By Chad Terhune March 31, 2016
Is that clinic tucked inside your neighborhood pharmacy making medical care too easy?
A recent study found that retail clinics may actually boost overall spending by encouraging people to get care for minor problems that mostly would have cleared up on their own. That challenged conventional wisdom that these in-store clinics could chip away at the nation’s $3 trillion medical tab.
The study, published in the journal Health Affairs, found that 58 percent of retail clinic visits for several minor conditions represented a new use of medical services. Just 42 percent replaced a costlier doctor visit or trip to the hospital.
Those additional visits led a modest rise in health-care spending of $14 per person per year.
Industry officials were highly critical of the results, calling them flawed and too narrowly focused on old data. More than 2,000 retail clinics operate nationwide, handling about 6 million patient visits annually.
To further explore these issues, we talked separately with Scott Ashwood, the study’s lead author and an associate policy researcher at Rand Corp., a nonprofit think tank in Santa Monica, and Dr. Andrew Sussman, president of the MinuteClinic unit at CVS Health Corp. It’s the largest retail clinic chain in the country with more than 1,100 locations. Overall, there are 80 retail clinics in California, according to research firm Merchant Medicine.
Dr. Ashwood, are retail clinics making care too convenient?
Ashwood: That is a valid point. The kind of care we studied is low-acuity care. Some people refer to it as self-limiting conditions. These are things that would go away on their own with minimal treatment.
We are not talking about pneumonia or something more serious. These are very simple conditions.
So getting more people treated for those conditions is probably good for the patients. They feel better and they may get back to work sooner. But from a broader perspective it may not be something we want to spend more money on as a society or [as a] a health plan.
We would rather focus on higher value preventive care services.
I think there are lots of good reasons why people would get care from a retail clinic.
Convenience being one, reassurance. There are lots of reasons. There is nothing wrong there. However, it is not saving us money. It is in fact potentially costing us more. We have to think about whether that’s a good or bad thing as a society or if I’m a health plan.
Dr. Sussman, what is the industry’s reaction to this latest study?
Sussman: It is not an accurate assessment of retail clinic cost savings and value. It is a step backward to think of people who did not have a primary-care physician … as excess utilization.
The authors describe this as new care or new costs, which I think is a step backward. It’s not excessive costs to take care of people who don’t have a doctor. In fact, we are reaching an underserved population with retail clinics.
That is an underlying objective of many innovations in healthcare. The Affordable Care Act is designed to make sure people have access to the care they need.
If you think about it, with millions of patients seeking care and a shortage of primary-care physicians, retail clinics can help keep these patients healthy and provide overall cost savings.
The study doesn’t look at the overall savings. It just looks at the visit costs.
If you think about a patient with the flu who doesn’t have a physician, they can get care at an inexpensive retail clinic on the weekend before their condition gets worse and they might need a costly hospitalization.
So we keep patients healthy and hold down overall health-care costs. Those overall savings are not measured in this study.
Half of our patients don’t have a physician so when they get care that is not excess cost. That is giving access to people who didn’t have an opportunity to be cared for.
There are other studies that show very significant savings. It’s about 40 percent to 80 percent less costly at a retail clinic compared to a physician office or an emergency room.
How do you respond to this criticism from the industry?
Ashwood: I am not surprised. They have some legitimate points. There are limitations with this study as we have with any study.
We did look broadly at all outpatient spending. We didn’t have inpatient or pharmacy data, which are major components of healthcare spending. But we did have outpatient care.
We looked at annual outpatient spending for retail clinic users and non-users and there was no difference. So again, [this was] evidence that at least in the outpatient setting there were no savings from retail clinics.
One of the things people think might be happening and think we missed is people show up at a retail clinic with a sinus infection, or upper respiratory infection, get it treated at that stage so it doesn’t become pneumonia, and pneumonia is much more expensive and much worse for the patient.
So part of the story I’m hearing from the industry is ‘we are catching conditions early so there are cost savings there.’
If that were true on a large scale, I would expect to see a decrease in outpatient spending. Because like for pneumonia, you would go to the doctor or emergency department. We have those visits in our data. But we don’t see any difference in outpatient spending.
One of the surprises to me in this study was the percentage of new utilization versus replacement of a doctor’s visit or ER visit. Replacement was just 42 percent, which I would have expected to be higher.
Ashwood: We kind of thought that too when we started this.
If you think about the price of getting treated for these conditions — From the health plan’s perspective there is the amount of money they spent. They negotiate some rate with the providers and that is how much they spend for that service.
From a patient’s perspective, there are two components. There is the price they pay out of pocket. And in this case that’s the copayment.
There is also the convenience. The amount of time they spend getting that care. If you are thinking of going to the doctor for an earache, well I have to get an appointment first of all. I might have to wait a couple of days depending on how busy they are. I might have to wait in the office to be seen. There are time costs to me getting care in the emergency department or the physician office.
The retail clinic essentially lowers the price of time.
And as we thought about this, usually when you reduce the price of something, you see an increase in demand. That is essentially what we have seen.
What does this mean for other delivery options that are being touted as ways to curb medical spending?
Ashwood: That to me is one of the more interesting, bigger picture aspects of this research. Retail clinics fit into this continuum of convenient care options now available.
And I would expect when we look at telemedicine or e-visits or store kiosks we would see a similar pattern. The convenience will increase utilization. It will not replace as much as we think it will.
So the net effect of all this convenient care will probably be an increase in spending.
Who is typically visiting a retail clinic?
Ashwood: The population using retail clinics tends to be younger, female, and healthier and we know from other studies a lot of retail clinic users are people who don’t have a usual source of care.
So they don’t have a primary care physician, in part because they are younger and healthier. And coming from wealthier neighborhoods.
Some experts think one of the big payoffs from retail clinics could come in helping people with their chronic illnesses, which account for a big portion of medical costs. Where does that stand now?
Sussman: Currently about 40 percent of our retail clinic care is for preventive services, wellness, chronic disease monitoring. All of which are designed to keep people healthy and hold down overall health-care costs.
If we see a patient at a MinuteClinic with high blood pressure and refer them to a physician for follow-up care, that is an investment in the health of that patient and preventing more costly illness.
That is not an excess cost. These services were not evaluated in this study.
We check blood pressure, weight, blood sugar, all types of things relevant to their care and send that along to their physician. We don’t take over their care. We believe in a team approach. We want them to be anchored in a medical home.
Obviously, we do other preventive services, like smoking cessation counseling, weight-loss counseling and vaccinations.
Ashwood: The retail clinics have evolved into treating more kinds of conditions, which is a good thing. I agree it’s worth expanding beyond what we looked at here.
What we are showing is people respond pretty strongly to the convenience. You want to do something positive with that and chronic disease management may be one way to go.
I don’t think people by default think of a retail clinic or CVS MinuteClinic as the place to go for diabetes care. You might have to overcome that.
This study used claims data from Aetna Inc., the nation’s third-largest health insurer. After the study came out, Aetna expressed support for retail clinics and said it looked forward to more research.
What are you hearing from insurers Dr. Sussman?
Sussman: Despite the flawed conclusions of this study, millions of patients and hundreds of insurers appreciate the benefits we provide.
Insurers have various approaches to encourage people to use retail clinics.
The insurers have access to all the claims. They can see everything. They are supportive because they want to keep people healthy and it makes sense to keep costs down. They have that broader view that this paper doesn’t look at.
Another trend has been big health systems partnering with retail clinics to expand access to patients. How has that been working?
Sussman: As you know from California and in general, we don’t see ourselves doing this in isolation.
We work in affiliation with 67 major health systems, including places like UCLA, the Cleveland Clinic, Emory Healthcare (in Atlanta) and many others.
We are integrating our electronic health records with theirs. We have a national Epic electronic record and we are working together on chronic disease programs.
The reason why these health systems are working with us is because they don’t have enough access to care and we can be a low-cost option for patients. That is not an excess cost. That is an investment in keeping people healthy.
We have put in the Epic electronic record, the most widely used record in the country, so we can integrate and send notes back and forth. Even if they [the health systems] are not on Epic, we can integrate with other records or send notes by fax. Sharing information can create a larger medical neighborhood.
Ashwood: I’ve seen that in action. I lived in Pittsburgh for a while before I moved here [Los Angeles]. There is a big system, [University of Pittsburgh Medical Center], and our primary-care doctor there specifically said if you get sick on the weekend or during the evening go to the retail clinic and I will know you got sick. They had integrated the system so that my primary-care doctor was still getting a picture of what was happening to me medically even though I wasn’t sitting in his office.
Do you or your family have a personal experience with retail clinics?
Ashwood: I have used them a few times for a strep test for my kids. We used it for my daughter’s sports physical. We had friends visiting from out of town and one of them got sick with a bad cough so we took them to the retail clinic.
As a consumer, the experience was great. I was able to schedule a time really convenient for my daughter’s sports physical. The nurse was great.
My personal experience is they are as advertised. They are convenient. For the care we sought they did a good job.
But my main takeaway from this study is they don’t appear to be saving money, which is what everyone hoped. On the other hand, there is an opportunity to take advantage of that model.
Even physicians themselves are changing what they do in their offices. There are practices adopting weekend hours and different ways of getting people in quicker in response to retail clinics and other convenient care options.
What’s next in this area of research?
Ashwood: We are looking into more of the follow-up patterns for patients. We are looking into more detail into certain conditions, tracking those changes over time.
To me what is interesting is this new use.
I am interested in these new users who don’t have a usual source of care and to me that seems like an opportunity to engage that population sooner than you normally would on healthcare. And retail clinics say they refer people to doctors after the treatment they prescribe. I’m interested in whether that is happening and the long-term benefits.
We are also looking at innovations like telemedicine and e-visits to see if there are similar effects on cost.