Will retail take over primary care?

Walgreens and CVS pharmacy chains are aggressively developing primary care venues within their stores. Their approaches are similar yet different, although the underlying strategy is the same for both.

The idea is to deliver “episodic care” to those in need with a motto of, essentially, “you’re sick, we’re quick.” The CVS model is known as MinuteClinic with 800 units nationwide and an expectation to grow to at least 1,500. The CVS health services are staffed by nurse practitioners or physician assistants.

CVS has relationships with physicians, available to offer advice to the NP or PA on request. Not only medical care is offered, but also counselling for nutrition, weight loss and smoking cessation. About 85% of clients have insurance and most of those have their own primary care physician (PCP).

Recently, Target announced that it was selling its in-house pharmacies to CVS, who will in turn, run them under their own brand and in many cases open Minute Clinics in the Target stores.

Duane Reade, a large pharmacy chain in New York City, opened primary care clinics staffed with physicians in some of its stores. Called Dr Walk-In Medical Care or sometimes “Doctor on Premises,” they found it not only very successful as a product offering, but also because it brought customers into their stores and generated downstream sales of drugs and other products.

Customers tended to be those who might have their own PCP but who did not want to wait days to see the doctor for a minor, but troubling, issue. They found that the cost was low, the wait short and the doctor well trained.

Further reading: Strategies for making PCP practices more efficient

Dr Walk-In performs exams, basic treatment services, health screenings and vaccinations. The physician offers episodic and semi-urgent care, but does not invest in a PCP-patient, long-term relationship. Rather, he or she referred back to the individual’s own PCP or to a specialist if indicated.

The clinics were highly successful and when Duane Reade was acquired by Walgreens, Walgreens decided to purchase Dr Walk-In from its founders and expand the concept nationally as Healthcare Clinic with a switch to nurse practitioners and physician assistants.

Next: Should PCPs be worried?

Interestingly, Duane Reed, now owned by Walgreens, closed all of its walk-in clinics at the end of December 2016 with no explanation.

The Affordable Care Act has been one driver of this expansion of retail sites. With more people having Medicaid or subsidized insurance, the need for primary care has been expanding at a time when there are too few primary care providers.

More and more health policies, including those through the insurance exchanges, come with high deductibles so the patient must (ultimately) pay the primary care provider directly. The retail clinic is much less expensive than an ER visit and often less than going to a doctor’s office.

Another factor is convenience. These retail clinics tend to be open early in the morning, late into the evening, on weekends and no appointment is necessary. Prices are generally posted. It is a venue that appeals to someone with a high deductible insurance policy, who has a PCP at some distance or cannot be accessed immediately and/or to someone who needs to get treated without losing time from work or school.

The term episodic primary care seems appropriate to me because the provider is not representing himself or herself as a personal long-time primary care provider, but rather as a provider who is readily available for pressing issues such as a urinary tract infection or a minor injury, immunizations and counseling. “Family medical care made easy,” per Walgreens, although this would suggest that it is comprehensive primary care which it is not.

Not surprisingly, some PCPs and their professional associations have railed against pharmacy-based primary care.

Walmart, America’s largest retailer with as many pharmacies as the drug store chains, has begun primary clinics as well, beginning with a few stores and using QuadMed as the vendor. Unlike healthcare organizations that currently rent space from Walmart for their operations, Walmart’s Care Clinic will be more like a full-service primary care office staffed by nurse practitioners with PCP backup. Their employees will pay only $4 per visit, and customers will pay $40 per encounter.

The plan is to be open for 12 hours on weekdays and 8 hours per day on weekends. The Walmart Care Clinic will offer care for selected chronic conditions such as mild anxiety, asthma, uncomplicated diabetes, high blood pressure and elevated cholesterol, osteoarthritis and osteoporosis.

Further reading: Top tips for physicians to deal with uncertainty

When the requirements are beyond the scope of the nurse practitioner, the patient will be referred to an appropriate specialist. Each clinic will have the capacity for basic laboratory testing such as blood glucose, blood counts, rapid strep throat test, urinalysis and pregnancy testing. Vaccines such as influenza, shingles, pneumonia, hepatitis A and B, chickenpox and HPV will be available.

Next: Clinics will continue to grow

With an arrangement with a national laboratory chain, the clinic can draw blood or obtain other samples to send for most other testing needs, sparing the patient the need to go to a separate facility.

After test runs in a few stores are complete, we can expect Walmart, a disruptive innovator, to aggressively clone their clinics nationwide. Will Walmart become the country’s largest purveyor of primary care, just as it has become for food and toys? More importantly, will Walmart appreciate the importance of an appropriate patient-to-provider number to bolster real relationship medicine?

Duane Reade, Walgreens, CVS and Walmart clearly understand that they can lever the healthcare marketplace for downstream sales if they can control primary care or at least episodic primary care.

For many individuals this has become the entry point into the healthcare system. They are filling a need brought about by a very dysfunctional care delivery system including the current crisis in primary care.

The chains have seen the need and are aggressively acting to fill in where the traditional system has failed. Will PCPs be able to compete and bring the business back? Or will primary care further splinter and become just “the easy stuff” with still fewer graduates choosing primary care as a career?

As long as most PCPs cannot or will not offer relationship-based care to a limited number of patients per day, these clinics will expand to fill the gap.

Note: I have no financial relationship with CVS, QuadMed, Walgreens or Walmart; I own stock in Walgreens and Walmart.

Stephen C Schimpff, MD is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and Sanovas, Inc. and is the author of Fixing the Primary Care Crisis: Reclaiming Relationship Medicine and Returning Healthcare Decisions To You And Your Doctorfrom which this post is adapted.