A shortage of primary care physicians.  Interrupting the medical home.  Skimming the easy stuff.

The sentiment against in-store clinics by physicians remains strong.  And although lobbying efforts to stop retail clinics have failed, limiting the scope of these clinics is a primary agenda item for medical societies around the country.

Indeed, there is evidence that we’re about to face a primary care physician shortage and retail clinics could worsen that by driving new medical grads away and causing existing primary care physicians to retire early.  There is also evidence that more and more people are going through life without a medical home, and retail clinics could make that state of affairs worse as well.  And there is no question that retail clinics take away patients with non-complicated illnesses.  These visits require less time but are coded the same (and thus equally reimbursed) as problems that are more complex and take more time.

But there is a growing body of physician groups and health systems that are looking at retail clinics through a different lens.  They would argue that each of the above criticisms of retail clinics has a counter argument that supports the need for retail clinics.   For example:

Primary care physician shortage – The shortage, if any, is regional and the trend is fed not by retail clinics but on a reimbursement system that favors procedures vs. health maintenance and promotion.  Retail clinics have more potential to help access problems, rather than hurt them.

Lack of a medical home – For the last decade health insurers and employers have told people they need to take more control of their healthcare decisions.  On top of that, our society has focused on convenience and speed in just about every other industry.  There’s no turning back on this one.  The counter argument is that the healthcare community must accommodate this trend because there’s no controlling it.  With proper linkage to multispecialty resources, retail clinics could be the accommodation that is needed.

    Retail clinics focus on the easy stuff – The concept of lower-cost resources aimed at lower acuity care is not a new one.  Urgent care centers were to emergency rooms what retail clinics are to urgent care centers.  The same can be said about outpatient surgery centers vs. inpatient operating rooms.

What is striking, and perhaps ironic, about the above counter arguments is that they are coming from the traditional healthcare players.  And what is further striking is that some of these players are looking at whether the retail clinic model could extend into chronic disease management and health maintenance.

One important factor that makes this dialogue possible is that the emotion from physicians is starting to soften.

“When we first entered the market, I think many doctors thought retail clinics were a Trojan horse for the full scope of care,” says Web Golinkin, CEO of RediClinic.  “But we’ve been working closely with hospital systems and physicians from the beginning and by now they understand that our business model depends on a limited scope  of care to facilitate rapid and efficient patient throughput.”

Golinkin adds that most physicians he talks to realize “the toothpaste is out of the tube and this model is here to stay.”

It is also clear that hospital systems are forcing a change in attitudes.  These systems are looking to neutralize the competitive threat from retail pharmacy-owned clinics like MinuteClinic and TakeCare; they are responding to consumer demands for greater flexibility with scheduling and locations; and they are looking to restructure their delivery systems to prepare for the coming age of government cutbacks and pay-for-performance incentives.

There are now 30 hospital systems operating 108 retail clinics from coast to coast.  They range from players like Sutter Health in Northern California and Alegent Health in Omaha, NE,  to smaller systems like Valley Health in Winchester, VA.  These systems operate retail clinics under their own brand usually in partnership with their employed or affiliated physician groups.  And most are a virtual extension of primary care practices linked under a common electronic health record (EHR) system.  All are focused on simple illnesses like sore throats, coughs, ear aches and sinus pain.

But how long will the scope of care be limited to simple, upper respiratory illnesses? 

“We’re very focused on simple illnesses and have stayed away from things like chronic disease management,” says Russ Mulert,   operations director at Alegent Health.  “But you can see signs that the retail clinic platform could begin to intersect with more of primary care.”

Mulert tells the story of a women who began having her blood pressure checked each week by a nurse practitioner at one of the Alegent Quick Care clinics.

“She showed the card with her results to her doctor during her annual visit,” says Mulert.  “When he saw that these were legitimate weekly checks by a qualified practitioner instead of the pharmacy blood pressure machine, he realized how retail clinics can be a real help.  His office can’t afford to have all their hypertensive patients coming in every week.  But we can do that for free.”

Mulert adds that her physician eliminated one of her medications because she showed such significant improvement.  And even though Alegent is not formally moving into chronic disease management, three of their retail clinic NPs are certified diabetic managers.

MultiCare, a health system in the Seattle/Tacoma area, is a relative newcomer to the retail clinic space.  They have opened two retail clinics inside Rite Aid drug stores within the last six months.  Like Alegent, the clinics focus on non-complicated illnesses.  But that may change, says Dixi Gerkman, director of Pierce County MultiCare Medical Group.

“Once we’re a little more established we may be looking at some non-complicated chronic disease management like HbA1c and foot checks,” she says.  “We already are getting a fair number of referrals from our physician groups but nothing formalized. “

The MultiCare Express clinics are hooked together under the EPIC EHR system, the same system that is used by the medical groups and hospitals.  But linkages are more than the EHR, says Gerkman.

“Until now we’ve all operated independently, each doing what works best,” she says. “But this retail clinic platform enables us deliver care more conveniently and efficiently, so we’re going to have to work at the organizational linkages as well.”

 Thomas Atkins, MD, couldn’t agree more.  Dr. Atkins is president and medical director of Sutter Express Care in Sacramento.

“In my opinion we have a huge opportunity to deliver care more competitively than ever before,” he says.  “We can now deliver on a patient-centric view of the world.  If time of day is more important to the patient, we can deliver.  If location is more important, we can deliver.  But we as physicians shouldn’t be offended if our patient wants to pursue these options and it means seeing another provider.”

Sutter operates six Sutter Express Care centers in Sacramento area Rite Aid stores.  The system launched their retail clinic initiative in December of 2006 and, like other hospital systems, their current focus is on simple, episodic illnesses.

However, Sutter is in the early stages of looking at the potential of retail clinics as an integrated spoke of the primary care model rather than a standalone offering.  The idea is to broaden the scope of patient care and education slightly to include non-complicated chronic disease management tasks, with a system for rapid escalation.  Dr. Atkins, says this creates a stronger medical home under the Sutter brand.

But will Sutter physicians rally around such a concept?  Dr. Atkins says two things point to the potential of strong physician support.

“First of all, we’re at a point now where we realize we aren’t seeing a decrease in volume because of retail clinics,” he says. “That’s because there are more patients and fewer doctors.”

 But Dr. Atkins says there is a more fundamental change that physicians look at:  pay-for-performance.

 “Pay-for-performance incentives tend to pay out at certain percentile levels,” says Dr. Atkins.  “And we’ve found that reaching those higher percentiles may be just a matter of a few more patients.”

You can reach those patients and perform the required low-level tasks by creating more convenient access, and to cross into more meaningful revenue rewards.

“Functionally, there’s no reason we can’t be helping out with managing mild, uncomplicated diabetes, hypertension or lipid management,” says Dr. Atkins.  “Health maintenance is a little tougher because you’re doing things below the waist.  But for female patients with female practitioners, there shouldn’t be a problem.  Really anything in the health maintenance chart in EPIC (Sutter’s EHR) that needs to be done, there’s very little reason an NP can’t order that and send the results to the primary care physician.  It would improve our scores, the PCP may benefit from a higher pay-for-performance payment, and it doesn’t cost the PCP anything more than better care for their patients.”

In case you missed it, in the last two years the start of the flu shot season has moved up considerably. And the implications for retail clinics are mostly positive. In fact, this could be the best news retail clinics have seen in a long time.

We are all familiar with the predictions of a booming retail clinic industry. But if you think those predictions have ceased, think again.  Merchant Medicine estimates 2,050 retail clinics by the end of 2014.

Of any company we have followed in the retail healthcare space, Solantic seems to hit all the strategic buttons:  stand-alone urgent care centers in high-traffic shopping centers, clinics in Wal-Mart, joint ventures with area health systems, a clinic in the Orlando airport, franchises for physicians, outstanding consumer marketing and a relentless pursuit of customer satisfaction.

Over the long term, it could be that seasonality is the least of a retail clinic operator’s worries. As we noted last month in an article about the long road to breakeven for retail clinic operators, traditional medical practices are taking a page out of the retail clinic playbook and focusing more than ever on patient convenience and consumer marketing. The result is a trend that we call “ConvUrgentCare™,” the merging of convenient care, urgent care and any type of walk-in medicine that involves non-emergent acute medical care.  Today you can see retail clinic techniques crossing over not only to urgent care and emergency care, but also pediatrics, family medicine and work-site clinics.   And these techniques appear to be working to change the game in walk-in medicine.

He has lived in the world of corporate travel management and now the world of healthcare.  Oddly enough, the corporate travel world seems to know a lot more about Hal Rosenbluth than the healthcare world.  But that may be about to change.