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Can Retail Clinics Improve Patient Access, Reduce Costs for Payers?

Payers need to consider the operational components of retail clinics, and the opportunities to save on costs, before providing retail clinic access to beneficiaries.

Payers need to evaluate if retail clinics improve patient access and reduce costs.

Source: Thinkstock

By Thomas Beaton

- Retail clinics are gaining in popularity among patients looking for quick, convenient care for minor ailments.

Kiosks and no-appointment-needed offices located in corner pharmacies and big box stores have the potential to keep patients out of expensive emergency rooms or busy primary care providers.

Yet concerns about overutilization for issues that might not need any treatment at all can hold payers back from offering reimbursement for these services.

Before extending coverage to beneficiaries for retail clinic services, healthcare payers should evaluate how to strike the right balance between expanding access, reducing costs, and meeting a growing desire for on-demand care.

What are retail clinics and which healthcare services do they provide?

Currently there are over 2000 retail clinics across the United States. This number is expected to grow as pharmacy chains and other retailers start to see returns from their investments in these clinics. 

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Retails clinics are sometimes confused with urgent care centers, but the two types of organizations provide different services.

A retail clinic is a health center or kiosk that addresses minor healthcare needs at the patient’s convenience. Retail clinics typically employ certified nurse practitioners (NPs) and/or physician assistants (PAs) to administer treatment.

Independence Blue Cross explains that retail clinics can be helpful for beneficiaries seeking relief from cuts and external injuries, cough or sore throat, ear and sinus pain, minor fevers, or rashes.

An urgent care center is a medical facility that typically employs physician assistants and nurse practitioners that are overseen by board-certified physicians. Urgent care centers address medical conditions that need a little more attention but don’t require an ED.

Mount Sinai Hospital says that an urgent care center usually operates 24/7 to offer services including x-rays, treat sprains and muscle strains, and provide treatment for nausea, vomiting, fevers, sinus problems, breathing troubles, and the flu.

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Retail clinics are usually located at big-box stores such as Target and WalMart, as well as in pharmacy chain locations. Nationally-recognized retail clinics include CVS’s MinuteClinics and Rite Aid’s RediClinics.

Urgent care centers either operate in stand-alone physical locations or are part of larger health system.

Which beneficiary groups are most likely to use retail clinics?

Retail clinic visits are on the rise, according to research from the BlueCross BlueShield Association, but utilization patterns vary based on beneficiary age and health status - and the time of year.

Between 2011 and 2015, the number of retail clinic visits nearly doubled from 12.2 visits per 1000 beneficiaries to 24 visits per 1000 beneficiaries.

BCBSA also found that individuals with employer-sponsored insurance are more likely than individually-insured beneficiaries to use a retail clinic.

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Just over 70 percent of retail clinic utilization was for treatment of acute conditions, BCBSA found.

Acute respiratory conditions are the most common condition treated by retail clinics, as 48.8 percent of visits were for bronchitis and related coughs. Ear infection treatments comprised 9.8 percent of visits, followed by treatments for urinary tract conditions (4.1 percent), dermatologic conditions (3.9 percent), and conjunctivitis (2.2 percent).

Retail clinic utilization also varies by season and the time of year, and spikes during the fall and winter when individuals seek out flu shots and related care.

“The seasonality of visits is quite striking, with a 42 percent higher visit rate from January through March and October through December (fall through late winter) than from July through September (summer) on average for all five years in the study period,” BCBSA observed.

Younger beneficiaries are also more likely to use retail clinic services than older members. BCBSA found that individuals between the ages of 18 and 39 are the most likely to use retail clinics followed by the 0-17 age group, the 40-60 age group, and the 60 and over age group.

“Use patterns by age also deviate from what is typically observed in other health care settings; young adults are frequent users of retail clinics, visiting almost three times as much as older patients, even though older age groups use more health care overall,” BCBSA said.

What are the possible benefits of retail clinic access for addressing care costs and outcomes?

Retail clinics could cut payer costs over a long-term period, since these facilities promote the use of cost-effective preventive care at easily accessible locations.

Preventive care can help significantly reduce payers’ healthcare costs by addressing chronic conditions before they worsen and reducing the likelihood that beneficiaries need emergency or high-cost healthcare services. The CDC estimates that avoidable chronic conditions cost the US $260 billion annually in healthcare costs.

Payers may have an additional opportunity to cut costs and improve beneficiary behaviors by guiding members to lower-cost settings instead of urgent care or the ED.

Urgent care use has increased by 1725 percent in the last decade while ED utilization increased by 229 percent.

A 25-minute visit to an urgent care center can cost a payer $320, said FAIR Health.

However, retail clinic use grew by 847 percent, indicating that retail usage is outpacing ED use but still falls behind urgent care use. Payers that encourage beneficiaries to use retail clinic services could potentially cut back on high urgent care spending.

Retail clinic visits cost an average of $146 per visit, nearly half the cost of an urgent care visit.

Efforts to steer patients away from high-cost care are already underway. For example, Cigna and CVS Health recently entered a partnership to provide retail clinic access for employer-sponsored plan members to address climbing urgent care utilization within this membership group.

Cigna found that 45 percent of members who sought treatment at an urgent care center could have visited a retail clinic instead. If they had done so, Cigna would have saved 81 percent on costs.

Healthcare payers could also generate higher consumer satisfaction with their health plans by offering retail clinic access to members.

A Robert Wood Johnson analysis on the value proposition of retail clinics found that consumers reported high rates of satisfaction with retail clinic convenience and access.

Fifty-nine percent of consumers said they choose a retail clinic over another primary care facility because the hours were more convenient, and 56 percent said that they chose to use a retail clinic because there was no need for an appointment.

Forty-eight percent of consumers said they chose a retail clinic over a primary care setting because the retail location was more convenient.

Why beneficiary education is key to effectively provide retail clinic access

Providing retail clinic benefits to health plan members could provide a significant opportunity to reduce costs for payers. However, the financial opportunity could be limited if beneficiaries don’t understand how to correctly utilize retail clinics.

An analysis of the retail clinic market from RAND Corporation cautions that retail clinic utilization could drive up healthcare costs if beneficiaries overutilize services.

“Retail clinics generate cost savings only if less expensive clinic visits substitute for more costly care from physicians or emergency departments,” RAND said. “On the other hand, retail clinic visits could also increase costs if they generate new health care use by patients seeking care when they otherwise would have stayed home.”

Member education and outreach on appropriate utilization is key to lower overuse of healthcare services. Educational efforts from payers can help guide members to appropriate utilization.

BlueCross BlueShield of Texas and other BCBS companies have ramped up efforts to teach members when they should use a retail clinic, urgent care center, or emergency department for their healthcare needs. The payer provides members with a tool called SmartER that helps them navigate to appropriate care facilities.

Commercial payers like Aetna also provide digital content to educate members about appropriate retail, urgent, and emergency care use. UnitedHealthcare also provides members with resources about utilization options.

Payers that take the necessary steps to expand retail clinic access to members are most likely to reduce the risk of overutilization and provide a new low-cost, high quality healthcare service for their members.


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