Once the stepchild of the American health care system, primary care is now the linchpin of efforts to improve the health and health care of individuals and communities and to bring down costs. Factors contributing to the demand for primary care include the coverage expansion under the Affordable Care Act and an aging and growing population.
But here is the problem: we have a shortage of primary care providers, already acute in some areas of the country, and it’s expected to significantly grow in the years ahead. Coupled with consumer expectations that everything should be immediately accessible at the touch of a screen, it comes as no surprise that demand for accessible primary care, including through retail clinics, is increasing. What impact are these clinics having on cost, access, and quality?
In the March 2016 edition of Health Affairs J. Scott Ashwood and coauthors published a study that addressed the first part of that question — the impact on spending related to the use of retail clinics. The researchers found that 58 percent of retail clinic visits represented new utilization and not substitution for more costly primary care or emergency department (ED) visits. This net cost of this new utilization was determined to be $14 per person per year.
Central to the retail clinics’ business model is convenience. Thus, one can expect that retail clinics trigger both new utilization as well as substitution for more costly services. While the study found that retail clinics increased costs by creating new utilization, it did not consider the value of the new utilization for patients who previously, for whatever reason, did not or could not access such services.
In the article, new utilization is said to occur “when patients who previously would not have sought care visit a retail clinic because of its lower price or perceived convenience.” And, one might add: “or because of its accessibility.” Any assessment of the value of the new utilization to the individual, the community, or the health system was beyond the scope of the paper.
Nonetheless, we would posit that given the small amount of spending associated with this additional utilization, retail clinics have a potentially meaningful role to play in improving access to routine primary care for patients with low-acuity conditions, especially for underserved and uninsured individuals. In short, the cost associated with the increased utilization may well be worth it.
The Cost Of Enhanced Access
Retails clinics emerged over 15 years ago to solve a basic, intractable problem — how to make routine primary care services convenient and accessible. With increasing demand for primary care, a high and swelling rank of uninsured, and a low-margin, nine-to-five business model, the industry was primed for a new mode of delivering care.
This model of low-cost, routine primary care services after-hours in settings that most Americans could readily access has proven popular with consumers. There are now more than 1,800 retail clinics across the country, delivering a growing array of primary care services to millions of people. With virtually unfettered access to routine primary care services, one might expect that excess utilization would be generated.
As a fixture of the health care system, critical questions are rightly being asked regarding the impact that retail clinics are having on cost, access, and quality. While researchers in the Ashwood study who used claims from Aetna pointed out that they could not assess impact on total cost of care given lack of hospital and pharmacy claims in their analysis, they did find that 58 percent of retail clinic cases represented new utilization, with an associated $14 per person per year net increase in spending.
It is important to point out that the analysis did not include uninsured individuals or Medicaid beneficiaries, who are less likely to have a usual source of care or less able to access that care during regular business hours. For these individuals the retail clinic may be a much needed access point, enabling new utilization that at least the individual thinks is necessary and additional data may provide necessary by any standard.
What does $14 per person per year really mean when considering the cost of providing health care services for an entire population? The study noted that only 3 percent of Aetna enrollees actually used a retail clinic — if we spread $14 in costs across all of Aetna’s members, the cost per member per year would be 42 cents; less than 4 cents per member per month. If we assume a monthly premium of $500 per member per month, then the excess utilization translates to a premium increase of 0.007 percent.
What is the opportunity cost of such an increase? Could we use it in a way that better improves access to routine primary care services? We are assuming that there is value both in the kind of care received at retail clinics and in improving access to that care. There are some data to back these assumptions:
- Approximately 50,000 adults die annually from vaccine-preventable diseases in the United States. Nearly one in five adults now receive a vaccination in a pharmacy or retail clinic, second only to a doctor’s office, and 10 times the number of vaccines administered in public health departments. If we removed retail clinics as a vaccination source, how many more people might suffer an adverse outcome including illness or death?
- Over half of uninsured retail clinic users went to a retail clinic because they did not have a usual source of care.
- Publicly reported performance measures in Minnesota found that retail clinics ranked highly amongst other primary care providers in at least three measures.
It is hard to fathom a better way to increase access, at low cost, in a manner that doesn’t generate excess utilization. Meanwhile, primary care access is projected to get considerably worse.
The Perfect Storm – More Coverage, Fewer Providers
Since implementation of the Affordable Care Act, 20 million people have gained coverage, approximately 12 million through Medicaid with the remaining through federal and state marketplaces and other channels. Those newly covered individuals are seeking primary care in the midst of an expected shortfall of up to 31,000 primary care physicians over the next 10 years, even when factoring in increased use of advance practice nurses.
The median wait time for a commercially insured or Medicaid beneficiary ranges from five to eight days nationally. Some providers close their doors to Medicaid patients due at least in part to the lower reimbursement they receive relative to commercial or Medicare payers. The majority of retail clinics on the other hand accept all forms of insurance.
Provider shortages are not evenly distributed across the United States. Twelve states and the District of Columbia have an estimated 15 percent to 50 percent of the primary care capacity they need to meet current demand, while as many as 65 million people nationwide—many of whom live in rural and poor communities—live in “primary care deserts” with no providers, retail or otherwise.
Filling the Primary Care Gap
It is hardly surprising that retail clinics generate new utilization; they are highly convenient and relatively inexpensive. Most families that use retail clinics do so because of their long hours of operation, location, and walk-in policies, in addition to low visit costs.
These are especially critical attributes for many lower income and uninsured individuals who may not have a regular source of care or may not be able to access their primary care providers. These populations are less mobile and have less flexibility in their work schedules.
As a result, making appointments to see a primary care physician during regular business hours when most offices and clinics make visits available can be extremely challenging. Rearranging schedules to fill a next available appointment slot just isn’t an option for many. Retail clinics with extended hours, no appointments, and little wait can serve as an effective complement to primary care providers — as long as they open their doors in neighborhoods and communities where these populations work and live.
Thus far, retail clinics have not stepped up to entirely fill the gaping void. Retail clinics tend to be placed in higher-income, urban, and suburban settings, with higher concentrations of white and fewer black and Hispanic residents. An analysis by the United Hospital Fund found that in New York State only six of 18 retail clinics were located in medically underserved areas. Research examining this question nationwide also found that most such facilities are in higher income communities. Clearly, if retail clinics are to be part of the solution to primary care shortages in underserved communities, they’ll need to open more clinics in those communities.
Ensuring the Value Proposition of Retail Clinics
The consequence of the increased utilization described by Ashwood et al. must still be addressed, but it needs to be put into context. The U.S. health care system is riddled with examples of far greater “over” utilization.
A 2003 Dartmouth Atlas’s analysis cited by Atul Gawande in his 2009 New Yorker article, found that patients in some regions received 60 percent more care than elsewhere in the form of more tests, procedures, specialty visits, and admission to hospitals, with no better outcomes in terms of survival, functional ability, or satisfaction with the care they received. If any retail clinic utilization is unnecessary, it is for low-cost services related to primary or preventive care. The excess utilization driven by retail clinics would seem to be a tiny price to pay for the increased primary care access they enable.
Indeed the low cost of the retail clinic is the very reason to assure that we are maximizing their value and that means, among other things, linking retail clinics with or integrating them into health systems to support care coordination, chronic disease management, and prevention. Adopting and using protocols and clinical standards and sharing information would help reduce any unnecessary utilization and support linkages and integration. Incorporating retail clinics into accountable care arrangements in partnership with regional health care systems and making all parties accountable for cost, access, and quality would prove a powerful motivator to assure appropriate access and utilization across all sites of care.
Ashwood et al. note that: “if retail clinics also increase the use of preventive care or chronic disease care, this would likely be viewed as improving value because these are aspects of health care perceived to be underused.” Ensuring that they are doing so in close coordination with a patient’s primary care medical home provider (should they have one) will support a realization of that opportunity.
For those who do not have a usual source of care, having access to a provider to confirm that a fever isn’t strep throat, or just to get a flu shot is enough value to them. It is difficult to contemplate the harm that comes from a potentially unnecessary visit to a retail clinic. In order to assure access to care for all low-acuity conditions—those that require intervention and those that do not—we have to accept that easily accessible care will generate some “unnecessary” utilization.
Imagine taking away such an access point from a family that has little or no alternative. Policy and business decisions should focus on how to maximize the intrinsic value that retail clinics can provide and minimize the waste they may generate, rather than on their use as a blunt instrument to reduce health care costs.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/1WGuLJK
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