Effect of Retail and Urgent Care Clinics on Primary Care in Missouri

Missouri citizens, especially those living in larger urban centers, have more healthcare choices than they used to when seeking medical care.

These include 1) walk-in retail clinics staffed by advanced nurse practitioners operating in pharmacies, grocery stores, or other convenient locations; 2) traditional clinics staffed by physicians, nurse practitioners, physician assistants, nurses, and ancillary support staff (whether practitioner-owned or run by nearby hospitals and large independent healthcare networks); 3) urgent care centers (both privately owned and operated and those run by hospitals and networks); 4) emergency rooms operating in and run by local hospitals; and 5) on-demand virtual visits that has grown in popularity recently.

Patients factor in time, expense, urgency, familiarity, and insurance coverage when deciding which of these facilities to visit for their ambulatory healthcare needs. While physician offices and emergency rooms have long been a healthcare landscape fixture, urgent care centers and retail clinics are relatively recent developments that are changing the nature of ambulatory care provided by physicians in their offices and emergency rooms. To examine the effect of these choices on traditional office settings, a brief history of definition of these settings is necessary.

Retail Clinics

The first retail clinic appeared in Minnesota in 2001, when a frustrated father and future Minute Clinic cofounder, experienced a long wait at an urgent care center for treatment of his son’s strep throat.¹ Since then, this type of service has expanded to a market size of $3.49 billion in 2021, spurred on by a 21.5% growth during the first year of the COVID-19 pandemic, and projected to reach $4.22 billion by 2029.² Major players in this market include: Walmart, CVS Health, Walgreens Boots Alliance, The Kroger Co., Kaiser Foundation Health, Target Brands, Bellin Health Systems, and Geisinger Health.

Retail clinics are generally located within retail stores, such as pharmacies or “big-box” outlets like Wal-Mart. They offer a limited range of services and staffed by nurse practitioners or physician assistants. Retail clinics are typically open seven days a week, have extended hours in the evenings, and do not require appointments. Retail clinics compete with doctors’ offices for basic primary care services by offering lower and more transparent prices, shorter waiting times, and convenience. By-and-large, retail clinics limit their offerings to many low-risks servies, where 10 clinical issues such as sinusitis and immunizations comprise more than 90% of retail clinic visits. These same clinical issues make up only 12% of Emergency Department (ED), 13% of adult Primary Care Physician (PCP) visits, and 30% of pediatric PCP visits.³ The same study suggested retail clinics appear to be serving a patient population underserved by traditional clinics; young adults (ages 18 to 44) who pay out-of-pocket for their care and less likely to have established a relationship with a PCP. They also appear to be lowering the cost of this type of care. A typical visit cost ($110) is less than similar visits to physician offices ($156) or EDs ($570), while providing the same quality of care.⁴ One study in New Jersey demonstrated these clinics reduced nearby ED visits by 3–13% and estimated to generate $70 million savings if they were more readily available across that state.⁵

State regulations governing nurse practitioner scope of practice are one of the factors constraining the growth of Retail Clinics. Missouri is one of the states that limit nurse practitioners’ ability to practice medicine without physician supervision. The regulations limit the number of nurse practitioners a physician may supervise (six FTE) and requires the collaborative physician practice within a specific distance (30 miles) from the nurse practitioner’s site.⁶ There is evidence the number of retail clinics increases when states remove these restrictions compared to nearby states who retain restrictions.⁷ Studies on the effects of this expansion are still forthcoming. There are many arguments made on both sides of the debate. Recent legislative changes enable the nation to study the long-term effects of increased scope of care vs. continuation of closer supervision.

Urgent Care Centers

The first urgent care centers appeared in the early 1970s and now number over 8,000 across the United States U.S.), according to the American Academy of Urgent Care Medicine (AAUCM). This organization defines urgent care service as “the provision of immediate medical service offering outpatient care for the treatment of acute and chronic illness and injury.”⁸ In one survey using a 2014 national database or 31,022 communities from the Urgent Care Association of America, identified 6,898 urgent care centers. More than 75% of these centers are in urban communities associated with areas of higher income levels and higher levels of private insurance.

A Microsoft Bing^® Excel mashup, (an automatic add-in to Microsoft 356 versions of Excel that adds background queries based on elements in tables being used) lists 51 public urgent care companies with over 590 centers in the U.S. (Table 1). It should be noted this list does not include urgent care centers run by hospitals or independent healthcare networks. The distribution of these centers is concentrated in populous states (Figure 1). Missouri also demonstrates this, where more than 95 of the more than 130 are located in urban metropolitan areas (Figure 2). It should be noted that more than 40 urgent care centers are located in relatively rural areas. Most of these are associated with several of the larger healthcare networks in Missouri. These centers typically offer extended weekday and weekend hours, accept unscheduled visits, and provide low-acuity to mid-acuity episodic care to patients who would otherwise seek care at emergency departments or by primary care clinics.⁹ They are usually staffed by family medicine specialists with support from physician extenders such as nurse practitioners and physician assistants.

Table 1.

List of Urgent Care Companies

Urgent Care Company	Centers
Concentra Urgent Care	295
Urgent Care Extra	26
Hometown Urgent Care	21
Fast Pace Urgent Care Clinic	15
Urgent Team	11
Premier Urgent Care	11
PhysicianOne Urgent Care	9
Walk In Urgent Care	9
Fast Pace Urgent Care	9
Doctors Urgent Care	8
Cross Keys Urgent Care	7
Excel Urgent Care	7
Night Lite Pediatrics	7
Sherwood Urgent Care	6
St. Luke’s Urgent Care	6
Total Access Urgent Care	6
FastMed Urgent Care	6
MASH Urgent Care	6
Advanced Urgent Care	6
Alliance Urgent Care	6
A Plus Walk-In Urgent Care	5
Dusk To Dawn Urgent Care	5
First Med Urgent Care	5
Five Star Urgent Care	5
Greater Mobile Urgent Care	5
Northwest Ohio Urgent Care	5
Nova Medical & Urgent Care Center	4
Optum Clinic + Urgent Care	4
Sisters of Mercy Urgent Care	4
ProHealth Urgent Care	4
Rockwood Urgent Care Center	4
Urgent Doc	4
Glendora Urgent Care Center	4
Lansing Urgent Care	4
Le Bonheur Urgent Care Center	4
Meridian Urgent Care	4
MedPost Urgent Care	4
CityDoc Urgent Care	4
Community Urgent Care	4
Baptist Urgent Care	4
ASAP Urgent Care	3
Action Urgent Care	3
Advance Urgent Care & Walk-In Clinic	3
ERDOX Urgent Care	3
Evening Pediatrics	3
New England Urgent Care	3
Med7 Urgent Care Center	3
Hoag Urgent Care Anaheim Hills	3
Kootenai Urgent Care	3
Good Night Pediatrics	3
	593

Figure 1.

Distribution of Urgent Care Centers by State

SOURCE: Bind

Figure 2.

Missouri Urgent Care Distribution

Hard numbers are exceedingly difficult to come by, as there is a gradual continuum of clinic types from traditional clinics with walk-in services to urgent care centers that contain many of the services found in EDs. The number of urgent care facilities increased from 6,400 in 2014 to nearly 10,000 in 2020 according to several internet sources.¹⁰ Some of the largest urgent care operators in the U.S. include American Family Care, City MD, Concentra, Fast Med, GoHealth, HCA CareNow, MedPost, NextCare, Patient First, and US Healthworks.¹¹

These urgent care centers are filling the widening gap between primary care and emergency room care and usually include providing unscheduled care, after-hours access, expanded services compared to primary care, all at lower cost than emergency care. These include on-site laboratory, imaging, intravenous medications and fluids, repair of lacerations, foreign body removal, basic fracture care, and treatment of abscesses.¹² Only 8% of urgent care centers offer primary care in addition to urgent care while roughly 3% are “hybrid” urgent care/PCP centers.¹³

There is data to show the rate of urgent care utilization does not seem to impact the rate of primary care visits, despite the increasing number of urgent care visits over time.¹⁴ This may reflect that most urgent care clinics are staffed by physicians who do not want to interfere with a patient’s primary care relationship and as many as half of these are run by the same healthcare systems that employ many of the physicians in their own clinics.

Discussion

The increase in options for patients has anecdotally reduced simple visits from primary care clinic visits and subsequently increased the complexity of patients. With primary care transforming from care delivered exclusively in a physician’s office to care that can be delivered in multiple sites and through different venues such as virtually or in retail settings, we should carefully critique what is gained from this primary care transformation—and what, if anything, is being lost. For instance, entrepreneurs, policymakers, pharmacy and hospital chains, focused on perpetual growth, may believe that the retail clinic model of primary care must expand to include complex service delivery. However, the current body of research does not tell us nearly enough about whether this belief is founded in reality.¹⁵ Minute Clinic, as an example, with its Health Hubs, has been trying to move into comprehensive primary care and chronic condition management. Now, combined with Aetna, it has rolled out a nationwide virtual primary care practice that promises a broad scope of care with access to board-certified physicians and coordinated care from a consistent team of specialists.¹⁶

UnitedHealth and Blue Cross Blue Shield are also aggressively entering primary care. UnitedHealth is building a network around physicians who work for its Optum arm. This unit has acquired a sprawling network of physician practices, surgery centers and urgent care clinics.¹⁷ Blue Cross Blue Shield is following step with its SpiraCare clinics.

It is difficult to imagine how these convenience sites of care would be able to participate in many of the activities supporting longitudinal care aligned with Patient Centered Medical Home goals and alternative payment systems like Primary Care First. This is especially so as the distribution of clinics is severely restricted to only urban areas and are far fewer in number than urgent care centers (Figure 3). The American Academy of Pediatrics is but one professional society that has concluded retail clinics are not appropriate venues for primary care for children due the fragmented, episodic nature of their care.¹⁸

Figure 3.

Retail Clinic Distribution in Missouri

In a study of retail clinic utilization by traditional fee-for-service Medicare beneficiaries in the greater Houston area, patients without chronic conditions were more likely to use retail clinics compared with those beneficiaries with existing chronic conditions and those with established PCP relationships.¹⁹ The same study showed most of these visits were for vaccinations and simple acute infections, often when PCP clinics were closed. The study did find that 10% of the visits by Medicare beneficiaries were for management of chronic conditions. What is concerning is the study showed there was minimal PCP follow-up visits raising concerns about quality, coordination, and outcome of care among elderly retail clinic users. This lack of coordination and close follow-up raise questions as to the overall efficacy of this fragmentation of primary care despite studies showing nurse practitioners can provide the same quality of care for low acuity conditions and complaints seen in the retail clinics.²⁰ The primary difference lies in the tendency for advance nurse practitioners to limit their decision-making to the presenting problems where physicians were more likely to also address underlying comorbidities.²¹

Anecdotal evidence exists the presence of retail clinics has reduced the volume of minor acute care visits conditions that used to be the “bread and butter” of traditional family practice clinic and replaced these visits with complicated patients. Current CPT coding paradigms are not keeping up with the time required to adequately treat and manage these complicated patients and meet many quality standards required by third-party payers. These trends put increased competitive pressure on traditional clinics that face an uphill battle with little or no resources compared to retail clinics backed by large, corporate entities.²²

One approach is to integrate an urgent care clinic within a family medicine practice as done by the University of North Carolina’s Family Medicine Center. They allowed the practice to offer extended hours and enabled them to welcome more people into primary care and provide them with a comprehensive approach that would otherwise be lacking in a regular nonaffiliated urgent care center.²³ While this approach may be possible for larger centers with adequate staffing, it is probably beyond the scope and capabilities of most family practice clinics.

Another approach available to primary care clinics in urban areas is to participate and enter collaborative relationships with nearby retail clinics’ nurse practitioners who are seeing many patients without a PCP relationship who do need follow-up beyond their scope of care. These type of relationships have the potential to expand access to their patients by cross-referring them after hours to the retail clinic in return for being a place where nurse practitioners can refer patients needing care that is more complex.

Reimbursement and poor attribution cause major problems as care choices expand. Nationally, there is an inexorable attempt to move away from traditional fee-for-service to value-based reimbursements. Value-based reimbursements hinge on the ability of practices to meet an ever-expanding set of quality metrics for their attributed patients to qualify for incentives. If outside nurse practitioners and urgent care physicians see patients for minor problems but do not address the patient’s comorbidities, the practice may suffer in their quality metrics. It is unlikely the retail clinic provider will see these patients enough to be the attributed provider, nor allowed to be the attributed provider of record by covering entities. Even if allowed, it is hard to image these retail clinics will willingly enter value-based contracts with third party payers. The same is true for urgent care clinics, especially public ones. The business model limits them to episodic care and chronic care seems incompatible with that type of care.

There are hints of this changing in Missouri and the entire United States as acquisitions and mergers increase in both private and public health venues. When pharmaceutical companies acquire insurers who then acquire or expand their healthcare footprint their ownership and responsibility to the patients seen will increase proportionately.

Israel is a nation whose health care is highly managed with emphasis solutions that reduce cost, improve efficiency while reducing unnecessary utilization. The convergence of managed and consumer-driven care has led to a rapid growth of urgent care centers in Israel.²⁴ Lee Resnik, MD, in his commentary thinks the American urgent care model will eventually resemble the Israeli model, where a wide assortment of retail and urgent care centers are integrated and aligned with health systems and insurance companies. The entry of insured-owned clinics and networks supports this evolution.

It’s easy to imagine this happening within large independent Missouri healthcare systems like Mercy Health, SSM, St. Luke’s, and Cox Health who have a growing combination of retail, convenient clinics, urgent care centers, out-patient primary care clinics, emergency rooms, and hospitals. Most of these share a common electronic record system to provide continuity of across multiple venues. As insurers enter primary care and begin offering their own networks of care combined with their contracts with healthcare systems, we could begin to see some cooperation, if not integration happening to achieve cost savings and improve the convenience for their enrollees.

Recent legislative efforts are beginning to get serious about interoperability. Over the last couple of years, clinicians are beginning to witness record availability across platforms and among traditional competitors. This could lead to better shared chronic and complex care management while providing local and accessible convenient urgent care.

Summary

Patients have an increasing number of choices to receive medical care. The COVID pandemic has dramatically driven this trend. These medical venues include on-demand virtual visits, conveniently located retail clinics, urgent care centers that offer extended hours, in-house lab, and imaging leading to prompt care and diagnoses. Planned and scheduled physician-lead primary care or specialists can lead to effective longitudinal care. Traditional hospital emergency room services for true emergencies will expand. Ideally, patients will have choices of hospitals with care and insurance integration for a higher standard of care. Presently, insurance coverage and patient’s recognition of various scopes of care is problematic and can lead to unexpected, and sometimes devastating, financial burdens. These choices are not equitable along wealth and location axis. Ideally, the trends we have outlined here will lead to the highest possible level of medical care for all patients in all urban, suburban and rural locals.