Healthcare Disrupted: Transitioning Primary Care, Diagnostics and Chronic Disease Management to the Retail Healthcare Sector

IN MARCH 2010, the healthcare industry changed when the Affordable Care Act (ACA) was enacted and a flood of newly insured became empowered to seek, consider and choose their own healthcare options. This historic event, coupled with a near simultaneous advancement in healthcare technology (electronic health records [EHRs], telehealth and wearables capable of tracking and reporting data without user intervention) turned the industry on its heels. Ten-plus years later, this newly engaged public has evolved in many respects into a new type of patient: the healthcare consumer. Healthcare consumers seek simplicity and efficiency; they want convenient office hours and clear pricing. Enter the retail health center (RHC), a growing big-box and stand-alone trend that is filling voids and drawing interest, as well as raising questions. For some healthcare consumers, the lures of an RHC are convenience of location and availability of providers. For others, the lures are simple and more affordable pricing structures.

When RHCs first arrived on the scene in 2000, there were some considerable unknowns. For instance, would they cause care to be fragmented? How would they use EHRs, and would there be compatibility issues with other EHR systems? Yet, despite these unknowns, RHCs have continued to grow, serving an unmet healthcare need, particularly with declining numbers of primary care physicians.

The Doctor (or Physician Assistant/Nurse Practitioner) Will See You Now

Providers must deliver on patient needs. When operating hours and perceived level of care, including scheduling and billing, don’t meet patient expectations, the inclination may be to seek care elsewhere. This is where RHCs are gaining market share.

In turn, traditional healthcare is attempting to meet healthcare consumers’ needs by providing extended hours, easier appointment scheduling (including online portals) and improved access to telehealth. But expansion of hours and services isn’t always easy, particularly considering the prohibitive cost of staffing and technology. More than half of healthcare visits occur on weekends and holidays,¹ which RHCs seem better able to offer. “RHCs are not urgent care clinics,” stresses Nate Bronstein, COO of the Convenient Care Association (CCA). “We are not replacing doctors; we play an expanded role in the continuum of health.”

Originally created to treat limited acute conditions, RHCs have in many cases expanded facilities and services to routine care and management of chronic conditions. In fact, they are often patients’ first contact with the healthcare system. Generally, they are located within a 10-mile radius of nearly 50 percent of the population, and approximately 60 percent of their 50 million patients do not have an established primary care provider. According to Tine Hansen-Turton, founding executive administrator director for CCA, about 40 percent to 60 percent of those seeking care in RHCs do so for primary or chronic conditions.

Practice Authority

More than half of U.S. states and the District of Columbia have passed legislation permitting full practice authority for nurse practitioners (NPs), meaning they can evaluate, diagnose, order and interpret diagnostic tests and initiate and manage treatments for patients, including prescribing medications, under the exclusive licensure authority of their state board of nursing. According to the American Academy of Nurse Practitioners (AANP), those states without full practice authority generally see greater geographic healthcare disparities, higher chronic disease burdens, primary care shortages, higher costs of care and lower standings on national health rankings. For example, Bronstein cites Texas and Florida, the two states with the greatest number of RHCs, also have the greatest number of health disparities.

In these more restrictive states, NPs working in RHCs provide care under the remote supervision of an established medical practice, so they are not permitted to see patients and prescribe treatments without physician oversight. According to CCA, the fewer providers available, the more expensive these RHC practices become thanks to increasing collaborative agreement fees, insurance and other needed resources. CCA says the additional overhead could be as much as 5 percent to 10 percent. But, “that hasn’t impacted the model,” says Bronstein. “There are still more clinics needed.” Even so, he says, by granting full NP and physician assistant (PA) practice authority, the U.S. healthcare provider shortage could be reduced by 89 percent.

Out of the Box

But the American Medical Association (AMA) disagrees. AMA takes issue with RHCs as a solution to primary care shortages, particularly in underserved communities.² In its opinion, the level of experienced care offered in RHCs is less than that of traditional healthcare facilities. And, while the American Academy of Family Physicians (AAFP) encourages use of RHCs, it does not think it should be at “the expense of the comprehensive, coordinated and longitudinal care available through a medical home.” In AAFP’s view, chronic care management and comprehensive longitudinal care should be provided by a primary care physician and medical home team, not by a retail clinic. In addition, it says in cases where certain chronic conditions could be managed in retail clinics, care management should only be under a collaborative agreement between the patient’s primary care physician and the retail healthcare facility specifying the “guidelines, procedures and protocols to be used to provide such care.”³ Further, AMA urges patients seeking treatment in RHCs to become informed about the qualifications of the staff providing treatment, as well as their limitations in diagnosis and treatment. It also recommends RHCs have an established referral mechanism in the event the scope of care is beyond that of the practitioner or retail clinic.²

However, with 89 percent of practicing NPs receiving training in primary care settings, AANP believes NPs play a significant role in providing patients a viable healthcare option. Citing satisfaction surveys that rate NP care equal or superior to physicians for the same problems, NPs make up the most rapidly growing component of the primary care workforce.⁴

CCA agrees NPs and PAs provide valuable primary care roles, and that the establishment of relationships with the larger healthcare community is essential. Citing strong partnerships between member RHCs and hospitals, including RHCs that have been established by healthcare systems, says Hanson-Turton, “we are a national referral service for them.”

All oversight bodies without question agree on adherence to certain standards governing the setup and operation of RHCs, most importantly regulatory, certification and education requirements specific to the state in which care is being delivered. Currently, standards such as the use of evidence-based guidelines for diagnosing and treating patients, use of appropriate EHRs, evaluation of quality-of-care standards through peer and collaborating physician reviews and patient satisfaction surveys are in some cases law and in others best practice.

Bridging the Gap

For both traditional care settings and RHCs, opportunity can only exist in a proactive relationship in which established primary care patients know where to turn in the event care is needed outside of normal business hours. RHCs must have trusted places to turn when in-depth care is needed or when patients prefer a physician.

Established relationships also reduce the risk of fragmented care. Like the telephone game, the more relay points between a message, the more diluted the message becomes. With patients’ consent, the notification and forwarding of records to a primary care provider can be automatic, reducing the risk of information gaps and duplication of treatment protocols. It goes without saying that the mere establishment of relationships is not a panacea for fragmentation. The more access care points, the greater the risk of information lost in transit or translation. Dialogue with the patient and any outside providers are the keys to missing links.

Importantly for the stressed healthcare system, partnerships between hospitals, doctor offices and RHCs can help to reduce hospital readmissions, particularly when patients cannot get in to see their primary care providers. RHCs are also a viable option for patients who have follow-ups within 30 days of hospital release, which result in lower rates of readmission.

Value-Based Care

The movement toward value-based healthcare is resulting in shifting treatment to outpatient settings, reduced costs and improved patient experiences. It is also spurring a trend in consolidation whereby smaller entities are merging with larger entities to improve economies of scale and operational efficiencies. However, these larger entities, thanks to a dearth of competition, may be able to charge patients higher rates to better match insurance reimbursements.

On the other hand, RHCs that are staffed primarily by PAs and NPs offer a lower-cost alternative (in some cases between 30 percent and 80 percent) to traditional healthcare and generally accept most public and private insurance plans. In fact, 60 percent of smaller insurance plans and 73 percent of large plans cover services provided in RHCs, although AMA urges caution against the encouragement of retail clinics to take advantage of lower costs through reduced or waived copayments. However, it is ACA’s position that patients seeking care in RHCs do so predominantly for minor ailments and reassurance that their condition is on the right track. Therefore, in its view, RHCs are potentially “inconsistent with value-based care and payment” because they create “new use” through “improved access.” Furthermore, AMA also estimates that were treatment for low-level conditions sought in RHCs versus emergency departments (about 20 percent of total visits), the healthcare system could save $4 billion annually.²

Data Concerns

Retailers already collect and analyze a wealth of consumer data. When RHCs are added to the mix, where does customer marketing cross the line into violation of patient privacy?

Adequate use and data protection, including EHRs and telehealth technology, are at the forefront of healthcare. From Health Insurance Portability and Accountability Act (HIPAA) protections, Standards for Privacy of Individually Identifiable Health Information (known as the Privacy Rule) to the Health Information Technology for Economic and Clinical Health Act, numerous laws protect patient information and privacy. Even so, doing the bare minimum legally required may not be sufficient to satisfy healthcare consumers who have become increasingly concerned about privacy in the wake of breaches and poor security measures plaguing all aspects of online industries.

This begs a question: Although HIPAA protections prevent the sharing of patient care information to the retailer, what protections are in place when retailers through point-of-sale transactions identify who is being seen or who pays for care in RHCs? As data is collected, customers become viable marketing contacts, particularly when being opted-in or actively opting-in to retailer marketing.

The risks of this information collection came to light in April 2021 when consumer advocates urged District of Columbia Attorney General Karl A. Racine to stop the practice of some retail pharmacies from collecting customer information for marketing purposes as they signed up for COVID-19 vaccinations or inquired about appointment availability.⁵ Certainly, a 21st century extension of the Hippocratic oath could reasonably extend to that of patient data privacy, as is required for the ACA.

Here to Stay

At a time when primary care provider shortages are estimated to grow from 45,000 in 2020 to upwards of 51,000 by 2033,⁶ RHCs provide a necessary and viable option for patients seeking care. While the debate continues, perhaps with both parties agreeing to disagree on whether these clinics should be used in a primary care context, RHCs are here to stay, offering care and meeting patients and customers where they are: in their communities where they already shop, and with hours and pricing that may better suit their needs.

From a provider standpoint, RHCs offer an opportunity to reach an entirely new patient population, whether as a practicing clinician in an RHC or as part of the referral network for primary or specialty care. Clearly, these alliances between complementary providers have the potential to empower a greater focus on and awareness of health for the benefit of healthcare. As the industry balances the struggle between matching the long-term goals of patient health with short-term accessibility and payment options, it may be that the RHC model provides a key to success. Through RHCs’ adherence to established quality and practice standards and their ability to sustain satisfaction metrics while focusing on accessibility, healthcare consumers have every opportunity and every advocate for success.