Retail-Based Clinics vs. Private Medical Practices

Over the past few years, Terence R. McAllister has watched more and more retail-based clinics set up shop near his practice."I think four or five years ago there was one nearby; now, there's four or five, as well as some urgent-care clinics," says the Plymouth, Mass.-based pediatrician. "There definitely are more of them out there."

McAllister is not the only physician noticing this trend. Over the past few years, retail-based clinics, often referred to as "RBCs," have surfaced inside thousands of pharmacies, supermarkets, and "big box" retailers across the country, and analysts predict that their growth will continue. A June 2013 report from Accenture, a management consulting, technology services, and outsourcing company, projected that the number of retail clinics would grow 25 percent to 30 percent annually between 2012 and 2015. Overall, the report concluded, the number of retail clinics in the U.S. could reach more than 2,800. The authors of the report, "Healthcare Reform and Retail Medical Clinics: From Foe to Friend," recently confirmed to Physicians Practice that those projections are on pace with the current numbers.

For physicians who are concerned about their new retail clinic neighbors, there may be more troubling news: It appears that more patients are using them. A consumer survey by PwC's Health Research Institute, conducted in December 2013, showed that 35 percent of respondents had visited a retail clinic in the last 12 months, up from 9.7 percent in 2007.

So what does all this growth and increasing utilization mean for practices? To provide some answers, we asked several experts to weigh in. Here, they discuss some of the biggest challenges practices may face due to competition from retail clinics, and how practices can minimize any negative effects.  

CHALLENGES FOR PRACTICES: PATIENT CARE

While the quality of care patients receive in retail clinics is a common concern among physicians and physician organizations, many are also expressing reservations regarding the effect a patient's visit to an RBC could have on a patient's continuity of care. For instance, could the patient's visit to a retail clinic lead to a disconnect between the patient and his primary-care physician down the line? Or, could the RBC provider miss out on something relating to the patient's condition that the patient's long-term physician would not?

As initiatives that prioritize highly coordinated, team-based approaches to patient care, such as Patient-Centered Medical Homes, gain momentum, the continuity-of-care concerns associated with retail clinics may be increasing.

The American Academy of Pediatrics (AAP) published a policy statement in the March 2014 issue of Pediatrics that stated RBCs are an inappropriate source of primary care for children because they "fragment" healthcare and do not support the medical home. "The AAP recognizes that convenience and access to care will continue to be important drivers of how healthcare is delivered," lead author, pediatrician James Laughlin said in a statement. "However, the expertise of the pediatrician and the medical home should continue to be recognized as the standard for care of children, and we encourage all AAP members to provide accessible hours and locations as part of a medical home." To view the full policy statement, visit bit.ly/updated-policy-statement.

Brandon Betancourt, a practice administrator at Salud Pediatrics, a three-physician practice in Algonquin, Ill., agrees that the potential "disruption of care," and "disruption of the medical home" that comes from using retail-based clinics is a big concern from a pediatric perspective. "... If a patient goes to a retail-based clinic and then they're prescribed an antibiotic or something like that, the primary-care physician is not aware," says Betancourt. "Or, if they're going to a wellness visit to receive immunizations, then that's not part of the medical record, and so it creates further fragmentation as opposed to the medical home."

CONFRONTING PATIENT-CARE CHALLENGES

Despite concerns that retail clinics could have a negative effect on a patient's continuity of care, some physicians report positive experiences with them. McAllister says RBCs have been fairly good about letting him know when one of his patients has visited their clinic, usually mailing him notes on the care they provided within two weeks.

According to the Convenient Care Association (CCA), the national trade association for companies that provide healthcare in retail-based locations, this practice of sending information back to the primary-care physician should be standard at all of its members' clinics. "All CCA members build collegial relationships with the traditional healthcare system and its providers to share patient information as appropriate and ensure continuity of care," the CCA website states. "All patients are given the option of sharing their healthcare record with other providers."

Physicians Practice reached out to the CCA for an interview, but it could not be reached directly for comment.

If you feel like you aren't receiving enough information about your patients receiving care at outside clinics, communicate with the RBCs about your desire to be better informed, suggests internal medicine physician Simon Samaha, principal in PwC's health industries practice. "... I don't think it would hurt for them to reach out to the retail clinic and see if there's anything they can do to assure the continuity of care." He also suggests starting a dialogue with patients regarding their retail clinic use. Encourage patients to tell any RBC they visit that you are their established primary-care provider, and ask them to give the RBC permission to share information about the care they received with you, says Samaha. "Since the retail clinic is a separate entity from the physician office, [it] cannot release protected health information without the consent of the patient," he says. "So unless there is a formal relationship between the retail [clinic] and physician office, the retail [clinic] cannot just share such information with them. However, the patient can request that their info is released to their physician office."

To prevent information from slipping through the cracks, also encourage your patients to tell you when they visit a retail clinic. This is something McAllister does in his practice. "I want the patients to come back to me and tell me what happened," he says. "... It can take a couple weeks before I get those notes from [the RBC] so I like for the families or the patients to call us the next day to let us know that they were there."

To further encourage that transparency from patients, McAllister's practice website identifies retail clinics as an alternative option for care if his practice is closed. "If we pretend that they don't exist or don't address them, then parents [of patients] might feel reluctant to tell us they went there, that they are somehow going behind our backs to do something, and then we lose out on that communication," he says.

CHALLENGES FOR PRACTICES: ECONOMICS

In addition to concerns about patient care, retail clinics raise business-related concerns for some physicians. After all, they are new competitors in your local area, and they promise something that patients highly value: easy access and convenience.

But Alan Nalle, senior manager at Accenture and co-author of its retail clinic report, says RBCs may not be as harmful to patient volume as some physicians fear. Most patients, he says, use them as an "after-hours option," primarily for non-emergent sick visits or, occasionally, non-sick visits such as physicals or flu shots. " ... I think for a primary-care office, [an RBC] is a lower complexity visit, that's a less frequent visit," says Nalle. "I don't see that as a particularly huge amount of overlap in disturbing that primary-care physician's relationship with their patients."

Still, for practices that are already struggling to stay afloat, RBCs could begin to take a toll, especially if growing numbers of patients begin using them for services that your practice traditionally provided.

There is another negative effect that practices, particularly independent practices, may want to keep in mind, says Samaha. When patients who visit retail clinics require referrals, the clinics typically refer them back to their primary-care physicians. Still, about 50 percent of patients who visit RBCs don't have established doctors, so when these patients visit RBCs and require referrals, the clinics tend to refer them to healthcare systems with which they are connected, he says. Since many RBCs form relationships or connections with large integrated networks, independent practices could miss out on these referrals. "The patient is going to be exposed to options, and I wouldn't be surprised if the options take them more [often] into an integrated delivery network if they need follow up," says Samaha.

CONFRONTING ECONOMIC CHALLENGES

There are several different strategies practices can use to counteract the potential negative economic effects posed by RBCs. Here are three to consider:

1. Play their game. Most patients who visit RBCs are drawn to them because of the convenience, price transparency, and open access they provide, says Drew Boston, a manager at Accenture, who co-authored the RBC report. If you want to compete with retail clinics, determine how you can offer similar features. For instance, evening appointments one day per week might be appealing to busy professionals; and urgent-care hours one day per week might be a draw to patients who would otherwise go to the retail clinic. Another feature to consider? E-visits, says Samaha, noting that when it comes to providing access and convenience, nothing can beat e-visits.

2. Differentiate your practice. Since RBCs are "really good at what they do," going head-to-head with them, as in the above scenarios, may not always be the best move. Instead, some practices might benefit from exploring what they can offer that retail clinics cannot, says Betancourt. For instance, your practice might provide more of a personal touch, better continuity of care, a more comprehensive wellness visit, and so on. Once you determine what sets your practice apart, cultivate that and market it to patients, he says.

Also, consider other features and amenities that might appeal to patients. For instance, Betancourt's practice has a partnership with a behavioral health psychologist that many of his patients' parents appreciate. "We don't attract people that would normally go to a retail-based clinic because of the effort that we have put into creating a culture that would appeal to a certain group of people," he says. "... Everybody is welcome, but not everybody appreciates the same things or is willing to pay money for them."

3. Use RBCs to your advantage. Practices that are at full patient capacity with high patient demand might be able to use retail clinics to their benefit, says Nalle. Think of retail clinics as a "low-acuity triage channel," he says. "In other words, you could start to think about how you can incorporate or occasionally refer some of your members or patients [to the RBC], or educate them about how and when to use a retail clinic for some of those lower-acuity, lower-complexity, lower-reimbursement type of items. It's good for the overall health system but it also could be good for practices as they start to manage the complexity for some of their patients, which may impact reimbursement."

Looking for more ways to compete with retail clinics? Visit bit.ly/capko-tips for guidance from practice management expert Judy Capko.

IN SUMMARY

The number of retail-based clinics is growing, as is the number of patients using them. To ensure you are well-informed about the care your patients receive in retail clinics:

• Ask patients to inform retail clinics that you are their established primary-care physician.

• Ask patients to give retail clinics permission to share information about their care with you.

• Ask patients to let you know when they have visited retail clinics.

• Ask retail clinics how you can collaborate to make sure you receive information about the care they provide to your patients.

Aubrey Westgate is senior editor for Physicians Practice. She can be reached at aubrey.westgate@ubm.com.

This article originally appeared in the April 2015 issue of Physicians Practice.