Download - Ateev Mehrotra: Retail Clinics
Retail ClinicsVictors or Vanquished?
Ateev MehrotraDepartment of Health Care Policy
Harvard Medical School
Outline
Retail clinics as a case study of innovation
• Describe model
• Impact on health care
Next steps
• Why is the impact of retail clinics not larger
• Next wave of disruption
Retail Clinics Seen as Such an Innovation
• In retail stores
• Nurse practitioner
• No appointments: in & out in 20 min
• Short menu of conditions
• High-quality care through use of strict evidence-based algorithms
Retail Clinic Model
Typical “Menu” at a Retail Clinic
MinuteClinic Website
1,600 Clinics Have Opened Across the US
Rudavsky, Pollack, Mehrotra, Annals of Internal Medicine, 2009
Rapid Increase in Retail Clinic Use Among Commercially Insured
(visit per person per year)
Mehrotra et al., Under Review
Majority of Retail Clinic Visits Are fora Limited Number of Conditions
% of Retail Clinic Visits
Upper respiratory illnesses 27
Sore throat 21
Immunizations 20
Otitis media / externa 13
Eye infection (pink eye) 5
Urinary tract infection 4
Screening lab test or blood pressure check 1
Total, ten top reasons for retail clinic visits 90
Mehrotra et al., Health Affairs, 2008
Current State of Retail Clinic Industry
• Majority of clinics run by 3 large for-profit companies
‒ MinuteClinic (CVS)
‒ TakeCare Clinic (Walgreens)
‒ Little Clinic (Kroegers)
• Smaller fraction run by large systems (Geisinger, Mayo Clinic, SutterHealth)
• “Co-branding” of WalMart or other clinics by hospitals (UCLA, Cleveland Clinic)
Rudavsky, Pollack, Mehrotra, Annals of Internal Medicine, 2009
Many See Great Promise in Retail Clinics
• Promoted by politicians and policymakers
• WSJ February 2013 “…consider opportunities to shift more care to less-expensive venues, including for example, ‘Minute Clinics’ ”…
• Potential benefits:
‒ Improve access for all patients
‒ Safety net provider for the underserved
‒ Decrease non-urgent ED visits
Concerns From Physician Organizations
• AAP just reissued policy statement which states, “The AAP continues to oppose RBCs as a source of primary care for pediatric patients”
• AMA tried to prevent retail clinics from opening in several states
• AAFP’s 2010 policy statement strongly opposes expansion of care into management of chronic illnesses
Ongoing Debate
Issue Positives Concerns
Quality • Follow guidelines, thus ensuring quality
• Deliver poor quality services
• Overprescribe antibiotics
Access &PCP Relationships
• Improve access for all patients
• New safety-net provider
• Undermine patient-doctor relationships
• Decrease use of preventive care
Costs • Decrease ED visits• Decrease overall
costs
• Increase costs due to unnecessary follow-up
Ongoing Debate
• Quality
• Access & PCP relationships
• Costs
Antibiotic Prescribed for Ear Infection
Antibiotic Prescribed for Sore Throat
0%
20%
40%
60%
80%
Retail Clinic
MD Office
Urgent Care
ED
Antibiotic Prescribing Rates Are Similar
Mehrotra et al., Annals of Internal Medicine, 2009
Ear Infection Sore Throat Urinary Tract Infection
0%
10%
20%
30%
40%
50%
Retail Clinic
MD Office
Urgent Care
ED
Fraction of Patients with One or More Follow-up Appointments Is Similar
Ear Infection Sore Throat Urinary Tract Infection
0%
20%
40%
60%
80%
100%
Retail Clinic
MD Office
Urgent Care
ED
Quality of Care in Retail Clinics is the Same or Better as Found in Other Settings
Broad-Spectrum Antibiotic Prescribed for A...20%
40%
60%
Retail Clinic
MD Office
ED
More Recent Work on Broad Spectrum Antibiotic Prescribing Rates
Mehrotra et al, under review
Quality Findings Consistent With Other Research
• Patient satisfaction very high1
• Quality– Follow-up visit rates lower2
– Care concordant with guidelines3
1 Harris Interactive2 Rohrer, Qual Manag Health Care, 20083 Woodburn, AJMQ, 2007
Ongoing Debate
• Quality
• Access & PCP relationships
• Costs
Large Fraction of US Population Has Access to a Retail Clinic
• Almost 90% of clinics in urban areas
• 38% of urban population within 10 min drive
‒ Nashville 94%‒ Minneapolis 96%‒ Las Vegas 92%
• Few clinics in underserved areas
‒ 13% of clinics in Health Professional Shortage Areas (HPSAs) compared to 21% of population
Rudavsky, Mehrotra, JABFM, 2010
Age Distribution of Patients
Series10
10
20
30
40
50
<2
2-5
6-17
18-44
45-64
>65
%
Mehrotra et al., Health Affairs, 2008
Retail Clinics EDMD Office
Did not use insurance0
10
20
30
40
50
Retail Clinic
MD Office
ED%
Patients Less Likely to Use Insurance for Retail Clinic Visits Compared
to Other Settings
Mehrotra et al., Health Affairs, 2008
Have a primary care physician0
20
40
60
80
100
Retail Clinic
%Few Retail Clinic Patients Report Having a Primary Care Physician
Mehrotra et al., Health Affairs, 2008
Impact on PCP Continuity:8% Fewer Patients Have a PCP Visit
Year before Year after0
20
40
60
80
100
%Retail Clinic
PCP Retail Clinic
PCP
Reid et al. JGIM, 2012
%
Impact on Preventive Care:No Negative Impact on Breast Cancer Screening
Year before Year after0
20
40
60
80
100
%
Retail Clinic
PCP Retail Clinic
PCP
%
Reid et al. JGIM, 2012
Summary of Impact on Access & PCP Relationships
• Not focusing on underserved• Attract a different patient population • Often no PCP relationship to disrupt• Impact on PCP relationships
– Modest negative impact on continuity– No impact on preventive care or chronic
disease care
Ongoing Debate
• Quality
• Access & PCP relationships
• Costs
Ear Infection Sore Throat Urinary Tract In-fection
$0
$200
$400
$600
$800
Retail Clinic
MD Office
Urgent Care
ED
Significant Per Episode Cost Savings at Retail Clinics
Mehrotra et al., Annals of Internal Medicine, 2009
Ear Infection Sore Throat Urinary Tract In-fection
$0
$10
$20
$30
$40
$50
Retail Clinic
MD Office
Urgent Care
ED
No Notable Difference in Prescription Costs
More than 100 Million “Retail Clinic Type” Visits to Physicians and Emergency Rooms
Top 10 Conditions/Service...0
20
40
60
80
100
120
ED
MD Office
Millions of Visits per
Year
Weinick et al., Health Affairs, 2010Mehrotra et al., Health Affairs, 2008
Do Retail Clinics Save Money?Depends on Impact on Overall Utilization
• Substitution‒ Visiting retail clinic instead of physician or ED
‒ No change in overall utilization
• New Utilization‒ Visiting retail clinic instead of staying home
‒ Increase in overall utilization
Issue Our Findings
Quality Little evidence to support concerns Antibiotic prescribing is similar
Access & PCPs
Retail clinics serve different population than physiciansModest negative impact on PCP relationshipNo impact on preventive and chronic disease care
Costs Per visit, there are substantial savingsUnclear impact on overall spending
Summary of Research
Have Retail Clinics Fit the Disruptive Innovation Model?
• Offer affordability, convenience, and simplicity to previously-neglected markets– Southwest Airlines, Netflix, and TurboTax
• Markets too small and low-margin for incumbents to pursue or aggressively defend
• Disruptors improve and expand
Hwang, Mehrotra, Harvard Business Review, 2013
Barriers to Disruption
• Scope of practice laws• Health plan policies
– Included in network– Patient cost sharing
• Reimbursement policy– Fixed – Not tied to actual costs– Incumbents response
• Business model– Seasonality– Fixed costs
Hwang, Mehrotra, Harvard Business Review, 2013
New Wave of Disrupters
• Personal health records• eVisits• Phone visits• Kiosks• OTC testing