Are Retail Clinics Dangerous?

Target, Walgreens and CVS have recently started medical clinics in their stores. Opening up these “retail clinics” seems both potentially profitable and, at first blush, somehow pushes the lines on our tradition view of where medical services should be located. Giving the concept of retail clinics some thought might reveal store-based providers to be convenient and cost-effective, or alternatively full of conflicts of interest and potential harms. Should we be worried about retail clinics turning into the Walmart of medicine?

The retail clinic industry appears to have grown rapidly over the last few years. Most of these clinics are run by three large chains–Target, Walgreens and CVS–but there are also a mix of smaller providers branching out of existing chains like the Mayo Clinic. Their primary use seems to be the treatment of acute “urgent care” conditions such as symptomatic treatment of upper respiratory tract infections (lots of sore throats), or providing simple preventive care such as vaccinations. Most patients who visit these retail clinics will see a nurse practitioner. According to a recent study that tracked the growth of these clinics from 2007 to 2009, there was a four-fold rise in the number of these clinics, such that there are now over 1,200 retail clinics that see almost 6 million visits per year.

A couple key themes about retail clinics seem to have emerged from research studying their performance and utility:

(1) First, these clinics remain a very small part of outpatient visits. Those 6 million visits pale in comparison to almost 600 million to regular outpatient medical offices and over 100 million visits to emergency rooms across the country. That being said, it seems that a lot of the clinics are concentrated, often being located in the South and West/Midwest. Five states–Florida, California, Texas, Minnesota and Illinois–have almost half of the retail clinics in the country. One might assume that these retail clinics would therefore offer services in regions that might not have great primary care, but that doesn’t appear to be true; the clinics are statistically most likely to be located in regions with low poverty and high median incomes. Indeed, after adjusting for locations of pharmacies and supermarkets, the RAND corporation found that retail clinics are less likely to be located in medically-underserved areas, and are often quite urban. Only about 12.5% are located in underserved areas, even though 21% of the US population lives in such areas.

(2) Second, the types of patients who are visiting these clinics are not the typical outpatient clinic population. Indeed, the retail clinic population seems to be quite a bit younger; over 40% are aged 18 to 44. These folks noted that they are less likely to go to a primary care physician and fewer of them pay for their retail clinic visits through insurance.

Their ailments are correspondingly different: more than 90% of visits are for some form of respiratory tract infection, ear infection, urinary tract infection, vaccination or screening; such visits only make up a fifth of routine outpatient care in most regular clinics, which have a greater emphasis on complex medication management for chronic conditions. However, newer research does suggest that the patient population may be shifting to older aged visitors with time.

(3) Third, costs of care are a lot lower at retail clinics than most outpatient clinics. Surprisingly, the retail clinics actually seem to prescribe antibiotics less frequently for the same conditions than clinic-based outpatient providers. For example, retail clinics prescribe antibiotics 26% of the time for a sore throat versus 29% at clinics and 31% at emergency departments. The rate of appropriate vaccination was also equivalent to clinics.

We really couldn’t find any strong evidence that the retail clinics are providing inferior care in the United states, within the limits of what they do–providing quick relief for acute conditions among the relatively young and healthy (not complex medication management or long-term follow-up for people with chronic conditions). There is evidence from abroad, however, that the conflict-of-interest between a drug store and a prescriber can lead to unnecessary prescribing over time; retail clinics may be so new to the U.S. that scrutiny on them is still leading to a lot of caution within their walls.

What seems to be particularly attractive about the retail clinics for the young and healthy is their convenience–they’re open nights and weekends, often without requirements appointments, and without long waiting times. Almost half of their visitors arrive when regular officers are closed, making these clinics far more convenient to those who work.

Sanjay Bansu, MD, PhD, is a public health epidemiologist. His blog, EpiAnalysis, is a forum for public health epidemiologists who study global health data, healthcare policy, economics, and sociology.

6 replies »

  1. I believe they are 3 times removed from the Primary Care physicians and Hospital ERs for emergent services. First Primary Care physicicans and hospitals of course, then urgent care facilities and even special urgent care facilities such as orthopedic urgent cares like orthostathhi http://orthostathhi.com/ and then retail clinics. Dangerous? Probably no worse than the up and coming telephone doctors…

  2. Certainly these clinics will do better and have less to lose from Medicare if the garbage that plays out continues:

    Mark my words, if you are a person with Medicare and have a chronic illness, get ready to have to go to places like the above post. Because hospitals and physicians will not put up with this bs much longer, and they can’t punish Wash DC and their clueless bureaucrats and bean counters.

    Yeah, laugh or dismiss me off now. Let’s see who’s laughing at the end of 2013 when sick people start getting covertly turned away at hospital ERs!

  3. When competing, traditional health care providers are miles behind the experience of the retail market (CVS, Walmart) etc. The retail clinics are specifically tailored for the exact demographic they attract: young, cash paying, relatively healthy, don;t want to wait, possibly under-insured or large deductibles.

    Cost and convenience trumps all when it comes to this group who is constantly on the move. These venues also have data collection and mining pretty well established, so their ability to identify and improve care should be sound, but remains to be proven.

    The model might be particularly stressful for some health systems, cannibalizing relatively healthy, insured patients leaving the rest for expensive episodes.