There has been concern that the increasing number of patients receiving care at retail clinics might lead to increased health care costs, greater rates of misdiagnoses, over-use of antibiotics, and decreased delivery of preventive care. When we compared these aspects of care in retail clinics, physician offices, urgent care clinics, and emergency departments, we found little evidence to support these concerns.
In our study of the care for three acute illnesses, the costs of care in retail clinics were 30 to 40% lower than those in physician offices and urgent care clinics and were 80% lower than those in emergency departments. The differences were primarily attributable to lower reimbursements for E&M visits and also lower rates of laboratory testing in retail clinics. This is consistent with other cost comparisons using a different method.(31
We found that the quality of care in retail clinics was similar to care provided in physician offices and urgent care clinics and slightly superior to the quality in emergency departments. Nurse practitioners, rather than physicians, generally provide the care in retail clinics and our finding is consistent with previous research showing no difference in the quality of care delivered by nurse practitioners and physicians.(32
) There have been concerns that, because they are owned by pharmacy chains, retail clinics will be more aggressive in terms of prescribing antibiotics. We found similar rates of antibiotic prescribing at retail clinics, physician offices, and urgent care clinics. We could not independently assess the accuracy of diagnoses, but if patients are misdiagnosed at their initial visit to a retail clinic, we would expect more patients to have a follow-up visit which was not the case.
There have also been concerns that patients who visit retail clinics will be less likely to receive preventive care than if they had received similar care at a physician’s office. We found that the rates of preventive care received at the initial visit through the subsequent three months were similar. For patients who visit a retail clinic, preventive care was typically delivered in a physician’s office suggesting that the clinics are not disrupting opportunities for preventive services.
Our study had several limitations. We focused on commercially-insured patients in Minnesota few of whom had co-morbid illnesses. Consistent with previous analyses of the demographics of retail clinic patients,(2
) the majority of patients in our sample were female and young adults. Moreover, the patients in our sample lived in zip codes with higher incomes and all had insurance. Nationally up to one-third of patients who visit a retail clinic do not use insurance to pay for the visit.(2
) Therefore our findings may not generalize to other regions of the country, patients who are uninsured or with public insurance, the poor, the elderly, and those with numerous chronic morbidities. MinuteClinic is the dominant retail clinic in Minnesota and our results might not generalize to other retail clinic chains though most chains use a similar care model and MinuteClinic currently operates 52% of all retail clinics in the United States.(2
) Also, our comparison was limited to three acute diagnoses which are among the most common reasons for retail clinic visits, but our results may not generalize to other conditions. While we found no adverse impact on preventive care, it is possible that in the future if patients visit retail clinics for most of their care than preventive care might be adversely impacted. We analyzed claims, and this limited the scope of quality metrics and preventive care services examined. We measured costs by summing health plan reimbursement and patient co-payments, but the uninsured are often charged more than health plans(34
) and therefore we may have under-estimated the savings for the uninsured.
We matched patients on four criteria, but it is possible that the case and control patients remain different. For example, despite our matching, patients who visited a physician office could have had more severe chronic illnesses, patients who visited the emergency department could have a more severe acute illness, or patients who visited a physician could have been treated for both an acute illness and a chronic illness. In our sensitivity analyses that addressed these concerns we found similar results implying there was no notable selection bias after matching. Nonetheless, we acknowledge such differences remain a possibility because physicians might treat a chronic illness, but not list this chronic illness as a secondary diagnosis code. Aggregate patient costs over twelve months for the patients who visited a physician office ($1435) or emergency department ($2157) were higher than those who visited the retail clinic ($1236) and these differences could represent unmeasured differences in severity of illness.
In the emergency department, fewer patients were treated with antibiotics for otitis media or pharyngitis. This could be because these patients were less ill, there was more judicious use of antibiotics, or there was a different mix of clinical presentations between the care sites.
Our findings do not imply that the overall populations of patients who visit the care sites are similar. Our comparison is limited to a limited pool of patients who are matched on characteristics. It is likely that patients with a mild illness and few comorbidities triage themselves to a retail clinic while those with a more severe illness or more comorbidities will go to their physician or to an emergency department. From a societal perspective, if more patients with a mild illness go to a retail clinic this might lead to a better allocation of health care resources.
There are several concerns with retail clinics that our study cannot address. It is possible that greater market penetration of retail clinics will exacerbate the already substantial problems of fragmented health care and poor communication among health care providers and between patients and providers.(13
) 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.(37
) 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.(36
) Furthermore, because retail clinics are very convenient to use, patients who would not have sought any care previously may now go to a retail clinic.(38
) This would increase overall health care utilization and in turn increase costs. We found that overall costs of care for a one year period were comparable or lower among patients who went to retail clinics, but this issue needs to be addressed more fully in further research.
In conclusion, we found that for three common illnesses retail clinics offered services at lower costs than alternative settings with quality that is good or better and that patients who visited retail clinics were as likely to receive preventive care as those who visited other care settings.