Retail Clinics, Health Care Costs, and Medical Ethics

The March issue of Health Affairs includes an report by Ateev Mehrotra and colleagues about the impact of retail clinics on health care utilization and cost. His team used insurance claims from Aetna to study the question of the degree to which retail clinic visits replace physician office and emergency room visits or represent additional utilization.

In-store clinics like the 1,100 CVS Minute Clinics offer prompt attention for minor ailments and preventive care. They're convenient and cost less than physician office visits and vastly less than an emergency room visit. Health policy gurus have hoped that they would improve access and reduce costs.

It looks as if the hopes are half fulfilled. The clinics do improve access for minor conditions and as such are a welcome service. According to the Convenient Care Association - the trade association for retail clinics - to date consumers have made 35 million visits to these entities. But Mehrotra and colleagues found that 58 percent of the visits appeared to represent new utilization, with the result that covering retail clinic visits cost Aetna $14 more per patient per year.

The medical group where I and my family have gotten our care for decades operates its own internal version of retail clinics. During daytime hours it's possible to be seen for same day appointments and advance practice nurses are available 24/7 by telephone. When I've used the service my primary care physician has received immediate feedback via the electronic medical record. In one instance I would have gone to an emergency room if urgent care had not been available. And my impression from what I've read from Kaiser Permanente is that in the setting of an integrated group practice, walk-in capacity is cost effective as well as popular with patients.

So what's the big lesson from the Health Affairs report?

For me the study implies that our recurrent hope for a magic bullet that will reduce cost without integrating the care system and creating a budget for it is a pipe dream. Retail clinics have a lot to offer, but they won't solve our cost problem. Telemedicine also has a lot to offer, but it won't do the cost containment job for us either.

Instead of imagining that a magic bullet will solve the cost trend without our making hard choices, we instead need to bite the bullet and create budgeted care systems like the much maligned not-for-profit HMOs from past years.