Friend or Foe?

A woman stops by her local Target on her way home from work. With errands to run, dinner to make, and kids in tow, she doesn't have time to attend to the sinus infection that seems to have cropped up overnight. Except that if she's shopping at one of MinuteClinic's 61 locations throughout the country, she can be seen by a nurse practitioner, fill her prescription, and be on her way in less than an hour - no appointment, and no doctor, necessary.

Launched in Minnesota in 2002, MinuteClinic is a mini healthcare office set up inside supermarkets and pharmacies including CVS and Target. The rapidly expanding company is currently operating in seven states. The competing Take Care Health launched in Portland, Ore., in October 2005 and plans to open 1,300 clinics in Rite Aid, Osco Drugs, and Brooks/Eckerd pharmacies by the end of 2007. Other, similar projects are cropping up all over.

Most follow a similar model: the clinics are staffed entirely by nurse practitioners (NPs) or physician assistants (PAs) who treat about two dozen common ailments, including strep throat, pink eye, and ear, bladder, and sinus infections, as well as provide certain health screenings and immunizations. Most clinics operate seven days a week, have evening hours, and see patients age 18 months and up entirely on a walk-in basis. Both claim any wait time is minimal. At MinuteClinic, patients pay $44 or an insurance copay. At Take Care Health, fees range from $48 to $68 per visit.

Is this bad news for primary-care physicians, or a much-needed jolt to a healthcare system that's failing to meet patients' need for convenient, affordable care?

Competition or Collaboration?

Since these quick-access clinics - also called retail health clinics or onsite health clinics - are fairly new, chances are, many of your patients haven't seen them yet. Only 7 percent of U.S. adults have ever used an onsite health clinic in a pharmacy or retail chain, according to a recent Wall Street Journal Online/Harris Interactive Health-Care Poll. Among those who have never gone to an in-store clinic 59 percent say they would be not very or not at all likely to use one, and 41 percent say they would be somewhat or very likely to use one for basic medical services.

Of those who have used these health clinics, however, the vast majority were extremely satisfied with the experience. MinuteClinic claims to have a 99 percent customer satisfaction rate. According to the Harris Interactive poll, clinic users were most satisfied with the convenience (92 percent say they were somewhat/very satisfied), followed by the quality of care (89 percent), and the cost (80 percent).

MinuteClinic and Take Care Health are adamant about emphasizing that they in no way intend to replace primary-care physicians. Nurse practitioner Deb Benoit, MSN, manager of Baltimore operations for MinuteClinic, tells patients, "If you can get in to see your primary-care physician, that's definitely the preferred way to go. But if it's late at night, or they're out of town, or you can't get in" then quick-access clinics are a good alternative.

In fact, Benoit says physicians and school nurses regularly refer patients to MinuteClinic, and the clinics are happy to refer patients to primary-care physicians if patients don't have one or require more in-depth medical care. MinuteClinic, like Take Care Health, maintains a list of physicians in each market who are accepting new patients and have expressed interest in getting referrals from these clinics.

Initial response from patients seems positive, but how do physicians feel about this new player? "I'm intrigued by them," says Craig Wright, MD, a family physician in Beaverton, Ore. "They're responding to a niche market that's probably becoming a bigger issue as consumer-directed healthcare becomes a bigger part of the marketplace."

Wright, CEO of Providence Medical Group, a 27-clinic, 150-doctor group, has met with Take Care Health to discuss working together. He says, "As I talk with the docs in our group, I think the natural reaction is that they feel that this is competitive ... . But I think we need to realize this is going to be happening more and more in healthcare and our challenge is, as both primary care and medical group services in the community, that we need to be able to meet the same patient needs that [retail health clinics] are responding to."

Larry Fields, MD, president of the American Academy of Family Physicians (AAFP), has also encountered some resistance from doctors in response to retail health clinics. "In my experience, the general feelings of most physicians when they first hear about it is some skepticism about what they can do, their capabilities and all that ... . But what we think as an academy is that [these clinics] may have some benefit as far as increasing access to care, particularly on a quick time frame, for a very limited number of problems, all of which are acute and minor in nature." He adds, however, that retail health clinics should not overstep their bounds. "Where they have no role is in any kind of diagnosis beyond [these] limited types of things" nor in follow-up care, says Fields. "If somebody's not improving, they need to see a physician."

Quality of Care

Since retail health clinics are staffed entirely by NPs (and, in some markets, PAs), many physicians are concerned about the quality of care patients receive. Both MinuteClinic and Take Care Health rely on proprietary software based on medical guidelines to guide the visit via computer monitors in each exam room. The program allows NPs to take patients' medical history, check a drug interaction database, print a prescription and diagnostic record for the patient, calculate any copay, and submit the record to the insurance company for reimbursement.

It also allows retail health clinics to easily send a record of the visit to the patient's primary-care provider. Notes Fields, "It is incumbent on these retail clinics to notify the patient's personal physician whether or not that physician is associated with the clinic ... . It's important that they not be an obstacle to continuity of care."

MinuteClinic employs consulting physicians in each market to oversee their clinics. "We think it's a really good practice to have physicians available for NPs to call if necessary because we have such a limited scope of services," says Jim Woodburn, MD, Chief Medical Officer for MinuteClinic.

As for Take Care Health, "In markets where it is required, we work with a collaborating physician or doctor group that are on call as consultants to the NPs if needed," says spokesperson Darren Brandt.

Some physicians, like Wright, worry about the implications of a patient visit in a setting that is, by design, very limited. "At Take Care Health you're being seen by a nurse practitioner in a pharmacy with a limited scope of diagnostic and therapeutic options," he says. "When you come to one of our clinics you're seen by a physician in a setting that has a diagnostic lab and X-ray and support staff, specialists ... . It's a different experience in terms of ability to handle a whole range of acuities every time you walk through the door."

Wright also wonders whether there will be sufficient demand to see an NP in a pharmacy setting. In fact, his medical group considered developing its own retail health clinic and decided not to. "It takes a lot of time and energy to do something like this, and I think that if someone else is going to provide good care that's consistent with [ours], it probably makes more sense for us to partner with them than to try and compete," says Wright.

Fields sees retail health clinics as an opportunity to bring patients into the healthcare system. "Another role that these places could play is to identify patients who don't have a personal family physician and send them into the system in that way."

Changing the Way Physicians Do Business?

Opinions are divided on whether the rise of quick-access clinics will force physicians to change the way they run their practices. "So far I haven't heard of any physicians who are actively going to make large changes in their practice situation just to respond to this," says the AAFP's Fields.

But in markets where these clinics are already operating, it has spurred physicians to prioritize issues they have already been considering. "Accessibility, hours of operation, getting people in and out the door - those are all things we should be doing and this is probably a good reminder for us in a real way that we need to be doing that," says Wright.

Mary Figueroa, MD, a family practitioner in Edina, Minn., and medical director for MinuteClinic, says she has adapted her practice hours to be more flexible for walk-in patients, but she hasn't seen a negative impact from the MinuteClinics in her area. "I think the minor illnesses that I haven't seen have been balanced out by the referrals." Her four-physician practice has differentiated itself by focusing on sports medicine and holistic medicine. "To be competitive ... we have to find a different niche, so that's our niche. Our clinic has just done great because of that," she says.

Figueroa takes a historical approach to doctors' reaction to retail health clinics. "Like anything that's new, it's kind of taken the whole medical community by surprise," she says. "Look at what happened with the urgent care concept 20 years ago. At first, doctors were horrified. Now, urgent care centers are all over the place. And doctors and the public see them as a necessary thing."

Like many physicians, Figueroa sees the rise in quick-access clinics as inevitable and necessary. "When one of my patients comes to my clinic for a throat culture ... they're helping pay my overhead," she says. "But the reality is that healthcare cannot sustain that anymore." Retail health clinics are cutting the cost of healthcare for simple ailments that don't need to be seen in a doctor's office.

MinuteClinic's Woodburn says that while he's gotten a variety of reactions from doctors, "the vast majority say it's a good thing because it relieves pressure because they're busy enough. ... Everybody's got to look at the healthcare system and figure out how we can improve it.

Abigail Green, MA, is a freelance writer who specializes in topics including healthcare and higher education. She can be reached via editor@physicianspractice.com.

This article originally appeared in the January 2006 issue of Physicians Practice.