Doctors are having a hard go of things. Squeezed by falling reimbursements, soaring malpractice insurance and punishing patient loads, they shouldn't have much to fear from the likes of Wal-Mart. But the fact is, the greeter in the red vest is increasingly going toe-to-toe with the doctor in the white coat — and winning — thanks to the growing phenomenon of retail health clinics.
Retail clinics — free-standing, walk-in medical providers located in drug stores, shopping malls and stores like Wal-Mart, Target and Walgreens — are rapidly becoming to the health-care industry what Fotomat was to the camera world. There are roughly 1,000 clinics now operating in the U.S., offering acute care for such routine problems as throat infections and earaches as well as providing diabetes and cholesterol screenings, routine checkups and vaccinations. The fees are low — and conspicuously posted; nearly all of the clinics treat both the insured and uninsured, and there is little or no waiting time. With 50 million Americans lacking health insurance and family budgets collapsing under the weight of medical costs, what's not to like about the clinics?
Plenty, say physicians associations, whose members warn that clinics — which are typically staffed by nurse practitioners and are positioned in stores that also sell prescriptions — will be inclined to misdiagnose and overprescribe. Worse, they are not built to provide long-term care for chronic conditions such as hypertension, and they threaten the ideal of a lasting doctor-patient relationship, denying consumers a so-called "medical home."
Those, at least, are the arguments, though it was impossible to know how well-founded they were — until now. In twin studies published this week in the Annals of Internal Medicine, the Rand Corp. reports on an extensive survey of cost, quality and availability of retail health operations, and on nearly all measures, the clinics scored high.
The studies, which took months to compile, were based on the performance of the 982 retail clinics that existed in the U.S. as of August 2008 — a tenfold increase since 2006. While that proliferation is impressive, as with much else in the health-care system it doesn't necessarily mean equal access to care. Clinics exist in only 33 states, and in those that have them, an overwhelming 88.4% are in urban areas. Just 10.6% of the U.S. population lives within a five-minute drive of a clinic, and 28.7% lives 10 minutes away. The South is better served than the Midwest and West, and all three regions are better served than the East. Just five states (Florida, California, Texas, Minnesota and Illinois) are home to 44% of all American retail health clinics.
But perhaps the more relevant question is, How good is the care at these stop-and-shop operations? To answer that, the Rand investigators focused on just one state, Minnesota, because clinics are well-established there and because one large health plan has been providing clinic coverage for its members for five years, meaning that there was a rich vein of data to mine. The investigators focused on data on 2,100 patients who had gone to a clinic for one of three common complaints: sore throat, urinary tract infection and earache. These were compared to patients who had visited doctors' offices, urgent-care facilities and emergency rooms for the same ailments. The investigators judged quality of care by 14 different measures, including what kinds of tests were ordered, what drugs were prescribed and whether follow-up visits were scheduled.
If the results are any indication, the next time you have a routine medical need, you should probably make haste to a clinic. On a quality scale of 0% to 100%, the clinics finished first with a 63.6% while urgent-care centers and doctor's offices followed within a couple of points. Habitually overcrowded emergency rooms came in last at a distant 55.1%. When it came to fees, the results were even more dramatic. For the various kinds of services studied, the average visit to a retail clinic cost $110, versus $156 for urgent care and $166 for a family doc. As for ERs? A cool $570. While even $110 for a clinic visit seems pricey, that is only the average for the three procedures studied. Minute Clinic, the industry leader with 514 outlets, charges just $62 for a minor illness or injury exam and $20 to $66 for a wellness or prevention visit.
Average cost per lab test in the Rand study also differed significantly depending on the provider: $15 at retail clinics, $27 at urgent-care facilities, $33 at doctors' offices and a whopping $113 at the ER. The study did not bear out the fear that retail clinics would be inclined to overprescribe drugs, and when the clinics did write a prescription, the out-of-pocket cost was lower: $21 compared to a high of $26 for ERs.
"These findings provide more evidence that retail clinics are an innovative way of delivering health care," says Dr. Ateev Mehrotra, a professor at the University of Pittsburgh Medical School and the lead author of the study. "Retail clinics are more convenient for patients, less costly and provide care that is of equal quality."
Neither the clinics nor the studies are perfect, as the Rand team concedes. Even an exhaustive survey of one state is still a study of just that state. And the very accessibility of those Minnesota clinics might have encouraged more visits by mildly ill people whose complaints would have vanished on their own. Give the clinics so many easy pitches to hit and you may artificially drive up their average. Still, with local and regional hospitals such as the Cleveland Clinic increasingly working in partnership with such retail operations, more and more of these in-store outlets are likely to open. Which means more and more of us will be putting health care on the weekly shopping lists, along with the milk and bread.
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