Medical Device Daily Contributing Writer

Ateev Mehrotra, MD, joined the faculty of the University of Pittsburgh in 2006. He is an associate professor of medicine in the Division of General Internal Medicine. Mehrotra also is a health policy researcher with RAND Corp. His research focuses include the measurement and public reporting of healthcare quality and efficiency, pay-for-performance incentives, and consumer-directed healthcare.

He also is interested in new innovations in healthcare delivery such as retail clinics and eVisits, and his research group has done several studies connected with various aspects of the retail healthcare clinic segment over the past few years, including one which Mehrotra reported on recently, which focused on the impact of retail clinics on primary care medicine.

MDD: In your studies of retail clinics, have you been able to judge the impact – meaning patient compliance – of referrals that may be made by retail clinic or urgent care center personnel to traditional physicians?

Mehrotra: For another report that we did for the federal government, we interviewed a number of retail clinic providers and clinicians. One interesting anecdote was that patients who go to a retail clinic will say, "I have a primary care doctor, but please don't tell my doctor that I came here. If you give him/her the information that I came here, he or she will yell at me."

When we've interviewed patients who have gone to retail clinics, they say, "Oh, I don't need to go to my doctor for this; this is a simple problem." But they believe their primary care doctor may not be that supportive of them going there, so sometimes they're hiding that information from their PCP.

One potential positive impact we hear regarding the growth of retail clinics and urgent care centers is that it is leading existing providers to improve access to care, say by being open on weekends or in the evening.

MDD: Has the rapid growth of retail clinics over a relatively short period of time meant that we really don't yet have a handle on healthcare outcomes via such clinics versus traditional primary care?

Mehrotra: When you think about the care that's being provided at a retail clinic, you can divide it up into two parts. One is prevention – immunizations, say, in particular flu vaccines. There, outcomes are not that critical. It's more that we need to increase our immunization rates around the country, so retail clinics are regarded in a positive light.

The issue of outcomes becomes more critical for acute conditions that are being treated at retail clinics – sinusitis, colds, ear infections, etc. Ideally what you would measure is resolution of symptoms: Does going to a retail clinic vs. a doctor's office vs. just staying at home lead to resolution of patients' symptoms more quickly? It's a hard thing to measure, because many of these conditions being treated by clinics are self-limited by nature.

I tend to look at other quality-of-care metrics such as whether care is concordant with treatment guidelines. For example, at a visit for strep throat, did that patient get a rapid strep test? What fraction of patients get antibiotics? In other studies, we have found that the care at retail clinics was very consistent with what we saw at urgent care centers and doctors' offices, and in some cases actually superior to emergency departments.

MDD: How do retail clinics fit into the general concept of Obamacare as it is rolled out over the next few years?

Mehrotra: There are a couple of ways that the law will impact retail clinics. The first is that, as more patients get insurance, they are going to go out and seek care. Most likely, they are going to go out and try to get primary care. That's a positive, but may negatively impact access to care. If wait times to see a primary care doctor go up, those people will be more likely to look for alternatives, which could increase demand at retail clinics. At least that's what the retail clinic companies are thinking, and that's why they have gone into this growth phase of expanding their numbers.

The other parts are a bit more unclear. The Affordable Care Act has put into place a number of new initiatives to impact spending. Two of the most important ones are accountable care organizations and medical homes. Both are attempts to decrease the fragmentation that we see in healthcare and to create entities responsible for a patient's care. There, we don't really know what's going to happen.

On the one hand, if I'm an accountable care organization, I could see retail clinics being a huge advantage to add to my network of providers that I use to care for the patients who are assigned to me. So you could see an accountable care organization saying, "Look, let's add retail clinics, because they're going to be a lower-cost alternative and it's going to improve access to our patients."

On the other hand, you might find the accountable care organization saying, "Look, we don't want our patients going into CVS's Minute Clinic. Let's try to discourage them from going there and instead encourage them to come to our primary care offices, or we'll provide eVisits or other alternatives." If that's the case, it could negatively impact retail clinics.

MDD: I'm thinking that for the typical retail clinic customer, the convenience may be a bigger factor than the cost.

Mehrotra: You raise a bigger point that I think is really critical. We have interviewed a number of patients who went to retail clinics, and among patients who have insurance, what we heard is "I'm here because it's convenient. I work late, I've got two jobs, I don't have time to skip work and go to my doctor's office, or it's the weekend and I couldn't get in, etc." With them, it's all about the convenience.

For those who are uninsured or now increasingly have high-deductible health plans, the cost element is a huge aspect. What we heard from patients was that it isn't even just the amount of money – what they were focused on was the certainty of the cost. They would say, "I went to the emergency department, I got a shot, and the next thing you know I got a bill for $1,000." Or, "I went to my doctor's office and they said they didn't know how much it was going to cost, and then I got a bill for $350."

They will say, "I like the retail clinic because I know exactly how much I'm going to pay." That's very important, and I hear them, because it frustrates me no end that when a patient comes to see me, I don't know and they don't know how much it's going to cost. As more people join high-deductible plans, retail clinics can be particularly attractive to them because of the fixed-cost element.

MDD: As lead author of the study, you expressed concern that greater use of retail clinics may lead to fragmentation of primary care. That seems at odds with the general belief that moving care out of higher-cost settings to less-costly alternatives is a good thing as far as healthcare spending is concerned. Or does that thinking really refer to getting care out of hospitals and into physician offices?

Mehrotra: You make a very important point. Here again, there are two ways of looking at it. We've estimated that there are 100 million visits in the U.S. each year to doctors' offices and emergency departments which could be handled at retail clinics. That's a lot of visits, and retail clinics are about 30% to 40% cheaper than a doctor's office, so there's a tremendous amount of potential savings out there.

We did another study where we just focused on emergency department visits, and we asked how much our society would save if emergency room visits that could be handled in retail clinics or urgent care centers were actually moved there. Our estimate was $4.4 billion, so it's a significant amount of money, albeit a small fraction of total healthcare spending.

I do think that there's one caveat: If people go to a retail clinic instead of staying at home, then you'd increase healthcare spending. It's sort of like the example of smartphones. As soon as we made smartphones more affordable and convenient to people, they started using them a lot more. You could see the same thing in your community, where you have five new retail clinics and urgent care centers and people start to see them and decide to go to them seeking care.

MDD: Is there a question I haven't asked that you wish I had?

Mehrotra: I think a key issue is whether retail clinics can expand outside of their current scope of care. For example, for chronic illness care – because retail clinics generally are located in stores that patients visit frequently, you theoretically could have better management. Instead of having one doctor's visit every three months, it's better to have frequent visits, whether that's done while you're out shopping or via the Internet or over the phone.

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