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Approximately fifty million times annually, patients visit physicians for low-acuity conditions such as bronchitis and urinary tract infections.1 Many more would likely visit their primary care physician if there were shorter appointment delays at primary care offices – such delays will likely worsen with the Affordable Care Act as millions gain insurance and seek primary care.
Until recently, patients’ alternatives beyond primary care offices were limited: visit the emergency department or stay home. Now, patients can receive care via a plethora of new options - the internet, a store kiosk, a home nurse, or a grocery store clinic (see Table). These new options’ popularity indicates they fill an unmet need. For example, retail clinic visits increased four-fold between 2007 and 2009 and now account for almost 6 million annual visits.2
While these options target care that makes up a fraction of the US health care market, their growth challenges many larger health care models. They herald a future in which care is commonly provided using forms of interaction other than traditional face-to-face visits. Instead of one primary care “home” that handles all problems, these convenient care options offer specialization for basic primary care problems. Not-for-profit organizations currently provide much of health care, but many of these new care options are supported by venture capital or large for-profit companies. They might indicate herald a future where for-profit companies increasingly compete in the health care industry.
In this viewpoint, I provide an overview of factors driving their proliferation and the issues that need consideration with the increasing popularity of convenient care options.
Wait times for primary care appointments can be lengthy and many clinicians, except perhaps for pediatricians, do not offer evening or weekend hours. Even at a primary care office, patients no longer necessarily see their own primary care physician: the majority of acute care visits are provided by covering physicians or at other care sites.3 A “reasonable” wait time has also changed. A patient wait time of 24-48 hours might be clinically acceptable, but does not resonate with today’s US public. The availability of drop-in visits and evening and weekend hours at these convenient care options makes them comparably attractive. Moreover, they provide care at familiar and convenient sites: home, work, or retail stores.
Convenient care options attract those paying out-of-pocket because they provide lower-cost care--their overhead is lower than that of an outpatient clinic. E-visits and phone visits eliminate the need for physical clinics, and stores can offer health care with little-to-no need for additional space. Most convenient care options use nurse practitioners and physician assistants instead of physicians, minimizing labor costs. Attracted by their potential to save money, many health insurers now encourage and cover care by these new convenient care options.
The emphasis and growth of published clinical guidelines to address acute problems in a consistent algorithmic manner has facilitated the growth of convenient care sites. Kiosks or e-Visits require no direct clinician-patient interaction. Increased use of electronic health records, patient “portals,” and e-prescribing allows easier access and interoperable records.
With automation and interoperable medical records, a patient may identify with a certain convenient care brand, rather than with a specific physician. Just as a person walks into a Starbucks in Seattle or Boston and expects similar—if not identical—lattes, a patient can walk into TakeCare Clinics in Seattle and Boston and expect similar if not identical care.
Traditional systems often focus on higher revenue areas such as hospitalizations, imaging, and procedures over low-acuity problems. Yet, a substantial market for low-acuity care remains. With 50 million annual visits at approximately $100 each, this potentially represents a $5 billion annual market. Many of the alternative care options have an entrepreneurial and venture capital mentality consistent with internet startups. For example, significant investment for MinuteClinic and TelaDoc came from venture capital.
The benefits of these new options is largely conceptual as there is little evidence on their effects on public health. The foremost concern is how their care compares to care of traditional clinicians and whether a focus on patient satisfaction—which permeates these convenient care options —might lead to poor quality and overprescribing. To date, there is little evidence to support these concerns,4–6 however the evidence is limited. While the care is less expensive on a per-visit basis,7 these new care options could lead to more people seeking care which would increase both utilization and spending. While these convenient care options could improve access they could also decrease continuity of care and increase fragmentation, which is important given the link between continuity and better outcomes. Also, the loss of revenue from treating low-acuity conditions could lead to increased financial pressure on primary care practitioners and EDs.
The future influence of these convenient care options largely depends on two issues. The first regards whether they expand beyond the scope of low-acuity care. In the business model of “disruptive innovations,”8 new market entries first focus on the less expensive and less attractive aspects of the market (for example, low-acuity conditions), then gradually expand their scope. Signs of this expansion have manifested. Retail clinics have expanded into chronic illness care, some worksite clinics and urgent care centers offer full primary care, and e-Visits can offer specialty consultations.
The second issue is whether convenient care options offer an attractive alternative to existing primary care clinicians. Many health systems have begun to offer their own retail clinics, urgent care centers, or e-Visits. Whether these new efforts are sufficient remains to be seen, but primary care practitioners risk a slow but steady decline in their scope of care if they do not offer a viable alternative to these new convenient care options.
This study was supported in part by funding from the National Institutes of Health (R21 AI097759-01). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
The author has no conflicts of interest to disclose.