The Perils, Promise of Retail Clinics in California

The idea is simple: When you’re at the mall or shopping at a large drug store, you can also stop in to see a health provider about that cold you’ve had. Or you can get a flu shot. Or your daughter can get a quick physical exam for school sports.

There are now at least 47 retail clinics around California — set up inside more than three dozen CVS pharmacies spread across Southern California, and in Northern California inside Rite Aid and Farmacia Remedios drug stores, along with one Whole Foods grocery store.

Peter Dzwilewski is the director of Sutter Express Care, which is running three retail clinics in the Sacramento area. “When Sutter saw the trend in growth, they wanted to be the ones to provide this high-quality affordable care to the community,” Dzwilewski said.

Sutter launched a total of six retail clinics in 2006, but last year shuttered three of them. When no one has heard of retail clinics, and few people know about the counter in the back of a Rite Aid in Elk Grove where you can get flu vaccinations, then little things like proper signage and more foot traffic take on much greater significance. It’s the cost of trying something new, Dzwilewski said.

“We were the first one (in the Sacramento area),” he said. “And being first to market comes with a price.”

The remaining three outlets, all in Rite Aid pharmacies, have been successful beyond expectations, Dzwilewski said, with high rates of patient satisfaction in surveys.

“I can tell you, it’s been a very patient-satisfying model,” he said. “We’re also seeing that in growth of repeat visits. We’ve seen growing acceptance among patients. It just takes time to create awareness.”

California Challenges

Retail clinics have expanded more rapidly in other states, in part because they are able to directly hire mid-level practitioners to staff the sites. California laws limit direct hiring, and nurse practitioners are required to have some physician supervision when treating patients.

But because retail clinics almost exclusively utilize nurse practitioners to care for patients, interest for these clinics among California practitioners is high, according to Colleen Keenan, chair of the practice committee for the California Association for Nurse Practitioners.

“A lot of nursing (practitioners) have been interested in monitoring the Minute Clinics,” Keenan said, referring to the chain of 37 retail clinics in Southern California. “It’s a great concept in terms of access to health care; it’s a wonderful and needed service. There are many who wouldn’t have access to health care without it.”

There are now 8.2 million Californians without medical insurance, according to a recent report by UCLA researchers. For some of them, being able to get quick, low-cost, out-of-pocket medical care makes a lot of sense.

“Some access is better than no access, no doubt,” said California Medical Association spokesperson Andrew LaMar. “We want to be sure people get the care and treatment they deserve.”

That care and treatment may not be just at the shopping mall, LaMar said. Most retail clinics in California, he said, have been conscientious about ensuring patients get follow-up care with a physician for health conditions. LaMar was especially impressed with the Sutter effort to provide a high level of medical service and follow-up.

Using Retail Clinics

It is not just uninsured or underinsured patients who go to retail clinics. Dzwilewski said that about half of the Sacramento-area retail clinic patients have insurance, and half of them self-pay.

There is also a niche for retail clinics among the Latino community. Four QuickHealth clinics operate in Northern California, in the Farmacia Remedios chain of stores.

“So far, a lot of the business is seasonal,” Dzwilewski said. “We see more people during cold and flu season, and during sports-physical season. Kids are notorious for coming to parents with the physical-exam form the day before it’s due.”

The clinics do two things, he said. They make health care convenient for patients Sutter already has, and they attract patients outside of the Sutter system, so the possibility exists that they could become Sutter patients.

“It’s an important niche,” Dzwilewski said. “It’s affordable, convenient, accessible — with close proximity to the pharmacy, so everything can be done in a timely manner.”

Reform’s Effect

Accessibility is one of the watchwords of national health care reform. The federal law does not mention retail clinics, but the ready availability of medical care — particularly low-cost primary care — fits well with the concepts of health care reform.

“It all comes back to access,” Keenan said. “That’s what people need.”

“This model is integrated with the health care continuum,” Dzwilewski said. “We think there will be continual growth in demand, and we expect to see steady growth.”

However, the primary niche for retail clinics is to reach the uninsured and underinsured. And if the majority of that patient pool is expected to get health insurance coverage under the new legislation and, along with emphasis on the medical home, makes the future of retail clinics a bit uncertain.

“I don’t think we can predict the future at this point,” Keenan said. “Retail clinics right now bring in people who live outside the system. And in terms of health care reform, we’re looking at the patient-centered medical home.”

“Ongoing issues are going to be better served by the medical home,” LaMar said. “Health care reform will provide greater access, so patients can see a doctor in the office. And things aren’t so cut-and-dried in medicine, so if you have questions, you may want to see a physician. Not everyone who goes in for the flu has the flu.”

At the same time, for health conditions that are not necessarily ongoing, the retail clinics could act as a sort of primary care gatekeeper. “One of the predictions is that we’ll be providing access to millions more patients,” LaMar said, “and we have a shortage of physicians and nurses already. It does create this dynamic of how best to use primary care providers, and I’m not sure what the long-term solutions will be.”

From the retail clinic point of view, there is no question that the convenience of care will remain a strength, and retail clinics will adapt their approach to match the tenets of national health care reform.

“There are so many aspects of health care reform, it’s so hard to forecast what will happen,” Dzwilewski said. “But what I can tell you is, our model fits in well with the overall Sutter model of care, and with the concepts of reform.”

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