with physicians, and have a local physician as a medical director. Although these concerns are valid, it is important to note that many of these consumers don’t have a PCP to begin with. Retail clinics may actually increase access to care and patient engagement.

Another concern is that the quality of care is subpar, which is unfounded. The scope of practice allows retail providers to follow treatment guidelines 5 and, in some cases, provide better care 16 than that received in a primary care physician or ED visit. Studies also reveal comparable outcomes between nurse practitioners and medical doctors, which addresses concerns about quality of care from non-physicians 17. Conditions treated at retail clinics are conducive to standardized treatment protocols thus allowing replication and scalability across multiple site, with high quality of care.

Proponents of retail healthcare believe that retail health clinics can help fill the gap of care created by the lack of doctors. A shortage of 12,500 to 31,100 PCPs is projected by 2025 18. There is actually evidence to suggest that retail health clinics will drive growth of PCP practices because retail care will expand the base of patients treated, and identify those that require referrals for chronic care 2, and if the number of referrals increase, the AMA is correct in pushing for retail clinics to have a structured referral system.

Some healthcare organizations, such as Kaiser Permanente, do not view retail health clinics with hostility, but rather as an opportunity 19. After a successful pilot program in four Target clinics, Kaiser is expanding to 31 new clinics in Targets across Southern California. CVS will provide administrative support in these clinics, while the care will be provided by Kaiser NPs and telemedicine. This move allows them to expand their brand and their reach without significantly investing in infrastructure itself. This retail-centered approach for traditional hospitals has not been popular, though. Only a few hospitals are using retail sales for long-term financial revenue creation 20. This CVS-Kaiser partnership also highlights how retail health clinics have utilized the backend of traditional modalities to further the care of their patients. It is an important example of how health system affiliations may use retail clinics as an extension of its primary care services rather than a replacement. With further points of access, it could actually diminish care fragmentation. CVS, for instance, has developed over 70 health system affiliations 21.

Cost of providing care

For all patients, regardless of their relationship to traditional clinics and physician directed care, retail clinics provide a more cost-effective option. Prices average between $50-60 per visit, which is 30-40% less expensive than a doctor’s office visit and 80% less expensive than an ED visit 22. These prices are displayed upfront to provide as much cost transparency, and most accept commercial insurance, Medicare, Medicaid, or cash. More employers are starting to cover retail services in their health plans 23, increasing the number of visits to retail clinics (“Retail Clinic Visits Increase Despite Use Lagging Among Individually Insured Americans,” 2017). Blue Cross Blue Shield found a 19% higher utilization of retail health clinics among individuals with employer health coverage versus individually-insured members, highlighting the impact of such partnerships (“Retail Clinic Visits Increase Despite Use Lagging Among Individually Insured Americans,” 2017).

The most common reasons for visiting retail clinics are for preventative care and simple acute conditions that include upper respiratory infections, sinusitis, immunizations, and blood tests 5. These same conditions account for 18% of PCP visits and 12% of ED visits, which could be diverted to retail clinics. One study estimates that between 13.7% to 27.1% of all ED visits can be treated at a retail clinic or urgent care center 24. This could lead to a potential savings of $4.4 billion. However, recent reports cite evidence of increased overall health care spending 25 and no reduction in number of ED visits for these low-acuity issues related to retail health clinic utilization 26. This may be because many retail patients are accessing health care for the first time at a retail clinic, not substituting a retail visit for what would otherwise be an ED visit. There may have been some limitations to the study, but we must continue to monitor and perform further research.

The players

CVS (MinuteClinics) and Walgreens (Healthcare Clinics) make up almost three-quarters of the market, followed by Kroger, Walmart, and Rite Aid 27.

Of these five retailers, CVS is the clear leader with more than 1100 clinics in 33 states 28. They have a vast network of about 70 health system partnerships 28, including the VA 29 and Cleveland Clinic 30, that allow for consultations and referrals. CVS is also becoming a destination for workplace health. They now partner with Alere 31, a manufacturer of point-of-care diagnostic tests. Businesses that utilize the Alere eScreen service for occupational health screening (i.e. biometric screenings, physicals, drug testing) can now be serviced at any MinuteClinic.  More recently, CVS has further expanded their focus on convenient care by launching a clinical trial for an at-home dialysis device they developed32.

In addition to these partnerships, CVS has made large acquisitions, bringing Target 33 clinics and Aetna insurance into their ecosystem 34,35. This CVS-Aetna merger combines one of the largest pharmacy benefit managers with one of the largest health care insurers, possibly allowing for more services at more affordable prices for both minor conditions and chronic illnesses. They envision better chronic disease management by providing disease, lifestyle, and medication counseling all in one place. The combined merger could also provide employers a one-stop shop for health insurance and care for their workers.

CVS may be the largest, but the other retailers have their own distinguishing factors 27. Walgreens focuses on coordinated care, and provides mental health services and clinical trials information 36. Kroger engages dieticians and biometric screening for weight counseling 27. RediClinic, within Rite Aid and HEB grocery outlets, provide medication adherence services.

Walmart has taken a slightly different approach, marketing themselves as a primary medical provider. They also own the retail health clinic spaces, rather than leasing to outside providers 37. These clinics diagnose and treat both acute and chronic illnesses, and provide preventative services like health screenings. Additionally, employees and their dependents who are covered under the Walmart health plan, can be treated for as low as $4 37. The biggest limitation is their reach, with only 19 clinics in 3 states currently (George, South Carolina, and Texas).

Most recently, Amazon.com, the online retail giant, has made large strides to enter the health and healthcare spheres. In June 2017, Amazon acquired Whole Foods, an upscale healthy grocery outlet, for just under $14B 38. Then in January 2018, they announced a partnership with Berkshire Hathaway and JPMorgan Chase to create a healthcare company to address rising costs of healthcare for their US employees 39, and hinted at what is to come by launching a pilot to build clinics for its employees40. Most relevant to retail care, in June 2018 they acquired PillPack, an online pharmacy start-up, for about $1B 41. Each of these announcements shocked the respective industries. In the case of the PillPack news, stocks of Walgreens, Rite Aid, and CVS plummeted 42. Whether their ventures succeed is still uncertain, but it is a clear indicator of more outsiders encroaching the healthcare industry with hopes to change healthcare consumerism.

With changes and acquisitions between insurers, pharmacy managers, retailers, and hospitals, the lines between these traditional health models are becoming increasingly blurry.

Retail digital health offerings

The benefits of digital and software solutions for medical care include seamless integration and increased communication to supplement in-person retail care 43. Utilization of digital applications in healthcare has risen 4, and if implemented with a patient-centered approach, can be used to service the top three previously reported consumer priorities: creating more personalized care, at more manageable prices, with greater convenience.

Some retail clinics, particularly CVS and Walgreens, have developed mobile applications for easy access of care and resources through the phone, tablet, or computer. The offerings include monitoring wait times, making appointments, tracking and refilling prescriptions, and providing medication adherence services. CVS has also partnered with a social services-focused software maker, Unite Us, to launch a tool for connecting Aetna plan members to social services 44.  These digital health services, however, can be greatly expanded to incorporate continuous data streams from wearables and other health applications.

To further expand reach, telehealth is now an option for some retailers. MinuteClinic patients in Ohio and West Virginia are offered online and mobile visits with Cleveland Clinic physicians through the American Well telehealth provider 30. CVS has also piloted Teladoc and Doctor on Demand 21. Walgreens offers live consultations with a physician (MDLive), dermatologist (DermatologistOnCall), pharmacist, or therapist (MDLive) over mobile chat or video call. They have most recently collaborated with New York-Presbyterian to implement NYP OnDemand 45, a digital health suite of services. NYP OnDemand Urgent Care kiosks will be placed in private and secure rooms in certain stores, and will offer an instant high-definition video-conference examination with a Weill Cornell Medicine emergency physician.

As more clinics join forces with larger health systems, healthcare IT implementation is incredibly important. A solid infrastructure will allow crosstalk between the retail health clinics and local, regional, or national health systems, thereby promoting continuity of care for patients. This would address one of the major concerns of physician groups, which is fragmentation of care. CVS 28 and Walgreens 46 have already invested in the Epic EHR system, which provides an interoperability feature. With EHRs in place, retailers would be able to provide guidance between their retail clinics and traditional sites to create a network of multiple healthcare touchpoints, and thus a broader care team with greater scope of practice 47.

What’s next

As retail health clinics become an increasingly important part of the healthcare ecosystem, it will be important for them to continue their evolution.  We list a few recommendations below for retailers as they move forward.

Digital Health: As outlined above, some retailers are taking steps to provide alternative ways to access care. These are a start, but retailers should further expand the menu of digital options. EHR systems and network integration should be a necessary first step. Related to this network implementation, cybersecurity considerations and contingency plans must be a top priority, as patient data hacks become more common 48,49.

More Partnerships: Forging more relationships and collaborations with health systems and local physicians is extremely important 50. A larger network provides more options for patients, providing improved access to a coordinated effort of clinical support, medication counseling, and overall wellness. Consumers are significantly more likely to want to use a retail clinic if there is a partnership with a local healthcare provider 3, and this would quell critics from the traditional medical care establishment, including physician groups. It can increase access, improve care management, expand convenient care, and provide a direct access to advanced care if needed.

Chronic Care: Currently, the focus of retail clinics has been on more acute conditions, but there have been measured steps into chronic conditions as well. Walgreen’s was the first retailer to treat chronic conditions in 2013, and since then certain retailers have dabbled in chronic care management 51.

Many healthcare organizations have clearly stated that retail clinics are not built for such chronic care management. When retail health was in its early stages, these concerns were valid, but now that retailers have expanded and evolved, chronic care should be the natural next step. Consumers seem to be ready as well. A study conducted by Deloitte found that 68% of consumers were interested in visiting a retail clinic for chronic care management 47. These clinics can serve as a safety net for all patients with chronic conditions, both for those that have no current primary care and those that are being managed but may find it difficult to follow-up with care. Creating greater access for both populations can lead to better adherence to treatment and prevent complications of these complex chronic conditions, thereby helping alleviate healthcare expenditures. It is estimated that 90% of the nation’s $3.3T in annual healthcare expenditures are for people with chronic and mental health conditions 52.

Serve the Underserved: Currently, the majority of clinics are in higher-income and suburban settings 26. Only 12.5% are in medically underserved areas7. Retail clinics have a great opportunity to increase care in these underserved parts of the country. Through partnerships with local health providers they can have an important impact on care delivery.

 

Declarations

Acknowledgements: None.

Conflicting Interest: The authors declare no personal, professional, or financial conflicts of interest.

Funding: This work is independently supported.

Ethical approval: None required.

Guarantor: LS

Author Contributions: KG, MS, and LS conceived and developed the analysis framework for this review.  KG did the bulk of the research, with MS supplementing with academic research findings.  KG, MS, and LS wrote the manuscript, contributed to manuscript revision, read, and approved the submitted version.

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