Summary
Convenient care clinics staffed by nurse practitioners have proliferated in U.S. retail settings. Take Care Health Systems—a wholly owned subsidiary of Walgreens—offers high-quality, affordable and convenient health care at 15 clinics in Pennsylvania. In Philadelphia, problems associated with lack of access to health care are compounded by the city’s high percentage of low-income, medically underserved residents. Board-certified nurse practitioners at three Take Care Clinics in Philadelphia treat patients for common illnesses; write prescriptions; provide diagnostic screenings, physicals, and men’s and women’s health evaluations; and offer vaccinations. Emphasizing access, convenience, cost and quality, convenient care clinics integrate with the traditional medical community toward a shared goal of providing patient-focused care by delivering the right care at the right time.
Introduction
On March 22, 2010, Congress passed the Patient Protection and Affordable Care Act, offering an estimated additional 31 million people insurance through public and private means (Deloitte Center for Health Care Solutions 2010). As healthcare reform takes shape and many more covered lives enter the system, the need for access to healthcare services will intensify. Currently, there is limited access to routine care and preventative services, and millions of Americans do not have an established provider-patient relationship. More than 70 percent of patients say they have difficulty getting access to a doctor when they need it, and 30 percent say they could not get a next-day appointment with their physician. Forty percent of surveyed patients say it is difficult to reach their provider on the phone during regular business hours (How et al. 2008).
A critical need exists to enhance access to health care in the United States, particularly for individuals with common health problems who need timely attention but who do not have a convenient place to go or a familiar provider for this type of care. To meet this need, small health clinics, referred to as convenient care clinics, staffed by nurse practitioners have opened in retail settings including pharmacy and grocery store chains. Convenient care clinics have proliferated as the American healthcare industry has been unable to respond to increasing political, social and economic pressures and to the consumer-driven demand for accessible, low-cost, high-quality, and convenient health care.
Convenient care clinics offer a limited menu of non-emergent screening services and routine treatments. Commonly treated conditions include allergic reactions, upper respiratory infections, sinusitis, bronchitis, strep throat, otitis media, influenza and insect bites. Patients can use clinics for routine immunizations, pregnancy testing and school-, sports- and work-related physical examinations. Routine preventative health screening is available for chronic conditions such as diabetes and hypertension. Nurse practitioners are available to use their clinical judgment to diagnose common acute health problems, order diagnostic tests, prescribe medications as needed and refer patients needing additional care.
A local company is helping to address the issue of access to care for people who live in the Philadelphia area. In December 2008, Conshohocken-based Take Care Health Systems opened healthcare clinics in the Greater Philadelphia area, offering local residents high-quality, affordable and convenient health care. The hometown company, the largest joint provider of convenient care clinics and employer-based health clinics, is a wholly owned subsidiary of Walgreens (Take Care Health 2008). Take Care Health Systems has 15 clinics in Pennsylvania, including three in the Philadelphia area and 12 around Pittsburgh. Hal Rosenbluth, cofounder and chairman of Take Care Health Systems and a native Philadelphian, has made a positive difference in the community in which he was raised by providing access to quality health care and by creating numerous jobs for residents in the area.
The Problem: Lack of Access to Affordable and Convenient Primary Care
Although high-quality, technologically advanced care for complex medical conditions is available throughout the United States, many individuals of all income levels have difficulties accessing basic primary care and preventative services in a timely and convenient manner. Presently, more than 47 million people in the United States lack health insurance (Clark 2008). One of the national goals of Healthy People 2010 is to reduce the proportion of families that experience difficulties or delays in obtaining health care from 12 percent to 7 percent (U.S. Department of Health and Human Services 2009). Baseline data indicate that 17 percent of poor families, 9 percent of middle-high income families and 27 percent of the uninsured go without needed care (Lugo, Giorgianni, and Zimmer 2006).
Lack of easy access to affordable, high-quality care when and where it is needed may lead to unnecessary and costly emergency room (ER) use. ER care accounted for 10 percent of all ambulatory expenditures in 2003. One in five U.S. adults used an ER for care at a median cost of $299 per visit. Between 1993 and 2003, ER use increased 26 percent. Only half of ER visits are truly emergent or urgent, meaning requiring care within an hour of arrival (Lugo, Giorgianni, and Zimmer 2006).
A contributor to the overall pattern of poor healthcare access as well as increased prevalence of inappropriate ER use is the ongoing primary care shortage in the United States. The Association of American Medical Colleges estimates a shortage of between 120,000 and 160,000 physicians by the year 2025 (Dill and Salsberg 2005). A 2008 assessment found that only 2 percent of those surveyed indicated that they would pursue careers in internal medicine. Additionally, attempts to attract a greater percentage of medical students into primary care are failing (Hauer et al. 2008).
The Institute of Medicine (2004) reports that insufficient healthcare coverage results in approximately 18,000 unnecessary deaths each year in the United States. And, although the United States is the world leader in healthcare spending, it is the only industrialized nation that does not provide healthcare access to all of its citizens (Clark 2008).
As a major metropolitan area, Philadelphia faces many problems associated with lack of access to health care. These problems are compounded by the city’s high percentage of low-income, medically underserved residents. According to the U.S. Census Bureau, the percentage of people living below the poverty line in Philadelphia is 24.5 percent. Those living below the poverty level are more likely to have poor health and less likely to receive medical care than those who live above the poverty level (Clark 2008). About 28 percent of Philadelphia residents consider themselves to be in fair or poor health, but for those living below the poverty level; this percentage rises to 46 percent. Twenty-two percent of Philadelphia’s low-income residents report cost as being a barrier to health care, and 29 percent consider transportation to be a barrier to care. Over 16 percent of Philadelphians living below the poverty level do not have a regular source of care (PHMC 2008). These statistics demonstrate a need to be creative in finding solutions that can improve access to convenient and affordable health care for the residents of Philadelphia.
The Solution: Convenient Care Clinics
The first in-store medical clinic, also known as a convenient care clinic or retail clinic, opened in 2000 in the metropolitan St. Paul/Minneapolis area (Hunter, Weber, and Wall 2009). Since then the number of companies providing this form of quick, inexpensive and convenient health care has rapidly increased. According to 2008 statistics, 1,175 convenient care clinics operated in 37 states (Mullin 2009).
Convenient care clinics tend to have several common characteristics, which form the basis of the convenient care business model. The clinics:
- Have extended hours of operation and are open on weekends and most holidays;
- Treat a limited number of minor medical problems;
- Offer preventative services such as immunizations and physicals for sports and work;
- Use evidence-based treatment protocols;
- Use electronic health records (EHR);
- Have transparent pricing, typically posting menus with services offered and the cash prices of each service;
- Primarily employ nurse practitioners or physician assistants;
- Have collaborative relationships with physicians; and
- Are located in a retail space within a drugstore, grocery store or other chain store.
The average clinic is between 250 and 500 square feet in size and contains a small reception area and one or two examination rooms. Some have their own toilet facilities.
Convenient care clinics are not designed to meet the healthcare needs of all consumers. Ninety percent of retail clinic visits come from consumers with ten common medical problems or preventative health requests: upper respiratory tract infections, sinusitis, bronchitis, pharyngitis, immunization, otitis media, otitis externa, conjunctivitis, urinary tract infections, and blood pressure and cholesterol checks (Mehrotra et al. 2008). For treatment of simple illnesses, a substantial amount of time and money can be saved. The average clinic visit lasts from 15 to 40 minutes and costs between $40 and $70 (Mullin 2009). Some clinics have begun to incorporate preventative measures such as weight management, nutrition counseling and exercise instructions.
Take Care Clinics in Philadelphia are staffed by board-certified nurse practitioners who treat patients 18 months and older for common illnesses such as strep throat, ear and sinus infections, pinkeye and poison ivy, and are licensed to write prescriptions that can be filled at the patient’s pharmacy of choice. Take Care nurse practitioners also provide diagnostic screenings, physicals (for school, sports and camp), and men’s and women’s health evaluations, and offer vaccinations for chicken pox, flu, hepatitis B, measles, mumps, rubella, meningitis, pneumonia, tetanus and human papillomavirus. Clinics have two patient examination rooms with sinks, patient registration kiosks and EHR technology for visit documentation. Clinics are open Monday through Friday from 8 am to 7:30 pm and Saturday and Sunday from 9:30 am to 5 pm. They are located at Walgreens drugstores. Take Care Health Systems has partnered with numerous insurers including Aetna, CIGNA and Medicare. If insured by a plan that has contracted with the clinic, patients pay their regular co-pay. For the uninsured or cash payers, prices average $59 to $74 (Take Care 2008).
According to Sandra Ryan, the Take Care Health Systems clinics are differentiated by their commitment to supporting the professionalism of the nurse practitioners. Take Care supports a shared governance model where the nurse practitioners have a say in policies, documentation and new graduate orientation. They have developed a preceptor program so that new graduates can have a mentor for at least 12 weeks. All nurse practitioners are educated in providing good patient care. Also, they are educated in focusing on three main principles: quality, patient engagement and business.
Studies strongly suggest that convenient care clinics are providing satisfactory services to a wide variety of people and filling a need for low-income consumers or those without healthcare insurance at an affordable cost while decreasing use of emergency or urgent care facilities for non-emergent patient care. Fifty-one percent of survey respondents stated they would have used either an emergency room or an urgent care center if a convenient care clinic had not been available. Respondents also noted that a convenient location, the fact that no appointment was necessary and very little wait time were important factors in deciding where to seek care (Hunter, Weber, and Wall 2009). And, according to the Convenient Care Association (CCA), patients are very satisfied with their care, with a reported 98 percent satisfaction rating.
Not only are the clinics meeting a public need, they are doing so in a cost-effective manner, potentially saving consumers and the healthcare system substantial dollars. By way of illustration, in 2005, there were 16 million visits to ERs for non-urgent, low-acuity reasons (Mullin 2009). The estimated cost of these ER visits is $4.8 billion, or just under $300 per visit. The median cost of a visit to a convenient care clinic is $55. By diverting and effectively caring for patients with non-emergent needs, convenient care clinics have the potential to decrease healthcare expenditures by $3.9 billion (see figure).
Convenient care clinics complement traditional healthcare delivery models by serving as an entry point for care and taking the pressure off overburdened physician practices and ERs. In addition, most clinics accept many insurance plans, and the prices are intended to be affordable for those without insurance.
Convenient care clinics comply with all state and local regulations. Nurse practitioners, who are the main providers of care in these clinics, have a master’s-level degree and are fully credentialed. Practitioners adhere to evidence-based guidelines to diagnose and treat patients. Convenient care clinics incorporate the American Medical Association (AMA) and the American Academy of Family Physicians (AAFP) requirements in addition to following all applicable requirements and guidelines of the Occupational Safety & Health Administration, the Clinical Laboratory Improvement Amendments, the Health Insurance Portability and Accountability Act, the Americans with Disabilities Act and the Centers for Disease Control and Prevention. Convenient care clinics use EHRs to help improve the long-term quality and continuity of patient care.
Empirical data show that quality care is being achieved at high rates at convenient care clinics. A 2007 study revealed that retail-based healthcare centers using an electronic clinical decision support tool demonstrated a 99.15 percent overall adherence to evidence-based guidelines (Woodburn, Smith, and Nelson 2007).
Convenient care clinics also contribute to continuity of care. These clinics have a local referral network of healthcare providers for patients. With patients’ consent, the convenient care clinics forward medical records to their primary care provider, or help them find one if they do not have one.
Convenient care clinics are assisting in shifting the focus of the healthcare delivery model from curative to health promotion and disease prevention. Estimates are that 80 percent of coronary artery disease, 90 percent of type 2 diabetes and most cancers could be prevented through simple lifestyle modification (Mullin 2009). Convenient care clinics are in the position to reinforce this connection with consumers.
Challenges
As with most change, there are those who embrace it and others who resist it. The greatest critics of convenient care clinics are physicians (Evans 2007). Organizations such as the AMA, AAFP and American Academy of Pediatrics (AAP) cite concerns including the possibility that a patient might be misdiagnosed, thus allowing their health issue to escalate. Others have expressed concerns over the possibility of a lack of continuity of care and a risk that the retail clinics will replace the doctor-patient relationship.
Research conducted over the last 30 years has consistently found that nurse practitioners provide quality primary care that is comparable to the care delivered by physicians (Evans 2007). A recent survey conducted by the trade journal Retail Clinician appears to minimize the physicians’ concerns. The survey revealed that 85 percent of the nurse practitioner respondents currently have referral systems in place with local physician offices and physician groups. A total of 86 percent of the nurse practitioner respondents have established treatment protocols, and 88 percent report using an HER (Alexander 2008).
In response to the AMA, AAP and AAFP, the CCA incorporated quality standards into clinic operations. These standards were approved in March 2007 and updated in January 2011. The CCA’s Clinical Advisory Board, which developed the standards, includes representatives from nursing, physicians and accrediting bodies. The CCA guidelines exceed the standards recommended by the various physician groups (Hansen-Turton et al. 2009).
The practice of health care is heavily regulated, and the convenient care industry is no exception. Convenient care clinics are regulated at the local, state and federal levels. On the local level, before a clinic can open, leasing agreements must be signed, and plumbing, electrical, fire and safety standards must be met. States have broad authority to regulate the practice of health care, and stipulate the healthcare profession’s scope of practice. One of the major issues targeted by the states is the collaborative practice agreements that most states require between nurse practitioners and physicians. For example, some states regulate the percentage of charts a collaborating physician is required to review. Another issue is the maximum distance from a convenient care clinic at which a collaborating physician can practice; some states mandate a 30-50 mile requirement. States may also consider the frequency with which the collaborating physician is required to be on-site at the clinic with the nurse practitioner. Many states allow the nurse practitioner and the collaborating physician to work out the details of their collaborative relationship based on their practice needs. In Pennsylvania, in particular, the collaborative practice agreement is enforced, there is no on-site requirement and the ratio of nurse practitioners to a collaborating physician is 4:1.
Several states have voiced concerns that convenient care clinics are located in businesses that also sell tobacco and alcohol. Policymakers in Massachusetts and Illinois solicited advisory opinions on the matter from the Federal Trade Commission, which cautioned that proposed limitations singling out tobacco and alcohol sales in proximity to the practice of health care could be construed as an attempt to limit the expansion of convenient care clinics. Convenient care clinics mitigate these concerns by posting signs outside the clinics stating the clinic operator opposes the use of tobacco products. The convenient care industry also continues to uphold its commitment to public health by providing smoking cessation counseling to patients in many clinics, as well as serving as a clinical condWhy Convenient Care Clinics Work.
Convenient care clinics integrate with the traditional medical community toward a shared goal of providing patient-focused care by delivering the right care at the right time. Consider the case of the Chicago patient who entered the clinic in hypertensive crisis. The nurse practitioner was able to evaluate his situation and steer him to the proper care, which in his case was the hospital ER. Convenient care clinics allow thousands of patients to take control of their health with easy access and at an affordable rate.
Convenient care clinics fit a pattern of business innovation identified by Clayton Christensen as “disruptive innovation” (Ridgway 2009). This term refers to a product or service that enters a market as a simpler, lower-cost alternative to an existing product that is overbuilt for the needs of the market. Using lower-cost technology or workers, the innovation improves until it establishes a dominant market share (Hwang and Christensen 2008). Health care remains expensive and inaccessible to many because of the lack of a business model innovation. The convenient care model emphasizes access, convenience, cost and quality, and addresses the needs of healthcare consumers that the traditional system has not fully met. Business expertise combined with high-quality health care can lead to a successful healthcare model. Convenient care clinics are one way to bring care to where people live, bridging the gap in health and wellness services.
Why Convenient Care Clinics Work
Convenient care clinics integrate with the traditional medical community toward a shared goal of providing patient-focused care by delivering the right care at the right time. Consider the case of the Chicago patient who entered the clinic in hypertensive crisis. The nurse practitioner was able to evaluate his situation and steer him to the proper care, which in his case was the hospital ER. Convenient care clinics allow thousands of patients to take control of their health with easy access and at an affordable rate.
Convenient care clinics fit a pattern of business innovation identified by Clayton Christensen as “disruptive innovation” (Ridgway 2009). This term refers to a product or service that enters a market as a simpler, lower-cost alternative to an existing product that is overbuilt for the needs of the market. Using lower-cost technology or workers, the innovation improves until it establishes a dominant market share (Hwang and Christensen 2008). Health care remains expensive and inaccessible to many because of the lack of a business model innovation. The convenient care model emphasizes access, convenience, cost and quality, and addresses the needs of healthcare consumers that the traditional system has not fully met. Business expertise combined with high-quality health care can lead to a successful healthcare model. Convenient care clinics are one way to bring care to where people live, bridging the gap in health and wellness services.
Theresa Stine is a recent graduate of La Salle University School of Nursing and Health Sciences.
References
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