September 10, 2008
BACKGROUNDER: RETAIL-BASED MEDICAL CLINICS
By: John Kasprak, Senior Attorney
“Retail-Based Medical Clinics,” which are generally located in retail establishments, provide treatment for basic medical conditions by non-physician providers and offer transparent pricing and convenient hours. While some groups believe that these clinics will improve access to care for underserved populations, others have raised questions about quality of care and adequacy of oversight. Such concerns have resulted in proposals for new state regulation of these clinics.
The information that follows is meant to provide a broad review of these clinics and is not Connecticut-specific, except where noted.
What are Retail-Based Medical Clinics?
A “Retail-Based Medical Clinic” is a clinic located within a larger retail operation that offers simple health care services to the public on an ongoing basis. These clinics are usually located in drugstores, grocery chains, and “big box” stores across the country. They are also known as “limited service medical clinics,” “in-store medical clinics,” “convenient care clinics,” and “retail health clinics.”
When and Where Did These Clinics Begin?
The first in-store clinics appeared in 2000 in the Minneapolis-St.Paul metropolitan area. They were operated by QuickMedx, which later became MinuteClinic. The first clinics charged a flat fee of $35 for rapid testing, diagnosis, and prescriptions for 11 common medical conditions including strep throat, flu, ear infection, pink eye, and seasonal allergies. Originally, they did not accept insurance. This was a deliberate, strategic choice to “compete on a purely retail level and be able to profit on a copayment-type basis” (see Health Care in the Express Lane: the Emergence of Retail Health Clinics, California Healthcare Foundation, July 2006, p.8).
Hundreds of retail clinics have since opened across the country. As of July 2008, there were over 960 such clinics; most operate in suburban areas.
Connecticut MinuteClinics are located in Ansonia, Avon, Cheshire, Coventry, Enfield, Hamden, Hartford, Rocky Hill, Newtown, Orange, Riverside (Greenwich), Southington, and Southbury.
Who Staffs the Clinics?
Most clinics are staffed by nurse practitioners (known as “advanced practice registered nurses” in Connecticut) or physician assistants, supervised by an off-site physician who is available by phone for consultation. Some clinics employ full-time physicians. Clinics maintain referral networks with local primary care, safety-net, specialty, and emergency service providers to address patients presenting conditions that fall outside of the clinic's scope of care.
Most clinics are open for extended hours and weekends. Visits take about 15 to 25 minutes and do not require an appointment.
What Services are Offered?
Most clinics treat adults and children over the age of 18 months. Their scope of practice varies by clinic company, state, and retail location. But there are practical, strategic, and regulatory reasons for clinics to have a relatively narrow practice scope.
Clinics rely on low prices, quick turnaround of patients, minimal staff, and proprietary software systems that can reliably manage selective medical diagnoses and information. This basically results in a short list of simple procedures performed by retail clinics as compared to traditional primary care offices. At MinuteClinic, for example, the six most frequently treated conditions are pharyngitis (sore or strep throat), bronchitis, otitis media (ear infections), sinutitis, conjunctivitis (pink eye), and female urinary tract infection (see California Health Foundation Report, p. 9).
Clinics may also offer preventative care, such as health screenings, vaccinations, and physical exams.
Most clinics are housed in small areas with physical limitations. At most, they have one or two exam rooms. While this serves to keep quality control manageable and overhead low, it also effectively limits the range of services that can be provided. Clinics are not equipped to handle complex cases or offer many diagnostic tests.
What Does it Cost to Visit a Retail Clinic? Does Insurance Cover Clinic Visits?
Prices are posted in retail medical clinics and generally range from $30 to $100. Some clinics accept insurance and all provide documentation for consumers to file for reimbursement on their own. Major insurers provide coverage for treatment at MinuteClinics in all 25 states where they operate, according to the CVS drugstore chain. (MinuteClinic is a division of CVS Caremark.)
In Massachusetts, Harvard Pilgrim Health care and Tufts Health Plan have signed contracts with CVS, which plans to open as many as 28 clinics in the state this year and 100 within five years. CVS is also negotiating for insurance coverage with Blue Cross and Blue Shield (BC/BS) of Massachusetts. BC/BS is also negotiating with Take Care Health Systems, the medical clinic subsidiary of Walgreens.
Are Retail-Based Medical Clinics Regulated?
Regulation of retail clinics varies from state to state. In January 2008, Massachusetts became the first state to adopt comprehensive regulations of limited service clinics. The regulations require them to be licensed and inspected as retail clinics. The clinic license application addresses a list of services that will be offered. Other significant regulatory provisions require the clinics to:
1. develop policies and procedures concerning staffing patterns, diagnosis and treatment, referrals, limits on repeat visits with individual patients, provision of medical records, and prohibitions on promotion of services provided by any host retail location;
2. maintain a roster of primary care practitioners, including community health centers, in the clinic's geographic area who are currently accepting new patients and who will accept a retail clinic referral;
3. have clearly marked, handicapped accessible pathways if located within another entity (e.g., a store); and
4. have bathroom facilities reasonably close to the clinic.
As noted above, the clinics are typically staffed with nurse practitioners and physician assistants who must be licensed but also who have different degrees of autonomy depending on the state.
Connecticut does not specifically regulate retail medical clinics. These clinics currently operate under the license of an individual physician. This is based on the Department of Public Health's policy governing “walk-in clinics” (the “Doc-in a-Box” concept), which have traditionally been operated by physicians under their individual licenses.
What are the Pros and Cons of Retail-Based Medical Clinics?
Some of the potential benefits of these clinics are improved access to care, lower cost care, a “one-stop” shopping approach to health care, no need for appointments, possible reduction in emergency department use, and an option to address the issue of a primary care physician shortage.
Potential concerns are fragmented or episodic treatment (lack of continuity or care; no “medical home”); the lack of follow-up care; the handling of referrals when a patient's situation is not appropriate for a retail clinic; possible missed opportunities for preventative care; possible increased use of prescription medicine; and the economic impact on community practices, including community health centers, which may lose patients and revenue.
What are Some Other Sources of Information?
-the California Healthcare Foundation (http://www.chcf.org)
-United States Federal Trade Commission (http://ftc.gov)
-Convenient Care Association (http://www.convenientcareassociation.org)
-Connecticut Health Policy Project (www.cthealthpolicy.org)
-Kaiser Network (http://www.kaisernetwork.org)
-Massachusetts Regulations on Limited Service Medical Clinics (105 CMR 140)