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Rena Rudavsky, RAND Health, 1200 South Hayes Street, Arlington, Virginia 22202-5050 Craig E. Pollack, RWJ Clinical Scholars Program, University of Pennsylvania, 1303-BBlockley Hall, 423 Guardian Drive, Philadelphia, PA 19104
As a new model of care in the United States (US), retail clinics have generated much interest. Located physically within a retail store, they provide simple acute and preventive care services for a fixed price and without an appointment.
To describe where retail clinics have opened in the US, their ownership structure, scope of practice, prices, acceptance of insurance, and the fraction of the population that lives within a short driving distance of a clinic.
Cross-sectional descriptive study
All retail clinics operating in the US as of August 2008
Population living within five and ten-minute driving distances of a retail clinic
In August 2008, 42 operators ran 982 clinics in 33 states; 88.4% were located in urban areas. An estimated 13.4% and 35.8% of the US urban population lives within a five-minute and ten-minute driving distance respectively from a retail clinic. The proportion of the population that lives close to a retail clinic is higher than 50 percent in some cities such as Nashville (56.7% five-minute, 93.7% ten-minute) and Minneapolis-St. Paul, MN (50.9%, 96.0%). The majority of retail clinic operators (25, 59.5%) are hospital chains and/or physician groups, but they only operate 11.4% of the clinics nationally. Simple acute conditions, skin conditions, and immunizations make up the majority of retail clinics’ limited scope of practice. Across operators, those without insurance paid on average $78 for a sore throat visit and $63 for an adult tetanus booster vaccine. In a random sample of clinics, we found that 97% accepted private insurance, 93% accepted Medicare fee-for-service, and 60% accepted some form of Medicaid.
Geographic access is only one of many factors that influence whether an individual visits a retail clinic
Retail clinics can provide care for simple acute conditions and immunizations for a significant segment of the urban US population.
California Healthcare Foundation
Retail clinics are clinics physically located within retail stores, such as grocery stores, drugstores, and “big box” stores like Wal-Mart (1–3),that provide walk-in care for a limited number of acute illnesses and preventative care services.(4) Generally staffed by nurse-practitioners, retail clinics focus on patient convenience by requiring no appointment and offering night and weekend hours. The costs of care are fixed, known to the patient before care is received, and reimbursed by most health insurance plans.
The number of retail clinics increased more than ten-fold from 2006 to 2008 (5) and an estimated three million patients visited retail clinics by 2008.(3) Some physician societies have expressed concern about the growth in retail clinics (6–8) while many policymakers cite their potential to improve access to care.(2, 7, 9–16)
To characterize this new health care delivery system, we describe the geographic distribution of retail clinics; their scope of services, prices, insurance policies, and ownership; and we estimate the proportion of the population that has easy access to a clinic.
We defined retail clinics by three criteria: (1) location within a retail store, (2) staffing by nurse practitioners or physician assistants, and (3) a limited menu of services with pre-specified fixed prices. Using this definition we compiled a list of retail clinic operators (owners) between June and August of 2008 using a 2007 foundation report on the retail clinic model (1); the membership list of the retail clinic industry trade group (17); and the website of Merchant Medicine, an organization that provides consultation services to the retail clinic industry. We included 17 operators whose clinics met fewer than the three criteria (used physician providers (n=2), had clinics located outside a retail store but within a retail setting such as a shopping plaza (n=13), or both (n=2)) but otherwise fit the model. Two retail clinic industry experts, one the author of several reports describing the retail clinic industry (1, 3, 18, 19) and the other an employee of the retail clinic industry trade group, reviewed our initial list. At their suggestion we examined six other operators and included three for a final sample of 42 operators and 982 retail clinics.
From the operators’ websites we collected information on the retail clinics’ scope of services, ownership, and prices charged for two commonly offered services: sore throat visit and adult tetanus booster vaccine. We also collected information on hours of operation and accepted insurance plans for a random sample of 100 of the 982 clinics. We contacted the operator directly for information when it was not available or ambiguous on the website. If a clinic accepted any type of Medicaid insurance including Medicaid managed care, we classified it as accepting Medicaid. Two of the 100 locations closed since we collected original study data, so we report data on hours and insurance for 98 clinics.
We obtained clinic addresses from operator websites and used Geospatial Imaging Software (GIS ArcInfo v9.3 ESRI Inc., Redlands CA) to map the location of each clinic.
To assess the proportion of the US population that has easy access to retail clinic services, we defined a clinic’s catchment area around each retail clinic to be a five-minute driving distance in each direction, because previous research has used five minutes as the time persons are willing to travel to some retail stores.(20) We used the ArcGIS Network Analysis service area tool within GIS ArcInfo to define point-boundaries for the area around the clinic in every direction based on road-based travel, and to create a boundary loop by making linear connections between the point-boundaries. The calculated travel time incorporates average driving speed on the type of road (e.g. faster speeds on highways), but does not incorporate typical traffic levels. We also used a 10-minute driving distance catchment area to provide less conservative estimates.
To estimate the fraction of the entire population that lives within retail clinic catchment areas, we used data from the 2000 US Census and totaled the population of census blocks whose centroid was in the retail clinic catchment area. As most retail clinics are located in urban areas, we also estimated the fraction of the US urban population that lives within retail clinic catchment areas. The US Census Bureau defines urban areas as regions with a population greater than 500-1000 people per square mile and adjoining areas.(21)
This work was supported by a grant from the California Health Care Foundation. The funder had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. None of the authors have a financial interest in or a financial conflict with the subject matter or materials discussed in this manuscript.
Figure 1 maps the location of the 982 retail clinics operating in the US as of August 2008 (Table 1). Most (88.2%) were in urban areas and most (73.2%) were located within drug stores, followed by grocery stores (15.2%), other retail settings (e.g. Wal-Mart or Target) (7.2%), and in other locations such as shopping plazas, malls, government buildings, or airports (4.4%) (Table 1) (see online Appendix Table 1 for location of clinics broken down by operator.) Nine hundred fifteen retail clinics (93.3%) were located in a store with a pharmacy (either a drugstore or non -drugstore retail setting such as a grocery store or retail warehouse).
More clinics were located in the South (425 clinics, 43%) and Mid-West (304 clinics, 31%) than in the Northeast (91, 9%) and West (162, 16%). Almost half the clinics (45%) were in Florida (134 clinics, 13%), California (89, 9%), Texas (75, 8%), and Minnesota (70, 7%)(Table 2).
Seventeen states had no retail clinics (see online Appendix Tables 2 and 3 for number of clinics and operators in each state and region.)
Operator information suggested that all clinics offered treatment of sore throat and cough (100%), and most offered treatment of minor skin conditions (99.7%); immunizations (98.9%); routine preventive health examinations or preventive screening (e.g. cholesterol testing, diabetes screening) (96.2%); pregnancy testing (96.0%); and treatment of allergies (95.6%). Less commonly, the clinics offered smoking cessation counseling (57.6% clinics), travel-related services (4.8%), HIV and/or sexually transmitted disease testing or counseling (3.0%), prescription refills (1.6%), and weight loss counseling (1.2%).
For a sore throat visit, operators charged an average of $78 (range $35-254). For an adult tetanus booster, the average price was $63 (range $15 to $254). The average price across operators weighted by the number of clinics run by the operator was $59 for a sore throat visit and $39 for an adult tetanus booster vaccine. In our random sample of 98 clinics, almost all (97%) accepted private insurance and Medicare fee-for-service (93%), and 60% accepted some form of Medicaid (including Medicaid managed care). In a random sample of 98 clinics, all had weekday and weekend hours, and 95 (97%) were open some weekday evening hours (after 6 pm).
Among the 42 different clinic operators, 25 (60%) are existing healthcare companies such as hospital chains and/or physician groups (e.g., MayoClinic, SutterHealth). They operate 11% of the retail clinic locations and of ten partner with retail stores to house the clinics.
Three retail clinic operators that are fully owned subsidiaries of for-profit retail chains (CVS (MinuteClinic), Walgreens (TakeCare), and Target (TargetClinic) operate 73% of clinics. Eleven of the retail clinic operators are for -profit companies that partner with retail stores to house their clinics. Often these operators have clinics in stores run by more than one retail store chain. The remaining 3 retail clinic operators (4 clinics) only have clinics outside a retail store (e.g. Aeroclinic has two locations in airports) (see online Appendix Table 4 for breakdown of operators by type.)
We estimate that 10.6% (29.9 million) of the total US population (281.4 million) lives within a 5 minute driving distance of a retail clinic, and 28.7% (80.7 million) lives within a 10 minute driving distance, although these proportions vary widely by state (Table 2). The five states whose populations live closest to retail clinics are Nevada (34.1% within a 5-minutedriving distance, 70.9% within a 10-minute driving distance), Minnesota (28.1%, 54.4%), Illinois (24.3%, 57.7%), Florida (23.4%, 50.7%), and Maryland (20.9%, 50.6%).
These proportions are slightly higher for the US urban population. We estimate that 13.4% (29.7 million) of the US urban population (222.4 million people) lives within a 5 minute driving distance of a retail clinic, and 35.8% (79.6 million) live within a 10 minute driving distance. The five cities whose population lives closest to retail clinics are Nashville (57% within a 5-minute driving distance, 94% within a 10-minute driving distance), Minneapolis-St. Paul (51%, 96%), Las Vegas (51%, 96%), Milwaukee (44%, 89%), and Miami (43%, 85%) (see online Appendix Table 5 for list of largest 50 cities in terms of population and fraction that lives within a retail-clinic catchment area.)
As of August 2008, 42 operators managed almost one thousand retail clinics in the US and almost half of the clinics were located in just four states. One third of the US urban population lived within a ten-minute drive of a retail clinic. Almost all clinics provided care for minor acute illnesses, immunizations, as well as preventive health examinations or preventive screening. Some clinics also provided smoking cessation or weight loss counseling. Nearly all retail clinics offered evening and on weekend hours. Most clinics accepted private insurance and Medicare and over half also accepted some form of Medicaid. Although hospital chains and/or physician groups comprised the majority of retail clinic operators, they ran just 11% of the clinics.
To our knowledge, our study is the first systematic description of the industry in the published literature. Of the 49 articles that have been published on the retail clinic industry (English-language MEDLINE search from January 2000 through May 2009 using search terms “retail clinic” or “retail health clinic” or “retail-based clinic” or “in-store clinic”), only six are empirical studies.(4, 22–26) The focus of these six studies is the quality of care provided, the impact of retail clinics on utilization or costs, or who visits retail clinics and for what reason.
Although previous published articles described retail clinics as a nascent healthcare delivery model, (2, 3, 27, 28) retail clinics are now operating in 33 states. Further, in some cities more than 90% of the population live within close driving distance of a clinic. It is possible that the state variation in number of clinics is driven by state regulations such as nurse practitioner scope-of-practice laws or how retail clinics are licensed.(2, 25, 29)
In prior work, the majority of retail clinic visits were shown to be for minor acute illnesses and immunizations.(4) There has been interest in whether retail clinics will expand beyond this basic scope of care, in particular in the area of chronic disease management.(2, 3, 27, 30) We find that, to date, there has been no expansion into chronic disease management and only limited expansion into counseling services.
Physician associations have expressed concerns that the growth of retail clinics will adversely impact the coordination of care and patient-primary care provider relationships.(7, 9-13) The increasing number of hospital chains and/or physician groups that operate retail clinics might lessen these concerns, because at these clinics primary care physicians and retail clinic providers can share a common electronic record.(22, 31, 32) In addition, new types of partnerships between existing providers and retail clinics have developed.(32) Wal-Mart has partnered with local hospital chains to “co-brand” clinics within their stores (33) and MinuteClinic and the ClevelandClinic have recently announced a partnership to run nine clinics together and to integrate their electronic medical records.(34)
In the original model retail clinics did not accept insurance,(2,18) but there has been a significant shift in practice. Now almost all clinics accept private and Medicare insurance and the majority accept some form of Medicaid. Evidence that retail clinics are less costly might have driven greater acceptance by these payors.(24) To encourage more retail clinics visits, one private insurer has waived the co-payment for retail clinic visits.(35)
Our analysis had several key limitations. Based on earlier retail market research, we used a five-minute driving distance to define a retail clinic catchments area. However, patients may differ from other retail consumers in the distance they are willing to travel. We looked at the entire population within a catchment area recognizing that this population is the “possible clientele” rather than the “probable clientele” of the retail clinic. A given clinic may accept one Medicaid managed care plan but not others, thus we may overestimate the number of clinics where a Medicaid enrollee could receive care. The distinction between an urgent care clinic and retail clinics is sometimes blurred and some might disagree with the inclusion of some clinics in our sample. For example, Dr Walk-In has two clinics staffed by a physician, but the clinics are located inside a drugstore and have a limited scope of care. Lastly, we created our inventory of clinics in the summer of 2008. Since that time, new clinics have opened, some clinics have closed, and two operators have gone out of business. But the overall rate of growth has slowed since that time (36) and we believe our findings are still representative of the industry.
Continuing to monitor the location and characteristics of retail clinics over time will help providers and policymakers better understand their potential impact on healthcare.
We thank Mary Kate Scottand Caroline Ridgeway for reviewing the list of retail clinic operators as well as Preethi Sama and Martha Timmer for their time collecting data and programming.
Grant Support: The study was supported by a grant from the California Healthcare Foundation. Dr Mehrotra’s salary was supported by a career development award (KL2 RR024154-03) from the National Center for Research Resources, a component of the National Institutes of Health, and Dr. Pollack’s salary was supported by the Department of Veterans’ Affairs and the Robert Wood Johnson Foundation Clinical Scholars Program.
Disclaimer: This is the prepublication, author-produced version of a manuscript accepted for publication in Annals of Internal Medicine. This version does not include post-acceptance editing and formatting. The American College of Physicians, the publisher of Annals of Internal Medicine, is not responsible for the content or presentation of the author-produced accepted version of the manuscript or any version that a third party derives from it. Readers who wish to access the definitive published version of this manuscript and any ancillary material related to this manuscript (e.g., correspondence,corrections, editorials, linked articles) should go to www.annals.org or to the print issue in which the article appears. Those who cite this manuscript should cite the published version, as it is the official version of record.