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Retail clinics are an increasingly popular new model of ambulatory care. To understand why patients seek care at these clinics and what their experiences were like, we interviewed 61 patients at six retail clinics. Patients were satisfied with the overall experience and were attracted to retail clinics because of their convenient location and fixed, transparent pricing. Patients with a primary care provider (PCP) sought care at these clinics primarily because their PCPs were not available in a timely manner. If retail clinics were not available, a quarter of patients report they would have gone to the emergency department. Retail clinics appear to be responding to the need for convenient, affordable, and consumer-centered care.
Retail clinics are an increasingly popular model for providing routine ambulatory care. An estimated 17% of Americans have already visited a retail clinic.1 Broader use of these clinics are expected in the upcoming years,2 and the number of clinics is expected to grow from 1,200 currently to almost 2,100 clinics by 2011.3 Generally located in retail stores such as pharmacy chains, these walk-in clinics are typically staffed by nurse practitioners (NPs). Services provided at retail clinics are limited in scope and generally range from acute care for common conditions such as sinus, ear, and urinary tract infections, to routine physical examinations and seasonal flu shots.3,8 Retail clinics focus on convenience and provide extended operating hours, walk-in care, quick service, and “co-locating” next to a pharmacy to ease prescription fillings.7,8 Policy makers hope that retail clinics will improve access to care, prevent unnecessary emergency department (ED) visits and thereby reduce healthcare costs.3,8,9
Since their inception, these clinics have generated much debate. One concern raised by primary care physicians is that the use of retail clinics will disrupt primary care physician-patient relationships.8,10 There is also the concern that patients will inappropriately seek care from retail clinics for serious conditions that should be seen in urgent care centers or the ED; and for chronic conditions that should be treated and followed up in primary care practices.6–8
Despite the controversy, little is known about patients’ perspective on retail clinics.11 Why do they seek care at a retail clinic? What is their experience with these clinics? What alternatives do they have to retail clinics? We sought to begin to fill this knowledge gap by conducting a series of semi-structured patient interviews at six retail clinics operated by two different retail clinic operators.
We purposefully selected six retail clinic locations in California to conduct our study. Three clinics were operated by Sutter Express Care and three by QuickHealth. These two operators, who operate 23 clinics in total, were chosen because they represent two extremes in operating models (Table 1) and have the most operating experience in California.12, 13 At each site, we attempted to interview every patient using a comprehensive sampling approach. However, due to interview staffing limitations, not every patient could be included in the sample (e.g., the interviewer is busy with one patient and misses the opportunity to ask another patient who just finished with the visit to participate in the interview). Resorting to the convenience sampling approach, we conducted in-person interviews with 61 patients who visited one of six California retail clinics. The six locations were selected to gain the widest diversity of patient populations.
The interviews were conducted between August and October 2007 by two different interviewers. To capture the full range of patients, interviews were conducted on weekends and weekdays as well as mornings, afternoons, and evenings. We conducted an opportunistic- sampling method and each patient who visited the clinic was asked to consent for the interview (90% participation rate). Our goal was to interview patients after their visit, but a small number (less than 20%) of patients were interviewed while they were waiting to be seen by a provider. On average interviews lasted approximately 20 minutes. We asked each patient for their permission to call them one week after the visit to assess whether the patient’s health problem had been fully addressed. The study protocol was approved by the RAND Institutional Review Board.
We developed a semi-structured interview instrument with both open- and closed-ended questions, based on a priori knowledge about the value propositions for retail clinics and patient care seeking rationale. These questions focused on: (1) factors that led the patient to visit the retail clinic; (2) alternative options the patient considered; and (3) the patient’s overall experience with the care they received at the clinic. Interviews were conducted in either English or Spanish and were recorded, transcribed, and translated.
To analyze responses to open-ended questions, we used standard qualitative techniques to identify major thematic categories.14,15 Two members of the study team read all transcripts and coded the responses. Disagreements between the two team members were discussed and resolved through an iterative consensus process. Atlas.ti software was utilized to facilitate the management and identification of key quotes.16
We interviewed 61 patients, the majority of whom were first-time visitors to the retail clinic (patient characteristics summarized in Table 2). Most patients (n = 31, 51%) were between 19 and 39 years old. Half the patients (31, 51%) were insured and 19 (31%) reported having a primary care provider (PCP). Patients who visited Sutter Express Care were more likely than those who visited QuickHealth to have health insurance (90% vs. 32%, p < 0.05) and have a PCP (60% vs. 17%, p < 0.05).
A majority of patients (n = 34, 56%) came into the clinic for an acute condition (e.g. sore throat, rashes, upper respiratory infection, urinary tract infection). Nineteen patients (31%) sought preventive care (e.g., physical exams or immunizations). Five patients (8%) came into the clinic for a chronic illness (e.g. diabetes, chronic seasonal allergies).
When asked to comment on their visit, 41 of 61 patients (67%) expressed satisfaction with their care, one expressed dissatisfaction, and the others did not comment on their overall assessment. Of those expressing satisfaction, patients reported that the provider was caring (n = 15); appreciation that the provider spoke Spanish (n = 12); the care was thorough (n = 7); and the provider was knowledgeable (n = 5) and trust-worthy (n = 5). One person said coming into the retail clinic made him feel empowered as a patient and a consumer because it was his choice. Only one patient expressed dissatisfaction and reported that the provider did not “give me what I wanted” without further elaboration.
One-week follow-up phone calls were conducted with 22 patients (36%). The most common reasons for loss to follow-up were wrong phone number, getting a non-verifiable voicemail, and not being able to reach the patient after three attempts. Fourteen of the 22 patients (64%) contacted reported needing no additional care after their visit to the retail clinic. Five patients (23%) were recommended by the retail clinic provider to return to the retail clinic for follow-up care or follow-up with their PCP (if the patient had a PCP). Four patients (18%) sought additional care because they felt their health problem had not resolved: one patient sought at urgent care center and three patients elected to return to the retail clinics.
Table 3 presents the top reasons patients gave when asked “What is it about this clinic that made you come here today,” along with illustrative quotes. The most commonly mentioned reasons included: short travel distance from home/work (n = 47, 77%); reasonable pricing (n = 42, 69%); fast service (n = 38, 62%); little or no wait time (n = 26, 43%); and dissatisfaction with other providers such as PCPs and EDs (n = 22, 36%).
One theme of the patient narratives was a “triage” decision by the patient taking into account the severity of their symptoms, their insurance status and ability to pay for health care. This was illustrated in the idea that for appropriate minor conditions, retail clinics seemed a superior choice than urgent care centers or the ED. Some patients also shared that retail clinics provided a reassuring alternative to the wait-and-see approach or self care because they can now “get a healthcare professional’s opinion.” Some patients with a PCP expressed the idea that if their condition was more serious they would have waited to see their PCP. Some patients without a PCP saw retail clinics as a potential source of primary care.
Patients were asked, “What would you have done today if this clinic is not an available option?” The most frequently considered next-best alternative was “wait to be seen by a doctor” (n = 23, 38%), followed by “just wait and see” including self care (n = 18, 30%), “visit the ER,” (n = 16, 26%), “other care” (e.g., trying to find a provider, non-specific “any clinic that could see me”) (n = 16, 26%), and “urgent care” (n = 11, 18%). Figure 1 shows how these next-best alternatives are further distributed among patients with and without health insurance. The most striking difference was that insured patients were more likely to say “wait to be seen by a doctor” while uninsured patients were more likely to say “visit the ER”.
This study assesses why patients seek care at retail clinics and their experience with the care provided. We find that patients are attracted to retail clinics by the convenient location, prompt care provision, and reasonable, fixed, and transparent pricing. In general patients were very satisfied with their care. This is consistent with results from proprietary patient satisfaction surveys conducted by retail clinic operators such as MinuteClinic, RediClinic, TakeCare, and The Little Clinic, as well as a 2007 healthcare poll and a 2008 health care consumer survey conducted by private firms.1,3,17
There are several lessons from this study that can help inform the current debate on retail clinics. First, our analyses help distinguish between two decision-making models, not always exclusive, that describe why patients seek ambulatory care at retail clinics. The first model conceptualizes the retail clinic as a complement to services provided by the patient’s existing PCP. This model was mostly used by the insured and those with a PCP and was driven by the lack of a timely PCP appointment. If retail clinics were not an option, these patients would have waited to be seen by their PCPs. During the follow-up phone call some patients noted they either had already seen or planned to contact their PCP. For patients without health insurance and/or a regular source of health care, retail clinics offered a superior substitute for urgent care centers and EDs which they found to be overcrowded, with long wait times, and high (and uncertain) pricing. Retail clinics were considered to be more accessible, logistically easier (e.g., less forms to fill out), and more affordable. Without retail clinics as an option, these patients would have no choice but to seek care at urgent care centers and EDs, try to find a provider that would see them, or delay seeking care.
There have been concerns that retail clinic visits would replace visits to PCPs and disrupt patient-provider relationships.6,7 A recent proprietary study of retail clinic users and potential users found that 12% of retail clinic patients with a PCP agreed with the statement “retail clinics have mostly or completely replaced my primary care physician for the type of treatments offered at retail clinics.”18 Our analyses of patient interviews revealed that patients did not wish to replace their PCPs. Rather they used retail clinics as a back-up or alternative for minor health care needs. For more serious issues or chronic illnesses they would continue to see their PCPs. Although retail clinic visits could potentially undermine provider-patient relationship, patients with PCPs mentioned that retail clinics helped them avoid unnecessary visits to the ED when their PCPs were not available. For patients without regular PCPs, there was no provider-patient relationship or care continuity to disrupt.
The operating model for retail clinics makes the assumption that patients are capable of triaging themselves for appropriate care. In other words, patients will not go to retail clinics for life-threatening complaints or those that require complex health assessment and care.6,7 Our study found that patients understood the differences between what problems retail clinics and EDs or urgent care centers could handle. Whether patients can always make the appropriate triage decision is unknown though a recent study found that only 2.3% of retail clinic visits were judged to be outside the scope of care for a retail clinic and triaged out to an ED or PCP.19
Our study lends credence to the potential for retail clinics to serve as a mechanism to deter unnecessary ED visits and thereby help alleviate ED over-crowding.8,9 Patients shared during the interviews that they were willing to pay out-of-pocket for the retail clinic visit in order to avoid long wait times and high prices charged at the ED. With many public health facilities and safety net hospitals facing budgetary constraints, retail clinics may offer a market-based solution to provide health care at a price that is sensitive to patients’ willingness and ability to pay.
This study has several limitations. First, this study had a small sample size and a low follow-up rate. Though our use of qualitative methods provides contextual insights on why patients seek care at retail clinics, we recognize that our findings may have limited generalizability to a larger population. Despite the small sample size, we found consistent themes that repeatedly emerged from interviews with patients at the same clinic and across different clinic locations. This suggests that we have identified the common underlying appeals of retail clinics. Second, this study was conducted at six retail clinics located in California and the two retail clinic operators in this study, Sutter Express Care and QuickHealth, do not represent the typical retail clinic operating model. Sutter Express Care is part of an integrated healthcare delivery system while most retail clinics are independent companies (though recent growing trend of retail clinics has been among well-established integrated delivery systems). QuickHealth employs physicians whereas the predominant model for retail clinics is the NP-model. This might limit our ability to generalize our findings to other geographic regions and to other retail clinic chains. However, these two retail clinic operators share the core elements of all retail clinics—they offer a convenient location in a retail store, walk-in model, extended hours, limited scope of care, and fixed prices. The fact that our study’s findings echo those from proprietary patient surveys conducted by other retail clinics and polls across the country suggests that the basic model and attractiveness of retail clinics are more universal than variant. Also, our study population was composed mostly of young adults who were frequently uninsured and only one-third report having a PCP. They visited the clinics primarily for simple acute reasons and immunizations. This socio-demographic mix and reason-for-visit mix is remarkably similar to the patients seen in a national sample of retail clinic visits and therefore suggests that the patient population attracted to these clinics and care provided is consistent across regions and retail clinic chains.19 Future research should use a structured survey approach with a larger sample across different geographical areas to confirm these qualitative findings and test hypotheses on how patient socioeconomic and health condition influence their choice and experience with retail clinics.
In summary we find that patients are generally satisfied with the care they received at retail clinics. The primary attraction of retail clinics is their convenience and their reasonable, fixed, and transparent pricing. Patients with primary care providers (PCPs) sought care at these clinics primarily because their PCPs were not available in a timely manner. A significant fraction of patients, in particular the uninsured, reported they would have visited an ED if the retail clinic was not available. Retail clinics appear to be responding to a need for convenient, affordable, and consumer-centered care.
California Healthcare Foundation
Conflicts of Interest:
None. The funder had no role in the writing the manuscript or decision to submit the manuscript for publication.
Margaret C Wang, RAND Health, Santa Monica, CA.
Gery Ryan, RAND Health, Santa Monica, CA.
Elizabeth A McGlynn, RAND Health, Santa Monica, CA.
Ateev Mehrotra, RAND Health & Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.