ateev mehrotra: retail clinics

Retail ClinicsVictors or Vanquished?

Ateev MehrotraDepartment of Health Care Policy

Harvard Medical School

Outline

Retail clinics as a case study of innovation

• Describe model

• Impact on health care

Next steps

• Why is the impact of retail clinics not larger

• Next wave of disruption

Retail Clinics Seen as Such an Innovation

• In retail stores

• Nurse practitioner

• No appointments: in & out in 20 min

• Short menu of conditions

• High-quality care through use of strict evidence-based algorithms

Retail Clinic Model

Typical “Menu” at a Retail Clinic

MinuteClinic Website

1,600 Clinics Have Opened Across the US

Rudavsky, Pollack, Mehrotra, Annals of Internal Medicine, 2009

Rapid Increase in Retail Clinic Use Among Commercially Insured

(visit per person per year)

Mehrotra et al., Under Review

Majority of Retail Clinic Visits Are fora Limited Number of Conditions

% of Retail Clinic Visits

Upper respiratory illnesses 27

Sore throat 21

Immunizations 20

Otitis media / externa 13

Eye infection (pink eye) 5

Urinary tract infection 4

Screening lab test or blood pressure check 1

Total, ten top reasons for retail clinic visits 90

Mehrotra et al., Health Affairs, 2008

Current State of Retail Clinic Industry

• Majority of clinics run by 3 large for-profit companies

‒ MinuteClinic (CVS)

‒ TakeCare Clinic (Walgreens)

‒ Little Clinic (Kroegers)

• Smaller fraction run by large systems (Geisinger, Mayo Clinic, SutterHealth)

• “Co-branding” of WalMart or other clinics by hospitals (UCLA, Cleveland Clinic)

Rudavsky, Pollack, Mehrotra, Annals of Internal Medicine, 2009

Many See Great Promise in Retail Clinics

• Promoted by politicians and policymakers

• WSJ February 2013 “…consider opportunities to shift more care to less-expensive venues, including for example, ‘Minute Clinics’ ”…

• Potential benefits:

‒ Improve access for all patients

‒ Safety net provider for the underserved

‒ Decrease non-urgent ED visits

Concerns From Physician Organizations

• AAP just reissued policy statement which states, “The AAP continues to oppose RBCs as a source of primary care for pediatric patients”

• AMA tried to prevent retail clinics from opening in several states

• AAFP’s 2010 policy statement strongly opposes expansion of care into management of chronic illnesses

Ongoing Debate

Issue Positives Concerns

Quality • Follow guidelines, thus ensuring quality

• Deliver poor quality services

• Overprescribe antibiotics

Access &PCP Relationships

• Improve access for all patients

• New safety-net provider

• Undermine patient-doctor relationships

• Decrease use of preventive care

Costs • Decrease ED visits• Decrease overall

costs

• Increase costs due to unnecessary follow-up

Ongoing Debate

• Quality

• Access & PCP relationships

• Costs

Antibiotic Prescribed for Ear Infection

Antibiotic Prescribed for Sore Throat

0%

20%

40%

60%

80%

Retail Clinic

MD Office

Urgent Care

ED

Antibiotic Prescribing Rates Are Similar

Mehrotra et al., Annals of Internal Medicine, 2009

Ear Infection Sore Throat Urinary Tract Infection

0%

10%

20%

30%

40%

50%

Retail Clinic

MD Office

Urgent Care

ED

Fraction of Patients with One or More Follow-up Appointments Is Similar

Ear Infection Sore Throat Urinary Tract Infection

0%

20%

40%

60%

80%

100%

Retail Clinic

MD Office

Urgent Care

ED

Quality of Care in Retail Clinics is the Same or Better as Found in Other Settings

Broad-Spectrum Antibiotic Prescribed for A...20%

40%

60%

Retail Clinic

MD Office

ED

More Recent Work on Broad Spectrum Antibiotic Prescribing Rates

Mehrotra et al, under review

Quality Findings Consistent With Other Research

• Patient satisfaction very high1

• Quality– Follow-up visit rates lower2

– Care concordant with guidelines3

1 Harris Interactive2 Rohrer, Qual Manag Health Care, 20083 Woodburn, AJMQ, 2007

Ongoing Debate

• Quality


• Costs

Large Fraction of US Population Has Access to a Retail Clinic

• Almost 90% of clinics in urban areas

• 38% of urban population within 10 min drive

‒ Nashville 94%‒ Minneapolis 96%‒ Las Vegas 92%

• Few clinics in underserved areas

‒ 13% of clinics in Health Professional Shortage Areas (HPSAs) compared to 21% of population

Rudavsky, Mehrotra, JABFM, 2010

Age Distribution of Patients

Series10

10

20

30

40

50

<2

2-5

6-17

18-44

45-64

>65

%


Retail Clinics EDMD Office

Did not use insurance0

10

20

30

40

50

Retail Clinic

MD Office

ED%

Patients Less Likely to Use Insurance for Retail Clinic Visits Compared

to Other Settings


Have a primary care physician0

20

40

60

80

100

Retail Clinic

%Few Retail Clinic Patients Report Having a Primary Care Physician


Impact on PCP Continuity:8% Fewer Patients Have a PCP Visit

Year before Year after0

20

40

60

80

100

%Retail Clinic

PCP Retail Clinic

PCP

Reid et al. JGIM, 2012

%

Impact on Preventive Care:No Negative Impact on Breast Cancer Screening

Year before Year after0

20

40

60

80

100

%

Retail Clinic

PCP Retail Clinic

PCP

%

Reid et al. JGIM, 2012

Summary of Impact on Access & PCP Relationships

• Not focusing on underserved• Attract a different patient population • Often no PCP relationship to disrupt• Impact on PCP relationships

– Modest negative impact on continuity– No impact on preventive care or chronic

disease care

Ongoing Debate

• Quality


• Costs

Ear Infection Sore Throat Urinary Tract In-fection

$0

$200

$400

$600

$800

Retail Clinic

MD Office

Urgent Care

ED

Significant Per Episode Cost Savings at Retail Clinics

Mehrotra et al., Annals of Internal Medicine, 2009

Ear Infection Sore Throat Urinary Tract In-fection

$0

$10

$20

$30

$40

$50

Retail Clinic

MD Office

Urgent Care

ED

No Notable Difference in Prescription Costs

More than 100 Million “Retail Clinic Type” Visits to Physicians and Emergency Rooms

Top 10 Conditions/Service...0

20

40

60

80

100

120

ED

MD Office

Millions of Visits per

Year

Weinick et al., Health Affairs, 2010Mehrotra et al., Health Affairs, 2008

Do Retail Clinics Save Money?Depends on Impact on Overall Utilization

• Substitution‒ Visiting retail clinic instead of physician or ED

‒ No change in overall utilization

• New Utilization‒ Visiting retail clinic instead of staying home

‒ Increase in overall utilization

Issue Our Findings

Quality Little evidence to support concerns Antibiotic prescribing is similar

Access & PCPs

Retail clinics serve different population than physiciansModest negative impact on PCP relationshipNo impact on preventive and chronic disease care

Costs Per visit, there are substantial savingsUnclear impact on overall spending

Summary of Research

Have Retail Clinics Fit the Disruptive Innovation Model?

• Offer affordability, convenience, and simplicity to previously-neglected markets– Southwest Airlines, Netflix, and TurboTax

• Markets too small and low-margin for incumbents to pursue or aggressively defend

• Disruptors improve and expand

Hwang, Mehrotra, Harvard Business Review, 2013

Barriers to Disruption

• Scope of practice laws• Health plan policies

– Included in network– Patient cost sharing

• Reimbursement policy– Fixed – Not tied to actual costs– Incumbents response

• Business model– Seasonality– Fixed costs

Hwang, Mehrotra, Harvard Business Review, 2013

New Wave of Disrupters

• Personal health records• eVisits• Phone visits• Kiosks• OTC testing

ateev mehrotra: retail clinics

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