Late last month, the American Academy of Pediatrics, the leading society for the nation's pediatricians, took aim at retail clinics. The academy didn't mince words in its policy statement, "AAP Principles Concerning Retail-Based Clinics":
"The American Academy of Pediatrics views retail-based clinics as an inappropriate source of primary care for pediatric patients, as they fragment medical care and are detrimental to the medical home concept of longitudinal and coordinated care."
In its press release, the lead author of the policy statement, James J. Laughlin, M.D., added, "The AAP recognizes that convenience and access to care will continue to be important drivers of how health care is delivered. However, the expertise of the pediatrician and the medical home should continue to be recognized as the standard for [the] care of children, and we encourage all AAP members to provide accessible hours and locations as part of a medical home."
On its website, AAP acknowledged the growing popularity of retail clinics, estimating 15 percent of U.S. children will be treated in one of the 1,600 retail clinics operated in this country today.
The issue is complex: pediatricians are not among the ranks of physicians whose incomes benefit from procedures and in-office testing, joint ventures with developers and special favor from hospitals and drug companies. Their earnings average less than half of most specialties. They have high overhead costs in their practices, challenging hours and demanding patients and families. And its trade group, the AAP, has been at the forefront of changes in the profession as an early advocate for team-based care and electronic health records and, most recently, the lead proponent for patient-centered medical homes as an alternative model in primary care. So the profession's battle with retail clinics must be contextualized around its longstanding commitment to accessible, affordable quality of care for children. That said, on this issue, they're wrong.
Retail clinics are a response to market demand not met by pediatricians and their counterparts in primary care. Retail clinic sponsors like Walgreens, CVS, Target, Kroger and others have faced relentless criticism from organized medicine in every state. Their major lines of attack have been two:
- Physicians believe that nurse practitioners and advanced practice nurses lack the training necessary to diagnose and treat patients accurately.
- Physicians challenge the clinical appropriateness of the retail clinic facilities, since most lack adequate privacy for patient counseling or dedicated restrooms for collecting/storing specimens.
But the growth of retail clinics has continued and will for the foreseeable future. The reason: Retail clinics meet a need with an innovative solution that most consumers, especially millennials, accept. The retail clinic business model and value proposition is built on six benefits:
- Convenience: Locations of retail clinics are close. Parking is accessible. Operating hours are longer. Getting in to see the nurse is quicker. And the pharmacy is only a few feet away.
- Safety: The trade group for retail clinics and the major players in the sector, including Walgreens, CVS and others, are sensitive to physician criticism about alleged quality and safety gaps in retail clinic care. They treat a dozen uncomplicated medical problems and refer others. They follow quality and safety protocols, measure outcomes, employ medical directors to review charts, and use electronic health record systems that provide front-line nurses with clinical decision support to assist in diagnosing and treating uncomplicated medical problems. As a result, retail clinics meet or exceed outcomes compared with local pediatric practices, and there are data to prove it.
- Cost: The cost to see the clinic nurse is $50–70; the cost to see a doctor in his or her office is $130–$175 under traditional insurance (with a co-pay of $20–30 in most cases). For patients in high-deductible insurance plans, the full cost of the visit is likely an out-of-pocket expense.
- Range of therapeutic remedies: Retail clinics allow pharmacists to participate in primary care — they're only 10 feet away. In turn, over-the-counter therapeutics are readily included in treatment plans in addition to or instead of drugs. Retail clinics incorporate OTC more readily than medical practices, often saving consumers time and money.
- Insurance coverage: Increasingly, retail clinics are covered by insurance plans that encourage their use. As high-deductible insurance replaces first-dollar coverage in employer-sponsored plans, and as individual insurance plans' enrollment increases, retail clinics will be a valuable alternative to traditional primary care.
- Satisfaction: Per Deloitte's consumer surveys, one in six in the population has used a retail clinic and they were satisfied. Seventy percent of these had a relationship with a local provider, but used the clinic instead. And two in five nonusers, and the majority of adults younger than 45, would use a retail clinic no qualms.
The lesson for pediatrics is this: Consumers respond to solid value propositions that meet their needs. Traditional pediatric care needs to upgrade its value proposition along the same dimensions as outlined. But there's a bigger story. Primary care is central to population health management programs and risk-based contracting the foundation on which health system transformation is rebuilding. Hospitals and health insurance companies are making big bets on capitation 2.0 in which primary care providers in teams will be the front door to revenues and conduits to contracts with individuals, employers and the government.
Retail clinics will play a key role as each sector calibrates its investments in retail health. It's a key element of a new primary care model that consumers want: dental, vision, nutritional and psychological assessment tools, therapeutic solutions and services blended with access to physicians and nurses. They want access to their own medical records, lab results and script refills without a required visit, and online tools that equip them to participate actively in their care with full knowledge of those costs before anything's done.
Retail clinics will be an important fixture in health care going forward. Pediatricians should rethink their opposition. They meet a need currently unmet. They are an innovative solution with a different business model and strong value proposition. And they might be the central feature in the patient centered medical home of the future.
P.S.: Here's an irony: I couldn't access the full text of the policy statement from the AAP website without paying $12 for a two-access pass to Pediatrics, the association's journal in which the statement was published. I could, however, access info about buying diapers and sinus infections and avoidance of antibiotics. I paid $12 to access the policy, but never received the download. So much for addressing the needs of consumers!
Paul H. Keckley is a health economist and leading expert on U.S. health reform and its impact. He recently retired as executive director for the Deloitte Center for Health Solutions, where he directed the center's nonpartisan studies that are prominently featured in congressional testimony and industry publications. His H&HN Daily column appears the first Monday of every month. He is a member of Health Forum's Speakers Express. For speaking opportunities, contact David Parlin.