Hospitals, Patient Engagement

While valuable, retail clinics haven’t resulted in lower ER visits

Retail clinics have fulfilled unmet patient needs used to traditional primary care, but haven’t lowered emergency-room visits for low-acuity conditions that aren’t serious or life-threatening.

MinuteClinic (courtesy of CVS Caremark)

The growth of convenient care clinics in retail settings has been a disruptive force leading to change in healthcare access, price transparency, and new roles for nurse practitioners. But one thing they haven’t led to is decreased emergency department use for patients with low-acuity conditions, according to a new study published in the Annals of Emergency Medicine.

Researchers looked at encounter-level data for 11 low-acuity conditions from emergency departments in 23 states (including California, New York, and Florida) between 2007 and 2012 using data from the Healthcare Cost and Utilization Project State Emergency Department Database.

Nationwide, the number of retail clinics increased from 130 in 2006 to about 1,400 in 2012. But the researchers found little difference in ED use among low-acuity-condition patients during the study period.

Except for a slight blip upward to about 15 percent corresponding with the avian flu epidemic in 2009, low-acuity visits stayed close to the 13 percent rate. Low-acuity ED visits fell slightly among those with private insurance, from 119 per 1,000 ED visits in 2007, to 108 in 2012.

“We were able to demonstrate that retail visits are not a substitute for ED visits,” said Grant Martsolf, the study’s lead author and a policy researcher with the RAND Corp. in Pittsburgh.

Martsolf and his colleagues theorized that retail clinic visits were, in fact, not replacing ED or primary care visits, but creating new encounters with the healthcare system.

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Martsolf, however, warned against characterizing retail clinic visits as just an add-on to traditional healthcare or as new spending without much worth.

“An unfortunate mischaracterization of the study would be that retail clinics don’t have a purpose,” Martsolf said. “Is that trip to a retail clinic to a retail clinic worthless? Not to a mother concerned about her child who gets reassurance and who would have stayed up all night worrying otherwise.”

Retail clinics are a disruptive technology that changed the previous nine-to-five nature of primary care by filling a gap in unmet patient needs, Martsolf said.

In agreement was Dr. Jesse Pines, director of the Center for Healthcare Innovation and Policy Research at George Washington University in Washington, DC.

“When it comes to unmet demand, the desire for episodic acute care often exceeds the supply of physicians or facilities in many communities,” Pines wrote in an accompanying editorial. “Convenience setting do not save lives; rather, they deliver services that make people feel better or reassure them that they are taking the right steps to get better.”

There could be an estimated savings of $4.4 billion if patients with low-acuity conditions were treated in a retail clinic or urgent-care center instead of an ED, according to a 2010 Health Affairs study that Pines cited.

“Unfortunately, theory and reality don’t always align,” Pines wrote.

In an interview, Pines said  that the study disproves the notion that retail clinics would save the healthcare system money by reducing low-acuity ED visits. He added that it also reaffirms the idea that increasing healthcare access leads to increasing healthcare utilization.

“People don’t often have enough individual knowledge of where to go for particular problems,” Pines said, adding that the practice of posting exact prices for services at retail clinics has helped changed that.

“Price transparency is another factor that helps people understand what costs they’ll have so they can make an informed decision about whether it’s worth it to them,” Pines said.

Research has shown that low-acuity visits are not a major factor in ED crowding, Pines said. Also, some insurance companies have argued against paying for ED visits that resulted in a “non-urgent” diagnosis, and that’s a policy Pines said he disagrees with.

“’Non-urgent’ is a term that really doesn’t mean a lot to patients who go to an emergency department because they think their issue is urgent at the time,” Pines said. “You don’t want to be at CVS for your heart attack.”

To get the best value out a retail clinic visit, Pines said it can’t just be an isolated episode, but connected to the broader healthcare system through an electronic health record or health information exchange.

Photo: CVS

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