DPC News

Part 4: Scalability in DPC | Can DPC and Retail Health Coexist?

Michael Tetreault, Editor

You must remove every possible obstacle from the path of the disinterested, suspicious, here-against-my-will, would-rather-be-somewhere-else, Patient.

By Michael Tetreault, Editor-in-Chief

ATLANTA, GA USA | SEPTEMBER/OCTOBER 2018 – It is no secret that there is no love lost between Primary Care Physician’s and Retail Healthcare. Despite somewhat positive data, evidence and quality reports to support retail healthcare’s position and stability in the healthcare marketplace over the years, the commentary in medical journals, retorts by Physician’s and even the social media comment threads are usually quite negative.

In 2016, total U.S. retail clinic sales are estimated at more than $1.4 billion, an increase of 20.3% per year from $518 million in 2010. Through 2020, sales are expected to continue expanding. Strong historic growth has been driven by aggressive expansion, particularly by MinuteClinic, which is now owned by CVS.[4] Hospital executives keeping a close eye on CVS continuing its push into retail healthcare should know that the company has gone live with a new telehealth option built on Teladoc’s platform.[5] With market share and headlines like that, and a staggeringly extensive physical presence, it may seem surprising to a Physician that concepts like Direct Primary Care, mobile urgent care programs and Concierge Medicine have been able to carve off an increasingly thicker slice of consumer interest.


But, we’re not there yet. In fact, if you’ve been working in healthcare for longer than a decade, you know better than most that healthcare is sloooooooooow to change and turning a battleship, a destroyer, a carrier fleet and a cruise ship multiplied by thousands of practices doesn’t happen all at once. Like many, I’m hopeful and optimistic that my work in this field will help leave a legacy for my children and grandchildren and Doctor’s like you who want to find a way to restore the Patient-Physician relationship. My hope is that one day, they will look back and say something like “So, you actually had to wait before you saw a Doctor?” or “You are telling me that you actually had to get cancer before they started treating you?”

One can dream, right?

I digress. Back to the article of interest today.

The question above Can DPC and Retail Health Coexist? may seem odd. You might even grimace and unsubscribe.

Medical Community Response: Keep Watching — As this healthcare market sector matures, reaction from the medical community will be an important factor influencing public opinion of retail clinic services. Negative reaction could severely impede growth in a number of ways: physician lobbying groups, which continue to be strong, could influence restrictive legislation;on a grass roots level, doctors could generate unfavorable impressions of the clinics with patients as well as the media; reaction from the leading medical organizations could affect the willingness of nurse practitioners and others to work for the clinics.Such negativity among physicians could be inspired by impressions of low quality of care, lack of cooperation with the medical community and/or rising competition from the clinics. Lack of cooperation could take many forms, particularly an unwillingness or inability on the part of convenience clinics to share medical information about patients with primary care providers. Since information sharing within the medical community is considered essential to provide appropriate care, a doctor who is not able to obtain treatment or other details about a patient from a retail center is likely to develop a very negative opinion about that clinic. To avoid such problems, the vast majority of clinics has established policies advocating the sharing of medical information, including the obtaining of permission from patients, and has developed electronic systems that facilitate quick transmission of patient files. (Source: Kalorama Information’s Retail Clinics 2017: The Game-Changer in Healthcare)

Click to Enlarge. WHERE DO WE GO FROM HERE? THE FREE MARKET HEALTHCARE DELIVERY FAMILY TREE IS GROWING … (C) The Direct Primary Care Journal | All Rights Reserved.

For those of you still reading and subscribing at this point or you’ve actually thought about this in some casual drive home as you passed one of these clinics, you should know that you’re not alone. You’re not in the majority of DPC Physician’s thinking about this, but if you are you’re one of the forward-thinking types that wants his/her practice to be around for a long, long time. So, you have to understand why people go to these places, keep visiting these clinics and how can you compete or coexist with them in the future.


The Evolving Role of Retail Clinics ~RAND

This is actually a more common question than you might think. We have these dynamic conversations at The DPC Journal with Physician’s quite often. I would say, it comes up about three times a week with Doctors. Comparatively, it came up a couple of times a quarter just four years ago. That’s kind of a big deal if you think about it. And, you should be thinking about it.

RELATED STORY | AMA Journal of Ethics | Physician Reaction to Retail Healthcare Clinics

Primary Care Practice Response to Retail Clinics

Hal Rosenbluth and Peter Miller in STAT say “Looking back, the retail health clinics touched everything we hold dear in health care today. They helped launch the era of patient-centric care; brought price transparency to the industry; made care for most — if not care for all — a possibility by introducing prices that were affordable and accessible; and spotlighted the value of right provider, right place, and right time. Not long after the emergence of retail clinics, the health care industry saw the rise of concierge medicine, urgent care centers, and telemedicine.”


The DocPreneur | Business Podcast Ep. 50 | DocPreneur Podcast: DPC and EHR, Lean DPCs, Employer-Based DPC and Retail Healthcare

Dark Daily also reported “In recent years, pathologists and medical laboratory managers have watched as retail clinics housed in drug and grocery stores became a go-to service for healthcare customers seeking relief from minor illnesses. However, to market research company Kalorama, retail clinics also are a “game-changer” that could pose a threat to healthcare providers if their growth remains unchecked. At risk are health systems and office-based physicians, along with the clinical laboratories and pathology groups that serve them. This would happen if patients shy away from primary care doctors in favor of cheaper, faster, medical care. However, as retail clinics expand the services they provide, they also could become an important source of orders for certain types of medical laboratory tests.”

Few things in the healthcare market can be as potentially disruptive as retail clinics, and for that reason so much attention is focused on them.  By their very existence, the retail could threaten and/or complement at least five parts of the healthcare system – hospitals, doctor’s offices, government and private insurance payors, pharmaceutical and device markers (particularly makers of POC test devices).  They are brought up in discussions of healthcare reform and repeal, in cost-cutting for governments or better preventive care.  They are seen as the answer in some quarters and controversial in others.  And they have grown, from a few hundred store locations a decade ago, to thousands.  If projections are correct, they will continue to grow and change the way healthcare is delivered. Kalorama Information’s[1] Retail Clinics 2017: The Game-Changer in Healthcare, examines the different ways retail clinics in the U.S. are shaping the healthcare market.

There are obvious differences between retail clinics and primary care practices; however, retaining a primary care doctor and frequenting the same retail clinic, when necessary, isn’t an awful practice. Ask your primary care doctor which local clinic they prefer at your next visit. When you arrive at the recommended retail clinic, request that they share visit information with your primary care doctor. Establishing a functioning relationship between both your primary care doctor and the retail clinic saves time and prevents error during future visits.[2]

Healthleaders Media reported While the scope of services and delivery mechanisms continue to evolve, the common denominators of such on-demand healthcare consistently come down to convenience, affordability, and access. These themes are essential to keep in mind as executives ponder the future of retail healthcare and what it means to their businesses.

One does not have to work in healthcare for more than a few years to see that healthcare delivery has changed. Patient trust in their community of healthcare providers and clinics has changed even more so. In fact, trust is the keyword here.

Debra Shute in September of 2017 at Healthleaders Media noted in her article ‘The majority (91%) of patients who recently used a retail clinic reported that they were “satisfied” or “very satisfied” with their visit, according to an April 17, 2017, retail clinic survey from healthcare market researcher Kalorama Information. Facing the undeniable popularity of various forms of convenience care, healthcare systems have increasingly gotten into the retail game through partnerships with or creation of store-based clinics, standalone walk-in and urgent care clinics, and supplemental telemedicine services.’


Further consumer research and evidence to support by The Direct Primary Care Journal finds that in 2018, we began to ask prospective patients seeking care from a subscription-based healthcare provider [e.g. DPC Doctor] across the U.S. to choose ‘Cost’ or ‘Convenience’ over ‘Friendship’ with a Doctor they know, like and can trust. Findings from this DPC Journal patient and consumer survey tell us that nearly 7/10 Patients want and choose … ‘Friendship with a Physician they can get to know, like and want to trust!’

But do Physicians feel the same way? Are they reading the tea leaves and feelings of their patients or going with how they believe the marketplace is. We found that in Contrast, when DPC Physicians are asked the same question, they ranked what they considered most important to their Patient which was Cost as most important (e.g. 46%) followed closely by Finding A Doctor I Know Like & Can Trust (e.g. 42%).

The DPC Journal then surveyed over 1,100 actively seeking patients from across the U.S. in 2017 and asked them about their overall ‘faith’ in a general Physician in today’s healthcare marketplace. Nearly 60% of those participants surveyed said ‘If DPC was not an option, they would NOT select an M.D. for their next primary care visit?’ 34% said they would prefer to see a Doctor of Osteopathic (D.O.) Medicine; 14% would prefer to see a Nurse Practitioner (N.P.) and 7% would prefer to see a Physicians Assistant (P.A.).

“There is a mystique, a temperament and a curious fascination about Doctors who spend an inordinate amount of time with their patients. It’s so simple, it’s weird. And today, like it or not, a Patient wants and deserves your time and attention. That’s why they pay the subscription, keep calling you and keep texting you. They want and expect that their Doctor will be ‘present’ and ‘mentally’ dialed-in. We’re hearing routinely that they will leave your [DPC] practice in a matter of weeks if they feel they are not a priority. That’s not fair, but it’s true … While the human spirit is willing to forgive your colleagues for long wait times, errors, staffing, etc., Patients will remember and share what their last Doctor’s office visit was like.” said Michael Tetreault, Editor of CMT/The DPC Journal.

So, while not massively adopted by every metropolitan community, direct primary care clinics, retail healthcare clinics, nurse in a box offices, micro hospitals and mobile urgent care programs for a flat fee or a subscription are popping up. The thoughtful and forward thinking Direct Primary Care (DPC) clinic Physician would be wise to consider how their patient base, usually similar in demography, see these clinics. While DPC may be more comprehensive, aware of the benefits of primary care vs. retail health care clinic quality and services, the consumer population at-large is not.

Click on Infographic to View Full Graphic … (Source: DPC Journal, 2015)

Can DPC compete with retail healthcare clinics? Absolutely. They already are. Many visits to retail clinics are in the evenings and weekends, when primary care offices are not available. Sound like DPC could compete here? Your answer should be a resounding ‘Yes!’

Does DPC currently compete with retail healthcare today? Absolutely it does. They already are. Younger adults and those without a regular care provider are typical users of retail clinics. Millennials and Gen-Xer’s are also regulars within DPC Clinics.

Do some in DPC see these providers and organizations working together? There are a few DPC Physicians practices we’ve heard about out there across the country who have reached out to these local clinics in there area and received positive reactions.

Is that a sign of the things to come? Can DPC and Retail Healthcare work together? The reactionary answer is more pessimistic than you might think. But, it really shouldn’t be. These clinics are quicker to meet the needs of a community in thousands of facilities across the country right now. Consumers and customers want transparency and convenience more than they want relationship. You might now like that fact, but it’s true. Why? Because the relationship(s) that consumers have previously had with healthcare providers has been so damaged in the past, that the customer would rather ‘get it fixed’ vs. ‘make a friend.’

So, can DPC really coesist with retail healthcare clinics? Time will tell. DPC is unique in many ways. They DPC Physician demographic alone is trending younger and more female physician-owned DPC clinics are owned and operated by a female physician in her 30’s or 40’s. However, another unique component of DPC is it’s self-awareness and reactionary reputation to ideas that threaten the business model and the patient-physician relationship.

By in large outside of DPC and in the medical community alone, if the emotional reactions from the Physician community continue to remain adversarial, the two groups will never see eye to eye.

It has been estimated that up to 20 percent of emergency department visits for a non-emergency condition could take place at a retail clinic or urgent care center, potentially generating cost savings as high as $4.4 billion annually.[3]

Summary and Implications[3]

RAND’s body of work substantially strengthened understanding of the patients served by retail clinics, the quality of the care that those patients receive, and the clinics’ net cost effects:

  • Younger adults and those without a regular care provider are typical users of retail clinics.
  • Overall, retail clinics are not improving access to care for the medically underserved; retail clinics are more likely to be located in relatively affluent sections of large urban areas.
  • Retail clinics provide care that is of equivalent quality to the care provided by physician offices and emergency departments.
  • Retail clinics have not led to any substantive decline in emergency department visits.
  • More than half of clinic visits for low-acuity conditions represented new health care utilization. As a result, contrary to expectations, retail clinics increased health care spending per person per year.

BUSINESS: Walk-in clinics tap market for convenient service … “It’s almost getting to the point that the only reason I go see my traditional physician is for the annual physical,” McDonough said … (Boston Globe)

For the consumer’s and families out there, I do hope some innovative Physicians will find a way to work together. What do I mean by work together? Well, here’s a closing example.

True Story, circa 2017.

A New Jersey Osteopathic Physician had a new subscription-based practice she was opening. She noticed her Patients were routinely visiting the local big box pharmacies to fill their prescriptions. So, one day, she walked in, spoke with the NPs, PAs, RNs and Pharmacist and started a happy, introductory conversation. She asked “May I leave you a few business cards in the event you have some people walk-in that need a place to call home?”

They excited replied, “Yes!”

Two weeks later, the Pharmarcist and PA both called the Doctor on her cell phone and said “Can you drop some more cards off, please? We’ve already given them all away?”

Excitedly of course, the Physician said, “Absolutely. I’ll be right there.”

EDITOR: “You have to define what “exceptional” means …

So in summary, you may disagree with what these clinics stand for. You may agree with the fact that trust has been lost by millions of people in “the system” and “providers” over the years that are supposed to take care of them. You are now trying to do something about it. That’s commendable.

Here’s one final thought as we unpack Part 1 is our series …

“You must remove every possible obstacle from the path of the disinterested, suspicious, here-against-my-will, would-rather-be-somewhere-else, Patient.”

In Part 2, we will examine and release our interviews with PA-led DPC offices we’ve interviewed recently and how Worksite Clinics present an opportunity and competitive force to small DPC clinics and programs.

Here’s a preview of Part 2 at The DPC Journal … One-third of employers with at least 5,000 workers now offering “a general medical clinic to their employees,” ~Mercer — Amazon’s Clinics Join U.S. Employer Push Into Worksite Healthcare — The idea for worksite clinics is to make it easier for employees to get primary care treatment and make sure they are getting regular treatment in the first place. ~Forbes, August 2018


Cited Sources:

  1. https://www.kaloramainformation.com/Retail-Clinics-Game-10780773/
  2. https://www.micromd.com/blogmd/retail-healthcare-primary-care-differences/
  3. https://www.rand.org/pubs/research_briefs/RB9491-2.html
  4. http://www.researchandmarkets.com/research/mj7qss/retail_clinics
  5. https://www.healthcarefinancenews.com/news/cvs-minuteclinic-rolls-out-telehealth-app-teladoc

Categories: DPC News, Scalability Series

Tagged as:

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s