Retail-Based Clinics & the Patient-Centered Medical Home

With drive-thru banking, fast food restaurants, Twitter, and 1-hour photo, is it any wonder that we would come to expect our health care in a similar manner? It is estimated that there are over 1,600 retail-based clinics^1,2 operating now and these numbers are growing in response to health care consumers seeking convenient, quick, accessible and affordable care.

Most of these retail-based clinics are do not require appointments, have extended clinic hours on evenings and weekends and are more affordable than a trip to the local emergency room.^3,4 Initially designed to provide care for a limited number of pressing but non-emergency conditions, some retail-based clinics are now marketing on their websites preventative care, physicals, health screening services, vaccines and chronic disease monitoring.

Patient-Centered Medical Home

The American Academy of Pediatrics (AAP) continues to question the role of retail-based clinics in the care of children in a recent policy statement.⁵ The AAP concludes that retail-based clinics are not appropriate sources of primary medical care for children due to the fragmented, episodic nature of the care they provide. Fragmented care often doesn’t have necessary follow up and lacks integration with the patients’ primary medical home. Coordinated, longitudinal care associated with the transformation many practices see when adopting a medical home model has been associated with improved outcomes and, at least in adults, at a lower cost of care.^6,9,10 With this in mind, the standard of care for children should be a medical home where the physician has received specialty training in the care of children and their specific health care problems. The physician should have an ongoing relationship with the patient and family. The care provided in the medical home should be high quality, coordinated, long-term and ‘whole person’ health care. (See Figure 1.)

Figure 1.

Addressing the Gap

While the principles of the patient-centered medical home are hard to argue, retail-based clinics that provide episodic, acute care outside the traditional medical home have clearly found a place in the pediatric health care market. Patients are consumers of health care, and in their use of retail-based clinics they are sending a clear message that convenience, efficiency, extended hours, and cost are important, especially in the context of acute care. This should not be surprising. When asked what factors most influence the choice of primary care physicians, patients most commonly state convenience and proximity to the home or workplace followed by quick relief from acute illness.⁷ Once continuity of care is established, comprehensive and coordinated care becomes more valued. Pediatricians are thus stuck with what appears to be competing patient demands; the need to provide comprehensive, coordinated, and holistic care while being flexible enough to allow for walk in or same day appointments with extended hours. This is increasingly difficult to achieve, especially in smaller practices, while also maintaining a modicum of work-life balance.

Merging Continuity and Convenience

A patient in a medical home has a single primary care provider that is responsible for all aspects of health care, including preventative and wellness care, chronic disease management and acute care. A number of studies document improved outcome measures and improved patient and provider satisfaction when a single provider is in charge of the patient’s medical care.^8–10 In the medical home, the patient should have the reasonable expectation to see their primary care provider who best understands their medical history and future health care needs for both preventative care and acute care needs. To match patient demands, scheduling processes should allow for same-day access to the primary care provider for acute visits. If health care consumers use these occasions to seek care from retail-based clinics, the opportunity for the primary care provider to address chronic disease management and preventative care is missed. Adding value to each patient visit by addressing preventative care needs or chronic disease management may provide the impetus to the consumer to return to the primary care office. However, when visit types were compared between retail-based clinics and visits to the primary care office, in only 11% of the visits to the primary care office were preventative care ordered or delivered.¹¹ In order to compete with the convenience factor, primary care offices should be willing to work to add increased value at every patient encounter offering preventative care and chronic disease management when applicable.

Health care consumers reported that an advantage to retail-based clinics were their close proximity to home, walk-in appointments, little to no wait times and accessible hours including evenings and weekends. In order to compete, medical home practices should be willing to meet the needs of their patients by providing same day access and access to routine and acute appointments outside of regular business hours. With the available advances in technology and increasingly tech-savvy patients, providing timely clinical advice by phone, patient portals or by secure electronic communication during and outside of regular business hours meet the demands of convenient access.

For practices unable to meet the demands of both continuity and convenience, the AAP suggests developing collaborative relationships with retail-based clinics to expand access to their patients while continuing to foster the principles of the medical home. In such a model, both parties should agree to the scope of practice, disease specific evidenced based standards of care, shared medical records and/or prompt communication, and referral back to the medical home for ongoing care.⁵

Providing Cost Efficient Care

For patients seeking care from retail-based clinic, it is estimated that nearly one-third of health care consumers are paying out-of-pocket compared to 10% in the primary care setting.¹¹ Indeed, the retail-based clinic may offer out-of-pocket savings for the uninsured consumer seeking health care for minor illness when the alternatives include high cost emergency room care. Despite the short term cost savings offered by the retail-based clinic, it is fragmented, episodic based care that has contributed to the current state of inefficient and costly health care system that is not sustainable.¹² Bringing care back to the medical home, with a focus on prevention, follow up and continuity can help drive positive outcomes without adding to the global fixed costs of health care (i.e. space, salaries for presumably unnecessary retail-based clinics).

The policy statement put forth by the AAP expresses the view that the standard of medical care for children is the medical home with a provider specifically trained in children’s health care issues. The AAP further states that retail-based clinics are inappropriate source for primary care for children. In order to meet the demands of the pediatric health care consumers, the primary care medical home must provide quality, organized and evidence based care that is also accessible and convenient. That’s what patients expect from us.

Biography

Kirsten Weltmer, MD, Assistant Professor, Medical Director, PCC Patient Centered Medical Home, Division of General Pediatrics; Nasreen Talib, MD, Professor, Associate Division Director, Division of General Pediatrics; and Keith J. Mann, MD, Associate Professor, Interim Division Director, Division of General Pediatrics, all the University of Missouri - Kansas City School of Medicine and Children’s Mercy Hospitals and Clinics, in Kansas City, Mo.

Contact: klweltmer@cmh.edu