Chronic Care at Walgreens? Why (Not)?

Walgreens, the country’s largest drugstore chain, announced on April 4th that its 330+ Take Care Clinics will be the first retail store clinics to both diagnose and manage chronic conditions like asthma, diabetes, high blood pressure, and high cholesterol. The Nurse Practitioners (NPs) and Physician Assistants (PAs) who staff these clinics will provide an entry point into treatment for some of these conditions, setting Walgreens apart from competitors like Target and CVS whose staff help manage already-established chronic illnesses or are limited to testing for and treating minor, short-lived ailments like strep throat.

A one-stop shop for toothpaste, prescription drugs, and a diabetes diagnosis? The retail clinic phenomenon has its appeal: it allows patients convenience and better access to care through longer hours and more locations than our health care system now provides. Walgreens leaders bill their latest offering as a complementary service to traditional medical care. They envision close collaboration with physicians and even inclusion in Accountable Care Organizations, according to reporting by Forbes’ Bruce Japsen (though it’s not clear how the retailer would share the financial risk or savings in such a model).

But the Walgreens announcement was met with skepticism by physician groups like the American Association of Family Physicians (which has responded defensively in the past to non-physicians’ growing roles as primary care providers). And there are certainly causes for concern, at least based on what we know so far: Such expanded clinics exacerbate the fragmentation in our already piecemeal system. Providers at retail store clinics don’t have access to patients’ medical records, so they might repeat prior efforts or miss key details in caring for these patients. Per standards set by the American Medical Association, retail clinic providers must establish continuity of care with a patient’s primary care doctor if he has one – this usually takes the form of a faxed note, which can’t compare to real-time communication within an integrated network. Providers at retail clinics are obliged to adhere to rigid protocols for evaluating and treating medical issues, but good chronic care management is customized to a patient’s particular lifestyle and needs. In short, chronic care, more so than one-off medical treatment, is best delivered with consistency by a coordinated team of providers (including NPs and PAs but also primary care doctors and specialists) who have gotten to know the patient over time and have built a relationship of trust.

The idea just might work if established health care systems with specialty providers forge meaningful partnerships with retail clinics – for example, with shared access to electronic health records and staff members who move between settings. If, in other words, the retail clinics are true extensions of the primary care home. It’s hard to say if a retail clinic could or would want to meet these criteria.

While those of us working in more traditional health care settings may have legitimate reservations about how Walgreens-brand chronic care will be delivered, we have to acknowledge that it addresses a need that we are not fulfilling. Walgreens made a savvy business move by targeting a growing population of aging Americans with diabetes and cardiovascular disease and offering services that are truly important and underused. We can and should learn from how their experiment plays out: Who will opt for this care? Will Americans use it as a stopgap between visits with their primary care doctor or only when they don’t have one to begin with (according to the Salt Lake Tribune, nearly half of current Take Care users don’t have access to one)? Will they come back a second time? What will they like about it? Which locations and hours will be most popular? Will the appeal of cheaper care (compared to paying out of pocket) fade as more Americans are folded into insurance plans? If we can better understand how these nontraditional clinics address gaps in the system, we can work with retail clinic providers more effectively and fill those gaps with truly coordinated chronic care.

Ishani Ganguli, MD is a journalist and a second-year resident physician in internal medicine/primary care at Massachusetts General Hospital. She blogs regularly at  Short White Coat, where this post originally appeared.

18 replies »

  1. continuously i used to read smaller content
    which as well clear their motive, and that is also
    happening with this paragraph which I am reading now.

  2. Please read my post a little bit closer. I believe that care not only is appropriately delivered by midlevel providers, but in most cases more complete and desired by patients compared to physicians (and have posted this opinion on this site many time). In addition, pharmacists definitely are the experts in providing the care associated with medications, safety and education. I partner with both pharmacists, pharm tech and students in our clinics to round out what I feel to be the best “team” for providing care. Finally, as I state, for these reasons I have no doubt that Walgreens will be successful.

    My concern primarily is a call to action for physicians to identify that their current model (and attitude) does not work, and that large companies have additional skills and infrastructure we can only hope for.

    I do not doubt the dedication, motivation and skill of pharmacists. My main point is that Walgreens is not just a pharmacist company however, no more than Wal-mart or Target. They are all highly successful retail organizations, hence the concern as to the true motivation for adding direct patient care to the list of consumer services. The economic value of bringing bodies through the door, who not only will get appropriate care, but also do their shopping and fill their drugs is obvious. When Walgreen’s starts opening stand-alone clinics removed from their stores, I might believe otherwise. Finally, I do see the value in co-locating pharmacy, DME, and care services, and point this out for physicians to consider this paradigm themselves.

  3. What is all of the fuss about a patient receiving care from a NP/PA? 9 times out of 10, when a patient goes to “their physician’s” office, they are seen by a NP/PA.
    This concept of care provided by NP/PA didn’t originate at Walgreens, people! Keep in mind a physician somewhere is listed as these NP/PA attending physician. So, there are md’s out there who approve of this.

  4. Wow! Are you saying every pharmacists who works for Walgreens have no interests in the health and wellness of patients? I take the health and wellness of my patients very seriously. I spend a lot of time educating patients on meds, their “Doctor”, who cares so much for them, didn’t tell them what the drug is, what its for, or how to take it. First question I always ask is “What did your doctor tell you about this medication?” Most common answer “nothing.”

    I work with many patient advocate groups, senior organizations, and participate in state pilot programs aimed at improving patient care and reducing readmissions to hospitals. Also, because I do care so much for my patients well being, I deliver their meds to them on my own personal time when they are unable to make it to the pharmacy, I even take them milk and eggs, which I can buy at Walgreens on my way out the door to them.

    Walgreens is a for profit business, as is most physician practices/hospitals, but this company does have the best interest of the patients in mind. Please educate yourself before assuming Walgreens & those who work for this company are any less committed to providing patient care than you good, Dr.

  5. Just another milking parlor. A big company milking government and insurance companies through the patient through milking the “provider”.


  6. Yikes. Until EMR gets MUCH better, I think the Wallgreens clinic thing is a bad idea. Chronic care ideally requires a relationship between patient and provider over time. Fragmentation is the worst possible outcome.

  7. Similar retail medical centers already exist. http://www.patientfirst.com
    We call them “Doc-in-a-box”

    OK for some things, like flu shots. But the level of competency at these places is far below par. i.e. Misdiagnosing a broken wrist as NOT being broken!

  8. @ Vik – “The AAFP’s complaint is just typical physician industry sour grapes”.

    No, actually it’s not. It’s exactly what SJ Motew and Dr Mike said. These large chain retailers who are data mining for profit and providing ‘additional revenue streams’ because they can are serving their P&L and certainly fulfilling a market need but not necessarily providing good care. If it’s a question of doctors griping, it’s because they aren’t allowed to provide the same one stop care in terms of dispensaries because there are regulations that prevent a conflict of interest type of situation. But the same rules are not applying to large businesses and retailers.

  9. Isn’t care provided by NPs and PAs reimbursed at lower rate than it would if MDs are providing the care? At least I hope it is; otherwise, the public isn’t gets its money worth in terms of receiving the best possible medical care.

  10. “Maybe they should have thought of opening drug stores.”

    Maybe this is why in so many states physician dispensing is illegal – because physicians never “thought of opening drug stores”?
    But off course, physician dispensing represents an inherent conflict of interest, unlike a pharmacy owning a clinic and employing their own “provider.”

  11. The model is plain and simple..a new channel for bringing-in paying customers. Don’t bet against it. Walgreens and others are undisputed experts at data collection/mining/analysis, bait and switch marketing, pharmacy education, customer service and drug/grocery/sundry sales. The concerning aspect is not whether they will be able to manage chronic conditions with NPs (they will folks), but that their motivation is revenue and market share, not improving the health and wellness of patients.

    The identification of the patient as they key commodity for revenue within newer payment schemes is upon us. The benefit driven by health providers is that we are primarily driven by the commitment to caring for the patient, now needing to manage the required revenue and income to flourish and survive.

    The response? Open pharmacies in our offices, hospitals etc. Drive the same concepts of customer service, competitive pricing, one-stop shopping. Yes, this has the strong motivation of generous revenue streams, but at least they would be run by those most committed to patient health and wellness.

  12. Agreed, Vik. America does not suffer from a shortage of diagnoses.

    And their press release noted they would be able to write prescriptions for these folks on the spot. How very selfless of them!

  13. I think that this move by Walgreens tells us two important things. First, that Walgreens knows a good market opportunity when it sees one. Offering itself up Take Care clinics to employers as their partner in “wellness” creates revenue opportunities that would not exist (hard to make much money just hoping to get enough sprained ankles and stuffy noses in the door). Walgreens is no doubt anxious that employers take the bait and perceive Take Care clinics in Walgreens as a full fledged, one-stop-shopping venue (see the NP/PA, get your drug without having to make another stop) in their ersatz battle against chronic disease.

    The second thing that this tells us is that the drive to give everyone a “diagnosis” is still in full swing. A diagnosis (and let’s not forget that this bar is rarely static) is your ticket to the coverage and reimbursement circus, where you are not really a person of record unless you have one. Walgreens and their Take Care clinics division are not interested in health as much as they are in creating a steady stream of customers. What employers still don’t understand (and may never) is that only the ticket to controlling their medical care spending is to actually find a way to keep their people healthy enough that they largely stay OUT of the medical care system for as long as possible. This just opens another entry door of dubious need.

    The AAFP’s complaint is just typical physician industry sour grapes. Maybe they should have thought of opening drug stores.

  14. Having taken care of patients in a VA system where NP’s are often called Doctor (due to their apparent ‘doctor of nursing’ degree) and thought to provide the same level of care, I am shocked on a daily basis at the lack of knowledge and ability that many of them show. And then I remember…there was a reason for the 4years of college, 4 years of medical school and the additional years of training. Physicians actually learned something and made mistakes in a supervised fashion during that time, and still made mistakes after come out of that level of training. No wonder someone with a few years of nursing training isn’t able to provide that level of service. The problem is in thinking that they do and thinking that there isn’t a level of distinction in the care between what they and physicians provide.

    Yes, there are obviously gaps in the system and it’s fair to take a look at what they are and how to integrate the various pieces and providers better. And yes, of course, it’s a savvy business move for Walgreen’s. But – and it’s a big but – homogenizing care isn’t the right solution. Most concerning, people don’t always understand the distinction – case in point, the VA, where patients are surprised on a daily basis that the care isn’t the same between different providers, and often have long delays in getting to someone of a higher expertise because they didn’t know they were getting someone relatively inexperienced to start with. I understand why the AAFP is making an issue of this and agree that they should. Once the scope of practice opens, there will be a series of consequences and errors that will be realized but not without a lot of issues occurring and not without a many year turnaround time to fix the problems.

  15. Given the way the ‘health care system’ is so broken and so many find it hard to navigate; these quick stops have a natural client base. It is far from ideal, but I think the need created the service.
    I went to a recruitment talk by Walgreen’s TakeCare staffers who said they would never get into chronic illnesses about 4 years ago. I thought, “yeah, right.”
    If every person could easily establish care with a primary care physician rather than have to wait weeks to months for their first appointment; these clinics wouldn’t exist. So, rather than integrating mid level providers into their traditional clinics, opening up access across the board, the AAFP has created an environment where these clinics can flourish.

  16. I wonder whether or not this will catch on with the general population, especially when everyone is so concerned with having “their doctor”. I think there is definitely a target market, especially with the older population and those who don’t have access to regular healthcare. Like you said, this could be an extremely savvy move. Target has become so huge that Walgreens really has nothing to lose here.