The Retailing of American Medicine



American medical care may be helpful much of the time, but rarely is it timely or convenient. A 2013 Commonwealth Fund international survey found that 26 percent of American adults reported they waited six days or more for needed appointments, much worse than in countries with national health systems like the Netherlands (14 percent) or Britain (16 percent). And trying to get in to see a specialist in the U.S. is even worse: Patients waited an average of 28 days to see a cardiologist in Denver, 49 days to see a dermatologist in Philadelphia, 35 days to see an obstetrician-gynecologist in Portland, Ore., and 18 days to see an orthopedic surgeon in San Diego. On top of that, the alternative to waiting — going to the emergency department — is not only a hassle but also quite expensive, oftentimes exceeding an average month’s rent, as The Washington Post notes, even if you have insurance. What’s a sick, price-sensitive patient suppose to do?

Enter America’s entrepreneurial 21st-century economy reacting to the need for better response times, lower cost and greater convenience in attaining medical care. Patients suffering chest colds, ear infections or simple sprains can now drive up to private retail health clinics inside large “big box” stores like Wal-Mart and Target, or access “right now” urgent care in pharmacies like CVS’s 1,000 walk-in MinuteClinics. There are seven times more retail clinics than there were just eight years ago, with a total of 3,000 scheduled to be up and running by next year. Visit prices range from $40 to $100 depending upon the service, although lab work, vaccines or other services carry additional fees. For the 40 to 50 percent of the patients who frequent retail clinics and state they have no regular primary care provider, this type of “convenience medicine” is filling a needed gap, and for the struggling brick-and-mortar retail industry, in-house clinics offer a new source of revenue with the bonus of driving consumers into their stores.
Is there a downside to retail health clinics? The medical establishment has been critical: The American Medical Association (AMA), the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP) have all questioned the quality of care and disruption of the physician-patient relationship in these types of nontraditional care venues. Although the demand for convenience medicine — 10 million annual visits — represents only 2 to 3 percent of the primary care market, its burgeoning popularity and rapid growth forces even detractors like physician groups to recognize the appeal of same-day service, particularly since so may patients lack a primary care physician. Most medical groups have tempered their disdain with a call for retail clinics to coordinate care alongside primary care providers rather than cease altogether. However, pediatric groups are less tolerant and continue to take issue with the mostly nurse practitioner-run centers. A 2014 policy statement from the AAP asserts retail clinics are an “inappropriate source of primary care for children because they fragment children’s health care and do not support the medical home” model, where physicians typically are the head of the team.

Despite the admonition of physician groups, patients and even states are endorsing retail clinics through increasing consumer demand and public acceptance. In a June 2015 Advisory Board national survey, 56 percent of respondents said they would consider using “on-demand” retail clinics for an illness like the flu. When asked about what drives their healthcare decisions in seeking care, those surveyed ranked access and convenience higher than provider continuity or credentials. Likewise, states are moving ahead to enable the convenience medicine trend. Twenty states have authorized nurse practitioners to practice within the scope of their training without close medical supervision, and eight more states are considering similar legislation.

It is unlikely that retail clinics will effectively supplant “big medicine” in the U.S., but the lure of consumer ease plus lower prices resonates with patients, particularly those facing increased cost-sharing in high deductible plans. In addition, convenience medicine aligns perfectly with the 40 million or so working millennials who desire instant gratification in social and service arrangements. These cost and cultural trends will fuel the continuing development of various manifestations of on-demand healthcare. For example, there are now “house calls for hangovers” in New York City, The Wall Street Journal reports, and Uber-type apps for physician home visits in California and beyond.

The traditional medical establishment would do well to ride the wave toward the supply of more expedient healthcare and extend office hours, promote electronic communication, invest in video chats and provide easy access to urgent care. While the personal and monetary costs involved in convenience medicine are real — fragmented care, missed diagnoses and lower reimbursements — the inexorable movement toward cheaper and easier entry to medical treatment signifies a disruptive innovation in healthcare delivery. It will be difficult to overturn such a powerful force in which entrepreneurial ventures are rewarded in the marketplace and, from the consumer perspective, the price is right.

Engelhard is the director of the Health Policy Program at the University of Virginia School of Medicine’s Department of Public Health Sciences.

Garrett Hall at Sunset

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