Retail Clinics: Case for Concern?
HEALTHCARE PRODUCT DESIGN STRATEGY
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Retail clinics are here to stay. Globally-recognized healthcare business expert, Dr Maria Todd discusses the business model; its strengths and weaknesses.
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ALL RETAIL HEALTH OUTLETS ARE NOT THE SAME
What is retail care?
Maria Todd: Retail care and retail clinics are a fast evolving business model such as freestanding emergency rooms, grocery and pharmacy site clinics and other health sites such as urgent care clinics, walk-in centers and low-acuity service centers that will provide for more everyday needs with a focus on chronic disease management while offering services like blood draws and sleep testing. It’s been announced by some brands that they may also include dental centers in the not too distant future.
Are they eligible for payment through health plans?
Maria Todd: Absolutely! They are less expensive than walking into to the emergency department after hours and many have been established by the payers, themselves as a brand expansion product.
The average adult encounter in an emergency department can cost the health plan between $1300-1600 and the average pediatric visit to an emergency department can cost the health plan between $1500-1900. Even after a stiffer, higher penalty cost share, the savings afforded both the health plan and the insured beneficiary at a retail walk in health delivery and diagnostic site speaks for itself.
Most retail clinics have a $40-65 “visit fee” and then add on a la carte services such as mono-spot testing, urinalysis, swab testing, blood tests, prescription medications, immunizations, travel vaccines, and other services limited only by space and capital to purchase the diagnostic testing equipment.
Are retail clinics a financial threat to traditional primary care and specialty practices, nearby?
- telehealth which is rendered both synchronous (live communication by screen, phone or web app) and asynchronous (leave a message, fill in a form, and the practitioner gets back to you shortly thereafter with recommendations or calls in a prescription for you.); or
- retail walk-in services where they can just drop in if they have a cold, flu-like symptoms, a possible ear or sinus oor urinary tract infection, or need a flu shot or some other preventive immunizations, or similar. They can decide it’s more convenient to visit to their local CVS or equivalent in-store healthcare provider because they can seek care without an appointment without delay during expanded hours when their primary care office is not open; or
- they can choose a freestanding emergency room or an urgent care center that offers x-rays, casting, and other expanded services and basic on-site lab tests.
Traditional physician practices and medical groups are transitioning to a slightly higher level of care for patients with more complex healthcare management issues where they can establish a relationship with a specific physician or medical group on an ongoing basis.
How many retail clinics exist across the USA?
Maria Todd: CVS Pharmacy is stepping up its healthcare offerings by rolling out 1,500 “HealthHUBs” by the end of 2021. Currently there are 1100 MinuteClinics mostly located in Target Stores. Walmart, Walgreens and other pharmacy and retail outlets also exist. Urgent care centers number about 9,000 and there are around 550 freestanding emergency rooms, many of which have been having difficulty contracting with health plans prior to the COVID19 pandemic. Will this change post COVID19? Nobody knows.
Are these retail clinics accredited by Joint Commission, AAAHC or some other accreditor?
Maria Todd: Retail clinics can be accredited by the Joint Commission or the Urgent Care Association of America (UCAOA). These two accrediting bodies offer slightly different “products” for retail care site accreditation.
Accreditation is is a voluntary process of review that allows healthcare organizations to demonstrate their ability to meet regulatory requirements and standards established by a recognized accrediting body. Each accrediting body sets standards for patient safety, quality and operations.
Trained external surveyors arrive (usually by appointment, rather than unannounced) and review operations, documentation, policies and procedures, to “assure” that the operations, documentation, policies and procedures meet the pre-established performance standards to the average level of service, operations, quality and safety in the community in which the care is delivered.
What this means to the layperson is that the care of an accredited retail clinic in Cedar City, Utah, for example is not necessarily the same as one might encounter in Los Angeles, Las Vegas, or Chicago or even in St George, Utah about 50 miles south.
Accreditation formally started in the United States with the formation of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1951. That organization is now rebranded with the name “the Joint Commission” (TJC). On the international scene, a separate and distinctly different organization (separate board, corporation, standards, etc.) is known as Joint Commission International” (JCI). Both are headquartered in Illinois – in the same office complex – but they are not related other than the fact that they are healthcare accrediting bodies with huge advertising and marketing budgets to aid in positioning and branding. TJC does not accredit healthcare entities outside the USA and JCI does not accredit healthcare entities inside the USA.
There are also many private accrediting bodies that are unrecognized but market as if they are a “legend in their own minds.” Boasting about accreditation is meaningful in marketing and advertising messages only if the accrediting body’s reputation is meaningful to the consumer or payer. Otherwise, the mention is just “noise”. An unrecognized accreditation adds little value in the reputation and trust analysis by the patient.
In addition to accreditation, there are other bodies used worldwide in healthcare to regulate, improve and market the services of healthcare providers and organizations. These include, but are not limited to Certification and Licensure. Certification involves formal recognition of compliance with set standards (e.g., ISO 9000 standards) validated by external evaluation by an authorized auditor. Licensure involves a process by which governmental authority grants permission, usually following inspection against minimal standards, to an individual practitioner or healthcare organization to operate in an occupation or profession. I am often hired by healthcare organizations to help coach them through successful preparation for accreditation, certification and licensure, as I bring them experience with these programs as a former healthcare administrator, a former OR nurse, and I have experience preparing for surveys by about 11 of the 20+ recognized accrediting bodies around the world.
Pricing for many of the accreditation “schemes” as they are called (not intended or used as a derogatory term) is often based on the total patient volume of all centers in an operation, as well as the number of sites to be accredited. Last I checked, with TJC, a five-center urgent care operation with each center averaging 12,000 visits per year, would cost $23,960 plus travel and expenses for surveyors. For a 12-center operation each with 12,000 visits per year the TJC accreditation would would cost about $33,400 plus travel and expenses. In addition to this, they would incur costs for internal preparation and any consultation by a prep coach such as myself. The cost for the consulting is usually broken up into three parts: the initial evaluation and “gap analysis” which requires interviews with key personnel in the field work and report writing. Travel costs are incurred as well.
The second part is where any gaps are corrected prior to survey. The retail clinic decides if they will address them independent of the with the support of a consultant either in person or by remote telephone and web-meeting support. If remote, travel time and costs are spared.
The third part is a “mock survey” in which the consultant returns to the field and conducts a rehearsal survey in an attempt to ensure readiness and successful passage of the survey. None of my clients have ever failed their survey – either in the USA or abroad.
In both the mock survey and the actual survey by the accreditor, surveyor(s) will come visit your retail site(s), interview staff and patients, and validate that you meet the published standards for the urgent care versus retail clinics.
The average “mock” or actual accreditation survey lasts two to three days. As surveyors or the consultant(s) prepare for departure, an exit conference is held and preliminary findings are provided on-site in a written report at the end of the survey. If there are findings that need correction, the organization works with to correct any deficiencies.
During my mock surveys, I include what is called a “tracer” analysis whereby I randomly choose a de-identified patient and examine every aspect of that encounter, who interacted with them, and review credentialing and privileging of the clinicians, job descriptions, what occurred during the entire encounter, forms filled in, insurance verification and billing if applicable, staff job descriptions of each person involved (admin or clinical). Some of the accrediting bodies use this method to ensure that the policies and procedures are not simply “window dressing”.
Accreditation lasts for a set period of time, typically 24-36 months. At the appointed time, the healthcare entity decides if it will invest in re-accreditation by the same accrediting body. Regardless of which accrediting body is selected, the entire process I described above is repeated and the cost is whatever the then current price is charged by the accrediting body and/or the consultant if the client entity chooses to engage the consultant for a gap analysis or mock survey and the coaching time for any gaps noted.
What are some of the drawbacks associated with retail clinics?
My primary concern is care continuity and clinical fragmentation. I’ve experienced it for myself, my husband, my family members, and friends. Personally, I prefer to have a physician with whom I have an established trust relationship.
I actually prefer to work with a concierge physician. I am willing to pay more per encounter and a membership fee with the right physician operating a concierge medical practice that offers the extra amenities I want to purchase even if my insurance won’t cover the costs of the membership fee. Some people simply don’t care. They want what’s cheapest and convenient – to them.
In the concierge business model that’s right for me (they aren’t all the same) the doctor limits their practice to a maximum number of patients they feel they can manage at a certain service and quality level and that physician and his/her/their staff become my “medical home” to coordinate care continuity for me with other diagnostic and specialist services.
Because of my clinical training and experience, I am an excellent diagnostician for a non-physician. Paired with the right clinician, and with trust established between us, my concierge physician can manage my care via email, text, phone, webchat or in their office during extended hours, on a weekend or during regular office hours.
By selecting a concierge physician, I have avoided the use of an emergency room (and its associated costs) for the past 10 years. They trust me when I describe symptoms and I trust them. They have access to my medical history on their phone, tablet or computer anytime, anywhere. I don’t have to reiterate everything for them each time I speak with them.
In contrast, if I use a walk-in or urgent care outlet for a first time, all that care coordination is absent. There’s little if any care coordination, I have to describe symptoms, allergies and past medical history right there on the spot. At 62, with my complex medical history and chronic conditions, that takes time. When one is unwell, often patience is in short supply. The care I receive from a concierge physician versus a retail clinic is incomparable.
I’ve used retail clinics since about 2005 when it was appropriate to do so. For example, I visited a Walgreen’s outlet for travel vaccines prior to traveling to Africa for a consultation in Nigeria. They had to order the vaccines I needed, but the price was cheaper than my doctor’s office and they could get them sooner. I had to provide proof of the vaccines to obtain my VISA for Nigeria. Time was of the essence. But it was up to me to provide all the medical records of each vaccine to my concierge physician – which I was able to do by fax with a scan of all my documentation and receipts.
In another instance, in Minneapolis, several speakers at an event all became ill with some virus that left us hoarse and miserable. We walked across the street from the multi-day event venue and came back to the hotel with what we needed to relieve our symptoms so we could carry on with what we were hired to do.
In Florida, I woke up in a hotel in the middle of the night with renal colic associated with a kidney infection and passage of a kidney stone. I have had them in the past and knew exactly what was happening. The retail clinic was open at 8am, and between pain medication that I had with me and a check with the nurse practitioner on duty and some prescription medication for the infection, I made do without having to present unaccompanied in an out of state emergency room or make a claim through my annual executive travel insurance policy with Allianz. Once the stone passes, the majority of the pain is diminished and the crises is not as bad.
Again, I gathered up all the receipts and prescription stubs from the bag, faxed them to my primary care physician with a note of explanation, and I manually ensured that the care continuity dots were connected. If one doesn’t do this, retail clinics won’t do it for you, so care continuity is in jeopardy. In some instances, that’s no big deal, but in other instances, it is critical. What if I had an allergic reaction to the medication that the nurse practitioner described? How would my personal physician be informed? It isn’t fair to blindside my physician with gaps in care or information. But many laypersons simply don’t realize how important care continuity can be. This is especially true if they are rarely ill or see a doctor infrequently.
Should physicians and investors be worried about competition?
Competition is complex and tricky. Any of the models, be they retail, urgent, freestanding ER, concierge practice, traditional practice, direct primary care, (DPC) can compete with one another at certain levels. But when properly marketed and branded, and with adequate consumer education through marketing, web design and content, and proper branding, each can “teach” consumers when and how it is most appropriate to use their services to the patients’ best advantage.
As for physician competition with one another and between traditional, concierge, and DPC practices, competitive traditional clinics will need to evolve to be quicker, better, affordable, transparently priced with no more surprises and easier to get an appointment for more consumers to be satisfied with their services. No one can relegate them to be a commodity brand without their express consent.
Traditional medical practices who offer “drive through, bum’s rush” service like what I saw in Cary, North Carolina when my sister lived there where the signs throughout the practice waiting room and lobby that read, “Please note: We must limit patients to no more than three symptoms per visit. Please schedule another appointment to address additional symptoms, if necessary. A separate visit fee and copayment will apply.” is as absurd as it is bad medicine.
For information on starting, strategizing, branding assistance, or accreditation preparation for a retail model clinic, or if you are a reporter covering a story on retail health options, please contact Maria Todd for an interview.
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Maria is a bestselling author and a top healthcare industry influencer and thought leader. She has excellent references and a huge project portfolio spanning 40+ years in healthcare business development and management.
She holds 25 copyrights, several trademark registrations, and shares several patent applications for software inventions.
She’s been recognized with numerous industry lifetime achievement awards for her work in contracted reimbursement, managed care, physician integration and alignment, retail clinic startup and operations and health tourism in the USA and 116 countries.
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