Retail Clinics: A Promise Made Is a Promise Kept

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www.npjournal.org The Journal for Nurse Practitioners - JNP 51Retail clinics (also known as convenient careclinics) made their debut in 2000 as theresult of a consumer-driven mandate for eas-ily accessible, low cost, quality healthcare. In response,investors began to form corporations to make this visiona reality. As the new healthcare model began to evolve,with its focus on providing a limited number of primarycare services, it was thought that the most appropriateproviders to staff these clinics would be family nursepractitioners (FNPs). This determination was based bothon their scope of practice and the scope of services thatthe clinics proposed to offer.1As with any new enterprise, time has refined andchanged the landscape, mostly for the better. The promisewas to provide quality care at convenient times andplaces at a reasonable cost. The purpose of this article isto provide an update on some of those changes.INDUSTRY GROWTH As Figure 1 shows, the number of new clinics has slowedconsiderably since 2008. Since October 2008 there hasonly been a 17% (N 200) increase in new clinic open-ings. This figure falls far short of the 5,000 clinics esti-mated by national organizations.2 The economicdownturn of the past 2 years has had a noticeable effecton clinic growth, like most industries. In part, this can beattributed to the fact that the uninsured are less likely touse their scant economic resources for healthcare than formore basic needs such as food and clothing. On the other hand, those who are insured are morelikely to wait longer before seeing a healthcare providerand, hence, more likely to be sicker and need more com-prehensive care than a retail clinic can provide. Both ofthese phenomena, combined with other intervening vari-ables, such as lack of providers, site locations, regulatorystipulations, etc., could partially explain the slow growthof an industry that is volume dependent. Despite the slow growth of additional retail clinics,consumers are availing themselves of the convenienceof existing clinics. The Deloitte survey (N 4,001)notes that 13% (N 520) of consumers visited a retailclinic in 2008, and 30% (N 1200) said they woulddo so if the fees were 50% less than a visit to physi-cians office.3 Another noteworthy finding byMehrotra et al.4 was their comparison of patient visitsto retail clinics with visits to primary care physicians(PCPs [both adult and pediatric]) and emergencydepartments (EDs) for 10 simple acute conditions,namely upper respiratory infection, sinusitis, bronchi-tis, otitis media, otitis externa, pharyngitis, conjunc-tivitis, immunization, blood pressure or lab tests, andpreventive visits. Figure 2 shows the percentage of vis-its each entity saw based on these 10 ICD-9 codes.Given this type of self-referral process and consumerchoice, the advantage is that the trend in retail clinicvisits relieves the pressure on PCPs and EDs, freeingthem to see more complex patients who need theirexpanded scope of services. ABSTRACTRetail clinics (also known as convenientcare clinics) debuted in 2000 as the resultof a consumer-driven mandate for easilyaccessible, low cost, quality healthcare. Thepromise was to provide quality care at con-venient times and places at reasonable cost.This article provides an update on some ofthe changes in the industry, particularlyhow they affect nurse practitioners. Keywords: industry growth, nursepractitioners, retail clinics, scope of practice,scope of services 2011 American College of Nurse PractitionersRetail Clinics: A Promise Made Is a Promise KeptKenneth P. Miller, PhD, RN, CFNP, FAAN52 The Journal for Nurse Practitioners - JNP Volume 7, Issue 1, January 2011Another potential problem that could affect growth isthe availability of the NP workforce. Approximately6,000 NPs graduate from schools of nursing on anannual basis, and of this number 53% (N 3,180) areFNPs. With healthcare reform and the urgent need formore PCPs, FNPs are well positioned for easy entry intothe job market.5 The other factor is that most retail clin-ics prefer that the FNPs they hire have a minimum of 1year of experience before applying for a position. Thus,the nursing shortage makes these graduates a muchsought-after member of the workforce and heightens thecompetition for their services. There are approximately5,000 NPs working in retail clinics (personal communi-cation, CEO of the Convenient Care Association). POTENTIAL SCOPE OF PRACTICE LIMITATIONSThe recent release of the Institute of Medicine reportThe Future of Nursing: Leading Change, AdvancingHealth identifies as its number one priority (key mes-sage), Nurses should practice to the full extent of theireducation and training.6 Yet over the years multiple tac-tics have been used to thwart that mandate. TheAmerican Medical Association (AMA), the AmericanAcademy of Pediatrics (AAP), and the AmericanAcademy of Family Physicians (AAFP) have all raisedconcerns related to the functioning of retail clinics.4,7Table 1 identifies these concerns, each of which will beaddressed individually.The safety concern is a moot point. Each clinic haspolicies and procedures to identify any untoward event.Records are routinely reviewed by audit committees, andin states where there are statutory or regulatory require-ments for physician collaboration or supervision, thesecollaborators/supervisors review records on a recurrentset schedule. Regional NPs, who oversee a geographicarea, also review records on an ongoing basis. To date nota single malpractice suit has been filed against a providerin the retail clinics.The quality of care provided by NPs in retail settingshas been repeatedly shown to be equivalent to, or betterthan, comparable settings.4,7 Mehrotra et al. compared thecosts and quality of care for three common illnesses (oti-tis media, urinary tract infection, and pharyngitis) at retailclinics to physician offices, urgent care clinics, and EDs.7Figure 3 clearly shows that the cost of care in a retailclinic was significantly lower than in the other venues.However, he noted that the quality of care score for theretail clinics was equal to or better than the other setting,as noted in Figure 4. He also pointed out that the preventive care scoresdid not vary significantly across all three sites, alsodepicted in Figure 4. These data on the quality of careprovided by NPs have been consistently equal to or bet-ter than the data on care provided by PCPs for morethan 35 years.8-11Table 1. Scope of Practice LimitationsSafetyQuality of careOverprescribing antibioticsDisrupting physician/patient relationshipMissing preventive careFigure 1. Growth of Retail Clinics by Year* Figure 2. Percentage of Visits Based on Ten ICD-9 Codes**Data derived from merchant medicine, 10/4/2010*Based on data derived from Mehrotra et al., 2008www.npjournal.org The Journal for Nurse Practitioners - JNP 53The overprescription of antibiotics was another concernraised by the medical organizations, yet Mehrotra and hiscolleagues found no such supporting data in their study.As a matter of fact, they reported that antibiotic prescrib-ing at the three sites they researched were equivalent.7The concern was linked to the assumption that if theseclinics were housed within pharmacies, the healthcareproviders would be overzealous with their prescribing.This has not been the case.A study by the Rand Corporation easily dispelled themyth that retail clinics would disrupt the relationshipbetween the physician and the patient. It is worth notingthat only 39% of the subjects in their study even saidthey had a PCP. Their data serendipitously noted, themajority of retail clinic patients did not have a regularprovider, so there was no relationship to disrupt.12The final concern, missed preventive care, centered onthe fact that retail clinicians might overlook identifyingsomething fundamental, to the detriment of the patient.However, prevention is one of the hallmarks of NP edu-cation. Mehrotra and colleagues noted in their compara-tive study of three illnesses and four venues that therates of preventive care received at the initial visitthrough the subsequent three months were similar.7Another rebuttal of this problem is that all patients aregiven a hard copy of notes from their visit to the clinicand directed to share it with their PCP at the next visit.Most clinics also fax or email the notes if the patient hashis or her PCPs address or the fax number. Illustratedwith documentation of their acute care visit to a retailclinic, preventive care could easily be addressed by thepatients PCP, if it were not noted at the retail clinic visit. FUTURE PREDICTIONS Having grown from a mere 50 clinics in 2005 to approx-imately 1200 clinics today, the retail clinics like any otherindustry is dependent, in part, on the economic factorsaffecting our country. When the economy turns around,so, too, will the retail clinic industry. But what does thefuture hold? From a speculative point of view, retail clin-ics are looking to enhance their scope of services. Sincemuch of the work they do is seasonally dependent, retailclinic operators will be looking for other revenuestreams. Some of these options might include additionalservices such as chronic disease management or preven-tive care classes for such conditions as diabetes, hyperten-sion, obesity, smoking cessation, etc. By providing theseadditional services, the retail clinics will become anotherpartner in improving the healthcare of all citizens.SUMMARYA number of myths and speculations about retail clinicshave been presented and addressed. Retail clinics are pro-viding a valuable service to the nation by relieving theburden on inappropriately used EDs for non-emergencyconditions. They have freed up PCPs to see more com-plex patients who need their services. And with the mil-lions of uninsured and underinsured who will be addedto the healthcare rolls under the new Congressionallymandated national healthcare plan, retail clinics will playa crucial role in triaging patients to the correct provider.These clinics started out with a promise to provideaffordable, quality care at a convenient time and location,and they have been true to this model. A promise madeis a promise kept! Figure 3. Cost of Treatment and Prescription by Site**Based on data derived from Mehrotra et al., 2009Figure 4. Comparison of Quality and Preventive Care Scores**Based on data derived from Mehrotra et al., 200954 The Journal for Nurse Practitioners - JNP Volume 7, Issue 1, January 2011References1. Miller K. Consumer-driven health care: Nurse practitioners making history. JNurs Pract. 2009;5(1):31-34.2. Miller J. Right size engineering: MinuteClinic Michael Howe puts retail servicesuite in context. http://managedhealthcareexecutive.modernmedicine.com/mhe/article/articleDetail.jsp?id439158. Accessed October 8, 2010.3. Deloitte Center for Health Solutions. 2009 Survey of health care consumers.http://www.deloitte.com/us/consumerism. Accessed October 8, 2010.4. Mehrotra A, Wang MC, Lave JR, Adams JL, McGlynn EA. A comparison ofpatient visits to retail clinics, primary care physicians, and emergencydepartments. Health Aff 2008;27(5):1271-1282.5. Routson J. Nurse practitioners in demand, but face pay, practice disparities.Available at: http://www.medhunters.com/articles/nursePractitionersInDemand.html. Accessed October 29, 2010.6. Institute of Medicine. Summary: The future of nursing: leading change,advancing health. http://iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx. Accessed October 7, 2010.7. Mehrotra A, Liu H, Adams J, Wang MC, Lave J, Thygeson NM, et al. Thecosts and quality of care for three common illnesses at retail clinics ascompared to other medical settings. Ann Intern Med. 2009;151(5):321-328.8. Mundinger MO, Kane RL, Lenz ER, Totten AM, Wei-Yann T,Cleary PD, et al.Primary care outcomes in patients treated by nurse practitioners orphysicians. JAMA. 2000;283(1):59-68.9. Ruby EB, Davidson LJ, Daly B, Clochesy JM, Sereika S, Baldisseri M, et al.Care activities and outcomes of patients cared for by acute care nursepractitioners, physician assistants, and resident physicians: a comparison.Am J Crit Care. 1998;7(4):267-281.10. Sox HC. Quality of patient care by nurse practitioners and physicianassistants: A ten year perspective. Ann Intern Med. 1979;91:459-468.11. Spitzer WO, Sackett DL, Sibley JC, et al. The Burlington randomized trial ofthe nurse practitioners. New Engl J Med. 1974;290:251-256.12. Rand Corp. Health care on aisle 7: The growing phenomenon of retail clinicshttp://www.rand.org/pubs/research_briefs/RB9491-1/. Accessed October 5,2010.Kenneth P. Miller, PhD, RN, CFNP, FAAN, is a professorand associate dean of the School of Nursing at the CatholicUniversity of America in Washington, DC. He can be reachedat millerkp@cua.edu. In compliance with national ethicalguidelines, the author reports no relationships with business orindustry that would pose a conflict of interest.1555-4155/10/$ see front matter 2011 American College of Nurse Practitionersdoi:10/1016.nurpra.2010.11.004Retail Clinics: A Promise Made Is a Promise KeptINDUSTRY GROWTHPOTENTIAL SCOPE OF PRACTICE LIMITATIONSFUTURE PREDICTIONSSUMMARYReferences