Patients who are using retail clinics differ from those being seen by PCPs. Retail clinic patients are more likely to be young adults (18–44) who pay out-of-pocket for their care, and who are less likely to have a PCP. The profile of visits to retail clinics is more similar to patients who visit EDs. If retail clinics were not available, it is unclear whether these patients would have gone to a PCP office, urgent care clinic, or ED or if they would have sought medical care at all.17
It is possible that retail clinics could serve as a safety net provider for some patients who currently seek care in EDs. If retail clinics are serving patients who would not have sought care at all, there is the potential for retail clinics to increase overall health care costs. Future studies should examine which, if any, alternative sources of care users of retail clinics considered and why they chose to seek care from the retail clinic.
The scope of care at retail clinics is focused on a small set of clinical issues including upper respiratory infections, sinusitis, pharyngitis, immunizations and conjunctivitis. Just 10 clinical issues encompass more than 90% of all retail clinic visits. In contrast, these same 10 clinical issues encompass 13% of adult PCP visits, 30% of pediatric PCP visits, and 12% of ED visits. Patients may consider these problems to be straightforward and value convenience more than they value seeing a particular provider. Retail clinics might be particularly attractive because it is often difficult to obtain a timely PCP appointment18
and EDs have long waiting times.19
In addition to providing care for acute health problems, retail clinics provide preventive services, primarily immunizations. Immunization rates for US adults continue to be low. As of 2007, 69% of adults 65 and older and 17% of adults 18–49 had received an influenza vaccine in the previous year20
and another study found that just 64% of elderly persons had been offered a pneumococcal vaccine.21
To the extent that convenience is a factor, retail clinics may offer a new venue to increase immunization rates.22
Some have raised the concern that retail clinics may disrupt primary care relationships. We found that three-fifths of patients did not report having a PCP, so for these patients there is no relationship to disrupt. Some argue, however, that urgent care appointments with a PCP enable patients to establish such a relationship as well as provide an opportunity to deliver preventive care.23
We found that in 11% of similar visits to PCPs there was some preventive care ordered or delivered. Future studies should assess whether retail clinics adversely impact receipt of preventive care.
A related issue is coordination of care and the concern that retail clinics could exacerbate the already significant problems in communication across care settings.24
Currently most independent retail clinic providers can provide patients with a printed visit summary from their electronic medical records or the clinic can fax the record to a physician on patient request.25
However, we do not know how often this occurs and whether the pattern of communication is better or worse than what is seen between other care providers.26
Most of the conditions generally cared for in retail clinics likely do not require the level of training of a physician. For some conditions, such as urinary tract infections, computer kiosks have been used to diagnose and treat patients.27
The shortage of physicians, in particular PCPs28
and the stress on EDs suggest that retail clinics could relieve some of the demand on both of these care settings.
Yet some worry that if such a shift of care occurs it could potentially hurt PCPs financially.29
We found that visits to PCP offices for the ten issues most commonly seen in retail clinics (e.g. immunizations, otitis media, pharyngitis) are on average almost 25% shorter than other types of visits. Therefore, if there is a shift in care, PCPs will be forced to schedule fewer visits per hour. Furthermore, simple acute visits, as opposed to visits for chronic disease management, are less likely to generate unreimbursed care outside of the visit.30
Therefore it is possible that a shift in care could hurt PCPs financially. On the other hand if PCPs replace these lost visits for these simple acute reasons with visits for more complex issues that are reimbursed at a higher rate, than the impact could be minimal. The financial impact of retail clinics on PCPs should be addressed in future research.
There are some important limitations of our findings. Although our analyses included the majority of retail clinics, we do not know whether our results are generalizable to other retail clinic companies. Given the expected rapid growth among retail clinics, we also do not know whether the patterns of utilization we observed will remain stable over time. We found no major time trends in patient demographics. As the sector expands, ongoing descriptive studies will be necessary to evaluate trends.
We found that 67% of retail clinic visits and 90% of PCP visits were paid for via insurance. We do not have a direct measure of insurance status of patients and relied on the method of payment as a proxy. Furthermore, because some retail clinic companies provided patient symptoms instead of a diagnosis, our estimates of the number of visits for some diagnoses such as otitis media might be high. We were not able to validate the coding of reason for visits by retail clinic providers, but we have no reason to believe that it is systematically biased. Lastly, our estimates on the frequency of diagnoses at retail clinics could be biased if nurse practitioners, the usual providers at retail clinics, systematically misdiagnosed conditions. But this seems unlikely as previous research has found comparable quality of care between nurse practitioners and physicians.31
The number of retail clinics in the US is increasing rapidly. Recent polls indicate that 15% of children and 19% of adults are very likely or likely to use a retail clinic in the future32
and one report estimates that by 2011 there will be 6000 retail clinics in the U.S. providing over 50 million visits per year.33
Retail clinics appear to be providing care to a patient population less likely to use PCPs and their focus is on a limited scope of reasons for which patients might prefer convenience over a relationship with a particular provider. To what extent the growth in retail clinics will lead to a shift of care from EDs or PCP offices to retail clinics or the disruption of primary care relationships is unknown.