Walk-In Clinics: “Commoditizing” Primary Care?

February 16, 2017

Like it or not, walk-in health clinics are here to stay. Their growth has been fueled by access and convenience. More convenient hours, more convenient locations, more convenient to walk in without an appointment. But as payers and providers shift towards Triple Aim goals of improved patient care, population health and reduced cost, do walk-in clinics fit into the new healthcare landscape going forward?

This series will review the growth and trends in the convenient clinic market and examine how these clinics impact care coordination, patient-provider relations and healthcare costs.

Retail Clinics vs. Urgent Care Centers

A walk-in clinic is an interchangeable term often used to describe retail health clinics and urgent care centers. While they both allow a patient to be seen by a healthcare provider without an appointment, there are differences in the acuity of conditions seen and services offered.

Retail clinics are set up inside larger retail stores such as Walmart, Target, Walgreens and CVS. They are staffed by nurse practitioners or physician assistants and see patients with minor illnesses, typically 20-30 of the most common diagnoses, such as cold and flu symptoms, strep throat, ear infections and skin conditions. Other common services include immunizations, annual physicals and health screenings. Retail clinics prescribe medications and most have adjacent pharmacies for pick-up convenience.

An urgent care center is a walk-in clinic focused on the delivery of ambulatory care in a dedicated medical facility, offering “primary care” type services as well as more acute care beyond the scope of a primary care office. They have at least one physician on staff, have on-site x-ray and lab equipment and treat injuries or illnesses requiring immediate care but not serious enough to require an ER visit, such as broken bones, burns and other non-emergent conditions including those treated at retail clinics. Many urgent care centers also offer occupational medicine services and other ancillaries such as medical weight loss programs and physical therapy.

Walk-In Clinic Growth

The first retail clinic appeared in 2000 at a grocery store in Minnesota and was operated by QuickMedx. The clinic was small, treated minor common medical conditions and operated on a cash-only basis. As QuickMedx grew, it changed its' name to MinuteClinic which was later acquired by retail pharmacy chain CVS. Retail clinics grew modestly between 2000-2006 as new retail clinic operators emerged. This was followed by exponential growth with 554 and 426 new clinics in 2007 and 2008 respectively. (1) Today there are over 2,000 retail clinics nationwide with projections of more than 2,800 by the end of 2017.

CVS MinuteClinics dominate the retail clinic market with a 50% share followed by Walgreens Healthcare (24%), Kroger Little Clinic (8%) and Walmart Care Clinics (6%). (2)

Urgent care centers first opened in the United States in the early 1980s. While this sector experienced rapid growth through the middle of that decade, it was followed by a precipitous decline due to competitive moves by local hospitals to protect their revenue streams and because of questions related to quality of care in urgent care settings, hence the moniker “doc in a box”. (3) With improved quality standards and greater acceptance by consumers, there has been a resurgence in urgent care growth with close to 10,000 centers operational today and another 1,500 projected to open their doors by 2020.

22% of urgent care centers are hospital owned, 20% are owned by two or more physicians, 19% by a corporate entity, 17% by a single physician and 15% are a joint venture with a hospital. (4)

Impact on Primary Care

Clearly from a business perspective, walk-in clinics have captured some primary care business. And while a study by Manatt Health indicated that retail clinics represent only 2% of primary care encounters in the U.S., consider the magnitude. (5)Retail clinics have 10 million visits annually. Ten clinical issues such as sinusitis and immunizations (i.e. primary care medicine) encompass more than 90% of retail clinic visits. These same ten clinical issues make up 13% of adult primary care visits and 30% of pediatric primary care visits. (6)

And retail clinics are not just being used by uninsured patients who don't have a doctor but are also being visited by those with established patient-physician relationships. In an article in JAMA Pediatrics in September, 2013, over 1,000 patients were surveyed in the Midwest to assess their attitudes toward, and experiences with, retail clinic pediatric care. Almost one fourth of parents who had a primary care pediatrician indicated that they had taken their children to a retail clinic. Convenience was cited as the primary reason. In fact, close to 50% of the retail clinic visits occurred during weekdays when the pediatrician's office was open. (7)

The most common illnesses treated at urgent care centers are upper respiratory infections, urinary tract infections and conjunctivitis (i.e. primary care medicine). And the most common symptoms treated at an urgent care center include swollen glands, rashes, minor abdominal pain, sore throat and headache (i.e. primary care medicine). (8) 66% of patients visiting an urgent care center are reported to have a primary care physician. (9) On average an urgent care center receives approximately 357 patient visits per week which translates to more than 3 million patients per week or 160 million patients annually nationwide. (10)

Trends

Retail clinics are increasingly offering expanded clinical services including primary and preventive care, pediatrics and wellness, health screening and testing, chronic disease monitoring and management and transitional care. Clinics are also purchasing more advanced medical equipment and record management systems to augment their expanding services. MinuteClinics for example are implementing an EHR system nationwide and Walgreens has partnered with a telehealth provider and introduced a mobile app to give its website users 24/7 access to U.S. board certified physicians. Retail clinics are also partnering with health systems and integrated delivery networks to improve information sharing and care coordination. (11)

In the urgent care arena, health systems will continue to jump in by acquisition, building or partnering with existing urgent care centers. The urgent care market, like the hospital market, will experience consolidation with urgent care players forming larger enterprises using the under three clinic location ownership model to feed them. The urgent care market will also see growth of digital connections for patient services and engagement by, for example, adding a telemedicine component and smart phone apps for making appointments, follow up and preventive care. And it is expected that urgent care centers will add patient services to fit regional needs, will expand hours and attract new patient groups (e.g. chiropractic). (12)

The lines are definitely blurring between walk-in clinics and primary care medicine. While I think there is certainly a place for retail clinics and urgent care centers, it remains to be seen how or if they will fit into a value-based care model. In my opinion the “episodic care” of walk-in clinics doesn't equate to “primary care”. Primary care not only heals you when you're sick but also focuses on your wellness, taking the time to get to know you and your overall healthcare needs.

What do you think about walk-in clinics in the value-based care continuum?

Jesse Gamez
Chief Operating Officer​
Northwest Physicians Network

Coming Next: Walk-In Clinics: Primary Care Friend Or Foe?

  1. Healthcare Retail Clinics: Current Perspectives, Amer Kaissi, March, 2016
  2. Becker's Hospital Review, “7 Key Statistics on Retail Clinics”, April 23. 2015
  3. Urgent Care Centers: An Overview, Sean McNeeley, M.D.
  4. 2015 UCAOA Benchmark Survey
  5. “Retail Clinics Hit 10 Million Annual Visits But Just 2% Of Primary Care Market”, Forbes, April 23, 2015
  6. “ A Comparison of Patient Visits: retail Clinics, Primary Care Physicians, Emergency Departments”, Health Aff (Millwood), August, 2009
  7. JAMA Pediatr. 2013; 167(9):845-850.doi:10.1001/jamapediatrics.2013.352
  8. American Family Care, AFC Urgent Care
  9. 2015 UCAOA Benchmark Survey
  10. Becker's Hospital Review, “ 20 Things to Know About Urgent Care”, June, 2015
  11. Accenture, “U.S. Retail Clinics Expected to Double by 2017”
  12. DocuTAP, “Urgent Care Trends to Watch in 2016”