Aaron E. Carroll
APRIL 12, 2016 – My wife and I both work. When one of our children wakes up complaining of a sore throat, we could begin a ritual stare-down to determine which of us is going to have to wait for the doctor’s office to open, make the phone call, wait on hold, schedule an appointment (which will inevitably be in the middle of the day), take off work, pick up the child from school, sit in the waiting room (surrounded by other sick children), get the rapid strep test, find out if the child is infected and then go to the pharmacy or back to school, before returning to work.
Or, one of us could just take the child to a retail clinic on the way to work and be done in 30 minutes. Strep throat is incredibly easy to treat (Penicillin still works great!). There’s a simple and very fast test for it. Moreover, physicians are really bad at diagnosing it clinically. A study found that a doctor’s guess as to whether pharyngitis, or a respiratory infection for that matter, is bacterial or viral is right about 50 percent of the time — no better than flipping a coin.
Aimee and I choose the retail clinic every time.
Why? Convenience is the biggest reason. Many doctors’ offices are open only on weekdays and during business hours. This also happens to be when most adults work and when children attend school. A 2010 survey of 11 countries found that Americans seek out after-hours care or care in a hospital’s emergency room more often than citizens of almost any other industrialized nation. More than two-thirds of Americans with a below-average income did so. But this isn’t just a problem for the poor. About 55 percent of those with an above-average income did so as well.
We complain all the time that people use the emergency room for primary care. But that’s not always about lack of insurance. It’s about access. The emergency room is open when people can actually go. Emergency room use has gone up, not down, since the passage of the Affordable Care Act. More people have insurance, and now can afford care when they need it.
That care is also coming from retail clinics, usually found either in stand-alone storefronts or inside pharmacies. Between 2007 and 2009, retail clinic use increased 10-fold. It turns out that my wife and I represent America pretty well. About 35 percent of retail visits for children are for pharyngitis — sore throats. Add in ear infections and upper respiratory infections, and you’ve accounted for more than three-quarters of visits for children. Parents bring their children to retail clinics to take care of quick, acute problems. Swap ear infections for immunizations, and you’ve got the main reasons adults use retail clinics, too.
Researchers for a study published in the American Journal of Medical Quality talked to patients who sought out care at retail clinics. Patients who had a primary care physician, but still went to a retail clinic, did so because their primary care doctors were not available in a timely manner. A quarter of them said that if the retail clinic weren’t available, they’d go to the emergency room.
It’s understandable why physicians’ groups might be opposed to retail clinics. Above and beyond the obvious economic loss when a patient goes elsewhere, many primary care physicians correctly point out that retail clinics often lack the knowledge and experience that come from continuity of care. For many years, experts have argued that medical homes are the optimal way to care for children, especially those with chronic conditions. Those are primary care doctors’ offices that offer a comprehensive, patient-centered, team-based, coordinated approach. Retail clinics are pretty much the opposite.
The American Academy of Pediatrics, the American Academy of Family Physicians and The American Medical Association have all released policy statements or guidelines that oppose, or at least advise, that use of retail clinics be restricted. That doesn’t seem to have deterred many patients.And research hasn’t borne out many of the physicians’ concerns. A 2009 study in the Annals of Internal Medicine examined the cost and quality of care delivered at retail clinics compared with physicians’ offices and urgent care centers. It turns out that aggregate quality scores were similar in all three settings, as were patients’ receipt of preventive care. The cost of visits, however, was significantly less in retail clinics: $110 versus $166 at the doctor’s office and $156 at the urgent care center.
This has led some people to believe that these clinics are a viable way to reduce health care spending. After all, if we can achieve the same quality, improve access and spend less, we will have achieved the triple aim that everyone wants. I have argued in the past that this is almost impossible. Health care systems function under the constraints of the iron triangle. If you increase access, and don’t let quality suffer, it’s likely that spending will increase.
A very recent study in Health Affairs would seem to support my beliefs. If retail clinics were just used by people to substitute less expensive visits for more expensive ones, they might help us to spend less over all. But if they encourage new health care visits that otherwise wouldn’t have happened, they could increase spending. That’s what’s happening. Researchers used insurance claims from Aetna for more than 13 million enrollees from 2010 through 2012. They found that 58 percent of visits to retail clinics were for minor issues that hadn’t been treated before. Retail clinic use was associated, over all, with an increase in spending of $14 per person per year.
In other words, when people found it easier to go to the retail clinic, they lowered their threshold for what they’d go to the doctor for. It’s likely that many of these visits were unnecessary. For example, people with upper respiratory infections, for the most part, don’t need a clinic visit at all. They may not be willing to figure out how to squeeze in a doctor’s visit, but they may be willing to swing by the retail clinic — and that extra spending in volume overwhelms the savings seen per visit.
New services that improve access may wind up increasing health care spending. Many people who use retail clinics might be willing to make that trade-off. If physicians want to reclaim that business, they will probably have to offer the same benefits of scheduling and efficiency that retail clinics do. But if we are looking for ways to reduce our national health care spending, retail clinics may not be the prescription we need.