JAMA VIEWPOINT: CAN RETAIL CLINICS TRANSFORM HEALTH CARE?

Whether the retail clinic model is the positive disruptive innovation in the health care system it could be depends on a clear leadership vision and commitment to the longer-term success in addition to short-term market and investor gains. Ultimately, success will depend on ensuring highest-quality care, enhancing patient satisfaction, and reducing health care costs.

By Christine K. Cassel, MD | April 12, 2018 | This article originally appeared in JAMA

A 2018 d.health Summit keynote speaker, Christine K. Cassel, MD recently completed her term as Planning Dean at Kaiser Permanante School of Medicine. Previously, she was President and CEO of the National Quality Forum and   the American Board of Internal Medicine, as well as the ABIM Foundation.

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The landscape of the US health care system continues to undergo change. As market forces are invoked to drive lower cost, better access, and improved quality, the entities in the health care market continue to diversify. For instance, Apple (with personal electronic health records), Amazon/JPMorgan and Chase/Buffett (with the promise of an affordable nonprofit employer health care system), CVS/Aetna (combining a health plan with retail clinics), Walgreens (acquisition of Express Scripts), and Walmart (in discussion to acquire Humana) represent major relatively recent developments. CVS/Aetna is the most well-developed of these changes. Nearly 6 years ago, the growth of retail clinics was described as a potentially positive disruptor, especially in the expansion of access and convenience.1 Many clinicians were concerned about lack of continuity and delegation of care to nonphysicians, yet these clinics seemed to offer a more accessible and less costly point of care compared with emergency department visits or even physicians’ office visits. If retail clinics could overcome the limits of legacy electronic health records to connect to other components of patients’ care, this model could even create a virtual comprehensive “system” as a point of connectivity and care coordination.

Research on the performance of retail clinics has shown mixed results.2 Measured quality and patient satisfaction are generally as good or better than traditional clinics or emergency departments.3 Cost savings have been elusive, however, as most evidence points to increased use rather than substitution for more expensive care.4 Still, these clinics seem to have become increasingly established features in the landscape of the fragmented US health care delivery system.

As payer and delivery systems watch the success of integrated systems such as Kaiser Permanente and Geisinger Health System, alignment of incentives to reduce overuse and improve quality and efficiency appears to be a successful model, especially on the premise of accelerating movement to risk-based and value-based payment models.

However, while the new administration purports to support the idea of value-based purchasing, recent federal policy has slowed progress in this area. Accordingly, it is likely that the private sector will be a greater source of innovation than the government in the years ahead. Will models such as CVS/Aetna retail clinics be that disruptive innovator? Will this approach lead to lower cost, better access, and higher quality? The vision, as outlined in public statements by the leaders,5 is to expand access and convenience through the “10 000 front doors” to this new health care system. Today, CVS/Aetna has an estimated 1100 retail clinics in operation, with a total of 9700 stores in which new clinics might be set up.6 Although “front doors” are important, even more important is who and what lies beyond those doors and what happens when consumers walk into and out of them.

A short-term goal, good for most for-profit and not-for-profit health care systems, is growing market share and controlling networks. A longer-term goal, also good for patients and society, would be creating a flexible, technology-driven, patient-centered integrated health care system that uses its reach to truly engage consumers, promote healthier communities, and lower costs for all segments of the market. The key components of this future are information and data, costs, and engagement of clinicians and health care systems.

Information and Data

Efficiencies and quality are both dependent on accurate, complete information being available to a clinician at the point of service. To make real the vision of the retail clinic in drugstores being the “front door” to the health care system will mean integration of medical records and real-time seamless communication with the patient’s other clinicians. Patient-owned apps that empower consumers to access their health information and organize their own health care from their homes will add additional complexity to this marketplace. Patients may see more reasons to access health care from retail centers or may find many of their needs met entirely through remote access to both information and to clinicians. Retail stores already have significant data about their customers, enabling more efficient inventory management and more focused marketing. Increasing the volume of individual medical encounters will add to this big data capability, giving CVS (and other retail clinics) more space in the commercially relevant data world. The disruptor could be connecting with health care systems in a meaningful way to enable predictive analytics and potentially more personalized medicine and patient engagement. The question is to what extent the data will become the product or will be used to drive better care at lower costs.

Costs

The current model of retail clinics is effective for relatively simple preventive care or acute problems. Two reasons retail clinics seem to increase use is (1) the “worried well” seeking care when such care really is not needed and (2) the limits of the clinics requiring that they often must direct some patients to urgent care clinics or emergency departments, meaning 2 steps and 2 costs instead of 1. However, in risk-bearing systems, easy access for even simple health care concerns can be cost-effective if overall use declines.

Most innovations in health care purport to reduce spending (such as by the insurer, the government, or the patient), but these promises are not always fulfilled from the consumer perspective. Similarly, the CVS/Aetna merger promises lower costs and greater efficiencies. Aetna has been successful in Medicare Advantage, and expanding Medicaid risk contracts could add to a large segment of a value-based market, although there are no data that Medicare Advantage has resulted in any cost savings. Mixed incentives still exist in the larger market. The CVS pharmacy benefit management, like others in the field, rewards pharmaceutical companies more than they provide lower costs to clinicians and health care organizations. Indeed, rising drug costs in the last 5 years have shown that aggressive pricing (ie, setting high prices) pays off. It is not clear what incentives will change that will drive CVS/Aetna to focus on quality and lower cost, rather than maximizing profit.

Clinicians

Other health plans have been purchasing clinical health care organizations. Aetna’s relationship with CVS and with accountable care organizations will expand these partnerships. This could be a boon to the integrated delivery systems in extending them into the community, reaching patients “upstream” in their illness to improve health, extending information systems and data analytic capability, and transforming models of delivery. Every organization has a culture of its own, and these relationships will not be like adding prefabricated modules. Even more ambitious would be an open-source patient engagement model available widely to large and small clinician groups, obviating concerns of some about a narrow network model emerging from this merger. This would be extremely complex to implement for the CVS/Aetna model but could have the most important benefit for consumers and clinicians.

What will be the future role of physicians in these kinds of systems? Retail clinics have built their success on a progressive expansion of clinical scope of practice in primary care and in other specialty areas that extend beyond physicians to include nurse practitioners, physician assistants, and pharmacists. These developments reduce the need for physicians in some settings and in some aspects of team care. Much of chronic care management, especially with good real-time clinical data and analytics, telehealth capability, and capable nurse/pharmacy/social work professionals does not require the presence or direct engagement of physicians.7 Artificial intelligence and machine learning may speed that trend, and a future as envisioned by the Aetna/CVS leaders could further reduce the need for physicians as a point of first contact, moving the physician to an analyst for difficult diagnoses, complex problems, and group leadership or management.

Conclusions

These trends, including big data, collaborative and distributed patient care, and alignment of financial incentives, are continuing and will produce other disruptive health care developments. Whether the Aetna/CVS retail clinic model is the positive disruptive innovation in the health care system it could be depends on a clear leadership vision and commitment to the longer-term success in addition to short-term market and investor gains. Above all, the ultimate success will depend on ensuring highest-quality care, enhancing patient satisfaction, and reducing health care costs.

Corresponding Author: Christine K. Cassel, MD, Santa Fe, NM (chriskcassel@gmail.com).

Published Online: April 12, 2018. doi:10.1001/jama.2018.2172

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: I thank Michael Chernow, PhD, Department of Health Care Policy, Harvard Medical School; Mark McClellan, MD, PhD, Duke Margolis Center for Health Policy; and David Cutler, PhD, Department of Health Care Policy, Harvard Medical School, for providing useful insights to this manuscript. No compensation was received for this work.

 

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References

1. Cassel  CK.  Retail clinics and drugstore medicine.  JAMA. 2012;307(20):2151-2152. PubMed | Google Scholar | Crossref

2. Christianson  J, Hamilton  J. Retail clinics are still here: now what? Academy of Managed Care Pharmacy. March 30, 2017. http://www.ajmc.com/contributor/medica-research-institute/2017/03/retail-clinics-are-still-here-now-what?p=1. Accessed January 29, 2018.

3. Shrank  WH, Krumholz  AA, Tong  AY  et al Quality of care at retail clinics for 3 common conditions.  Am J Manag Care. 2014;20(10):794-801. Google Scholar

4. Ashwood  JS, Gaynor  M, Setodji  CM, Reid  RO, Weber  E, Mehrotra  A.  Retail clinic visits for low-acuity conditions increase utilization and spending.  Health Aff (Millwood). 2016;35(3):449-455. PubMedGoogle ScholarCrossref

5. Merced  M, Abelson  R. CVS to Buy Aetna for $69 billion in a deal that may reshape the health industry. New York Times. December 3, 2017. https://www.nytimes.com/2017/12/03/business/dealbook/cvs-is-said-to-agree-to-buy-aetna-reshaping-health-care-industry.html. Accessed February 6, 2018.

6. Wahba  P. How the CVS Aetna deal will change how you get health care. Fortune. December 4, 2017. http://fortune.com/2017/12/04/cvs-aetna-healthcare-what-it-means/. Accessed April 3, 2018.

7. Squeezing out the doctor. The Economist. June 2, 2012. https://www.economist.com/node/21556227. Accessed January 29, 2018.

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