Retail Clinics

7/30/2019 Retail Clinics

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Retail Clinics Facts, Trends and ImplicationsProduced by the

Deloitte Center or

Health Solutions


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Challenging the Health Care Status Quo

The term retail clinic may sound a bit strange to the ears o American healthcare consumers. It connotes a non-traditional setting or obtaining primary careservices not a physicians oce where a patient signs in and waits. A retail clinicis dierent. And because it is dierent, it could have a proound impact on localhealth care delivery systems.

More than 800 retail clinics were in operation at the end o 2007. They are well-received bypatients, covered by health plans, and perceived as being somewhat threatening by local doctorsand hospitals, who see their potential to siphon-o business.

This paper is one in a series o proles by the Deloitte Center or Health Solutions, part oDeloitte LLP, about disruptive innovations in health care. The Medical Home: Disruptive Innovationfor a New Primary Care Modelproled a new payment method or primary care practices thatocuses on results or coordination o care. Connected Care: Technology-enabled Care at Home presentedtwo applications o in-home technologies that reduce unnecessary visits and hospitalizations andimprove care.Medical Tourism: Consumers in Search of Value analyzes the growing trend o medicaltourism, ocusing on both inbound and outbound segments. All o these innovations refect aundamental challenge to the health care status quo. And, similar to retail clinics, each is widelyacclaimed by consumers seeking better care, greater access and lower costs.

Disruptive innovations tend to ollow two routes: Either they are assimilated into the status quo,or they all by the wayside because they lack a sustainable business case. Deloitte believes thatthe medical home, connected care, medical tourism and retail clinics are sticky trends, not ads.

And Deloitte believes them to be disruptive they challenge the status quo.

Retail clinics impact on the U.S. health care system will be elt almost immediately. Their prowessin consumer marketing and ability to sell-through sel-care devices and care management servicesis potentially game-changing.

Retail clinics are a trend thats here to stay. They are a disruptive innovation worthy o note tohealth plans, providers and policy makers because consumers have already embraced the concept.Their potential is proound; their growth untapped.

Paul H. Keckley, Ph.D.Executive DirectorDeloitte Center or Health Solutions

NOTE: The Medical Home: Disruptive Innovation for a New Primary Care Model is available atwww.deloitte.com/us/medicalhome.

Connected Care: Technology-enabled Care at Home is available atwww.deloitte.com/us/connectedcareathome.

Medical Tourism: Consumers in Search of Value is available atwww.deloitte.com/us/medicaltourism.


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Retail Clinics: AcceleratingGrowth, Untapped PotentialThe growth o retail clinics has been accelerating. As seen in Figure 1,more than 400 retail clinics opened across the United States in the

year ending June 2008, pushing the current total to 971. Wal-Martrecently announced signed letters o intent to work with local hospitalsystems and RediClinics to open co-branded, walk-in clinics in 200

Wal-Mart Supercenters, and to partner directly with St. Vincent HealthSystem to open our co-branded clinics in Little Rock, Arkansas.

The Clinic at Wal-Mart co-branding is the rst step toward aplanned 400 clinics by 2010.

Acquisitions o clinic operators by established retail pharmacyorganizations have been driving the growth o this disruptive innovation.In July 2006, CVS/Caremark acquired MinuteClinic and its 83 clinics.

Since then, retail clinic growth has exploded. As o June 2008,MinuteClinic had 512 to 520 clinics,1 and the companys long-term

orecasts are calling or 2,500. Walgreen acquired Take Care HealthSystems in May 2007, and doubled operations in the ourth quarter othe same year: From October to December, Take Care grew rom 60

clinics to 130; it had 178 total clinics as o June 2008 (Figure 2) and hasplans to open in excess o 200 additional clinics in 2008.2

The growth o retail clinics illustrates how important it is or clinicoperators to establish alliances with a retail host: Colorado-based

SmartCare Health Clinics and Revolution Health-backed RediClinicshave both aced nancial issues that are partially due to a lack o

retail partnerships. SmartCare has now closed and RediClinic has alsoexperienced a short-term decline; it had 51 clinics in operation inOctober 2007, but only 35 as o June 2008. The recent announcement

o RediClinics partnership with Wal-Mart signies that operators arerealizing the importance o a host to help drive consumer visits.

Overall, the retail clinic market is beginning to show signs o maturity,with the largest operator slowing growth and smaller operators exitingthe market. MinuteClinic has lowered growth expectations or 2008:

It now expects to open only 100 new clinics in 2008 instead o itspreviously orecasted 200. A number o smaller operators have exited

the market as well, including the earlier-noted SmartCare HealthClinics as well as Corner Care Clinic and Checkups USA.

Figure 1: Retail Clinic Growth

1200

Retail Clinics in the United States

1000

800

600

400

200

0

10/1/2006 7/1/20082 /1 /2 00 8 2 /1 /2 00 89/1/20073/1/2007

Total Clinics: 971

Total Number of States: 34

Total Number of Operators: 40

Merchant Medicine, July 10, 2008

1 Ranges or clinic counts are due to methodologic dierences between Merchant Medicine and the Convenient Care Association (CCA).2 Ibid


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Why the boom in retail clinics? Almost hal o all health care consumersare receptive to the concept. They do not appear concerned about saetyissues or stang by advanced nurse practitioners, and they like the

convenience. Deloittes 2008 Survey of Health Care Consumers reported:

Sixteenpercentofconsumershaveusedawalk-incliniclocatedina pharmacy, shopping center, store, or other retail setting, and34 percent report they might do so in the uture.

Forty-fourpercentofconsumerssaytheywouldbecomfortablewith the accuracy, saety, and quality o care oered in a retail clinicthat is staed by a nurse practitioner.

Slightlymore(45percent)saytheywouldbecomfortableifthenurse practitioner uses a computer-based system that enableshim/her to access electronic patient records, check or drug and

allergic interactions, conrm treatment recommendations, etc.

Nearlyhalf(48percent)ofconsumerssaytheywouldbecomfortablei the nurse practitioner is aliated with a doctors oce.

Medicareenrolleesarealsoreceptive,with36percentindicatingtheyare open to using a retail clinic (11 percent have done so already).

Similarndingswerenotedintheuninsuredpopulation,with17 percent reporting they have used retail clinics.

Retail clinics are a disruptive innovation in primary care delivery becausethey provide services outside the traditional setting o a medical practice.The retail clinic concept trends away rom a conventional model oprimary care delivery and, as such, is viewed as competitive by local

primary care practitioners.

This paper answers our key questions:

Whatareretailclinics,andhowaretheydifferentfromtraditionalprimary care delivery?

Whatarethecurrenttrendsinthegrowthofretailclinicsandtheiruse, and what are the characteristics o their users?

Whatforceswilldriveorimpactretailclinicsgoingforward?

Howwillretailclinicsaffectkeystakeholdersinthehealthcaresystem?

Figure 2: Clinics Open as of June 2008

Convenient Care Association, June 2008

0

100

200

300

400

500

600

QuickHealth

14

Aurora QuickCare

21

Target Clinic

25

RediClinic

35

The Little Clinic

60

Take Care HealthSystems

178

MinuteClinic

520


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The Retail Clinic: Distinct Features,Unique Value PropositionThe retail clinic concept is still evolving. However, in its current orm, itcan be distinguished rom traditional primary care in its setting, access,

method o care delivery, technology use, and scope o services provided.

Characteristics o Retail ClinicsRetail clinics are generally ound in big-box discount stores such asWal-Mart or Target, grocery stores such as Publix or H-E-B, or in retail

pharmacies such as CVS or Walgreen. They operate within as little asa hundred square eet o retail space in the store. The clinics typicallyare open seven days a week with hours running into the late evening.

Care is primarily delivered by nurse practitioners with assistance romproprietary technology designed to help diagnose and treat non-serious medical conditions. There are no paper medical records; all

data are captured by the nurse practitioner in the patients electronicmedical record (EMR), which populates care algorithms to direct thenurse in providing care.

Scope o Services Oered by Retail ClinicsGenerally, services are limited to treatment o a set o common medicalailments. Some clinic operators also oer a suite o preventive care,including physicals and diagnostic screening. Figure 3 lists the most

common ailments treated by the major retail clinic operators.

The scope o services oered by retail clinics is ar more limited thanwhat can be provided in a traditional primary care setting. Primary care

physicians are well-versed in diagnosing a wide variety o conditionsand reerring patients or treatment by specialists. They deliver virtuallyall preventive care and, in some cases, provide routine treatment o

serious chronic diseases such as asthma and diabetes. Retail clinics, incontrast, do not treat chronic diseases or attempt to diagnose serious

medical conditions. Any condition which the clinic is not explicitlydesigned to treat will be reerred to the appropriate care provider.Retail clinics maintain networks with local physicians and hospitals to

reer any potentially emergent or unusual conditions.

Figure 3: Common Medical Conditions Treated at Retail Clinics

Service Category Example o Medical Conditions

Respiratory Illnesses Colds Sinusinfections Strepthroat Sorethroat Bronchitis Mononucleosis

Head, Ear and EyeConditions

Headaches Earaches Pinkeye Styes

SkinConditions P oisonivy Rashes Skininfections Sunburn Acne Warts

Stomach,DigestiveandUrinary Conditions

Nausea Vomiting Diarrhea Urinarytractinfections

Immunizations Flu Tetanus

Diphtheria Meningitis Hepatitis MMR

2008DeloitteDevelopmentLLC.Allrightsreserved.


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Outpatient Environment is Ripe or ThisDisruptive InnovationTodays health care system allows multiple entry points or consumers.Outpatient care has been evolving, with standalone ambulatory

surgical centers splitting rom traditional hospitals to handle lessserious day procedures; urgent care clinics emerging as low-acuityemergency rooms; and, most recently, retail clinics opening to treat

basic medical conditions and provide certain routine preventive care inplace o a traditional primary care setting. Overlap among the various

sites providing outpatient services can make it dicult or consumersto identiy the most appropriate point o entry (Figure 4).

The traditional U.S. primary care inrastructure model has been in need

o improvement or a number o years. A general shortage o primarycare doctors, as well as concerns about inconvenience, saety/qualityo care, and the relatively high cost o traditional primary care delivery

locations, have created opportunities or new market entrants.

Inconvenience has primarily maniested itsel as excessive time spent

waiting: Whether it is waiting or an appointment to be scheduled,waiting or physician oces to open, or waiting in the oce to see

the physician, consumers increasingly are becoming rustrated withlong wait times. Barely more than hal o the time (52 percent) doindividuals always receive an appointment as soon as they want; only

23 percent o the time ater they make it into a physicians oceare they always seen within 15 minutes.3 This situation occurs in

emergency rooms as well, where patients presenting themselves withnon-urgent conditions wait or over an hour to be seen.4 Patientsare not happy about their time being wasted long waiting times

correlate with low patient satisaction.5

Retail clinics oer superior convenience by curing the ills and therustrations o waiting patients (i.e., no appointments needed, eveningand weekend operating hours, and 15-minute-or-less wait times)

and by situating themselves in convenient locations (big-box discountstores, grocery stores and pharmacies) that already are visited byconsumers multiple times per week. This type o access can also help

to address the general shortage o primary care providers, as retailclinics can handle less-complex care.

Figure 4: Market Position of Various Outpatient Care Settings

Retail healthclinics

Urgent careclinics

Physicianoffice

Emergencyrooms

Complexity of Care ProvidedLow

2008 Deloitte Development LLC. All rights reserved.

High

Defined by:1) Hours of service2) Flexibility in scheduling(i.e., walk-in or appointment)3) Wait time

Convenience

ofCare

Provided

High

3 Agency or Healthcare Research and Quality, Consumer Assessment o Health Plan Satisaction, https://www.cahps.ahrq.gov/content/ncbd/Chartbook/2006_

CAHPS_HealthPlanChartbook.pd4 Centers or Disease Control and Prevention, National Hospital Ambulatory Medical Care Survey: 2004 Emergency Department Summary, http://www.cdc.gov/

nchs/data/ad/ad372.pd5 BMC Health Services Research, http://www.pubmedcentral.nih.gov/picrender.cgi?artid=1810532&blobtype=pd


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Retail Clinics Value PropositionThe services provided by retail clinics compete directly with the

low-acuity and non-urgent care traditionally delivered in physicianoce settings or urgent care clinics. This type o low-end market entryis typical o disruptive innovators. Retail clinics have not only embraced

the low-end market, they also have developed an entirely new servicedelivery model based on convenience.

Consumers who have a choice between a quick, convenient health

care experience in a retail setting or the long wait times associated withphysician oces, urgent care clinics and emergency rooms are likely tochoose a retail clinic (Figure 5). This choice is made even easier due to the

relatively low availability o primary care physicians or non-emergencyconditions during weekends and evenings. Previously, the only optionavailable was to visit an urgent care clinic or an emergency room clearly

not preerable or most consumers when seeking care or a minor medicalcondition. The act that a retail clinics services cost less is an additionalincentive or consumers that will also be embraced by their insurers,

helping to drive urther utilization.

Figure 5: Retail Clinics Convenience Important to Consumers

Satisaction regarding clinic care is growing. Convenience is becoming a more important criteria, suggesting an increasingopportunity or pharmacy retailers.

Satisaction with Retail-Based Clinics

Very/SomewhatSatisfed

(NET)

VerySatisfed

(%)

SomewhatSatisfed

(%)

Not at All/Not VerySatisfed

(NET)

NotVery

Satisfed(%)

NotAt All

Satisfed(%)

NotSure

Quality of Care 2005 89 46 44 6 5 1 4

2007 90 52 38 3 1 1 7

Cost 2005 80 42 37 12 12 * 8

2007 80 52 28 8 4 4 12

Convenience 2005 92 61 31 2 2 - 6

2007 83 63 21 4 2 1 13

HavingQualiedStafftoProvideCare

2005 88 50 38 7 7 *

2007 85 53 32 4 3 2 11

Note: Percentages may not add up to 100 percent due to rounding. Results represent online survey o 2,441 U.S. Adults, ages 18 and older conducted by Harris Interactive

between March 20 and 22, 2007. Base: Used Onsite health clinic (n=112)

HarrisInteractive


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McGlynn has reported that patients receive appropriate care 55 percent

o the time.6 Wennberg reports that up to 30 percent o admissions areunnecessary.7 Retail clinic nurse practitioners armed with EMRs can mitigateconcerns about saety/quality o care by leveraging physician-derived,

computerized clinical-decision-support algorithms to extend their scope opractice with evidence-based medicine. These nurse practitioners can act as

rontline health system sentinels by using clinical data to monitor emergingquality and saety issues.

The costs o services provided by retail clinics range rom $50-$75, withthe great majority priced at $59.8 Compared to a physicians oce visit,which can cost rom $55-$250, treatments provided at retail clinics oer

considerable potential savings. When compared to the same treatments

at an urgent care clinic or emergency room, the potential savings areeven greater. The cost or a retail clinic physical, at $25-$49, can alsoyield savings. At a physicians oce, physicals can cost anywhere rom

$50-$200. The dierence in cost or immunizations between retailclinics and physician oce settings is negligible.

Similar to the medical home, medical tourism and technology-enabledconnected care innovations proled in other Deloitte Center or Health

Solutions publications, retail clinics are disrupting existing models oprimary care (Figure 6) by shiting care to physical locations outsideprimary cares traditional clinical settings.

6 New England Journal of Medicine, http://content.nejm.org/cgi/content/abstract/348/26/26357 Geography and the Debate Over Medicare Reorm, Health Affairs: W96-W114. Web Exclusive, February 13, 20028 Clinic operator web sites: http://minuteclinic.com/en/USA/Treatment-and-Cost.aspx; http://www.takecarehealth.com/treat.htm; http://

www.rediclinic.com/services/services.asp

Figure 6: Retail Clinics as a Disruptive Force in Primary Care

Characteristic Retail Clinic Primary Care Practice

Site Retailoutlets(e.g.,pharmacies,big-boxdiscountstores and grocery stores)

Physiciansofcesandhospitalemergency departments

CurrentFocusofCare Acute,non-seriousconditions Chronic,acuteandpreventive

AppointmentScheduling Walk-in Dependsonphysiciansavailability

DiagnosisorTreatmentPathway Immediate, in less than 15 minutes Denedbyphysicianorhealthprofessionalavailability

LaborInput Nurse practitioner or physician assistant Physicians

Costs per Encounter $50-$75,withthemajorityofservicespricedat$59 $55-$250

Technology Input Portablediagnosticequipmentandelectronicmedical records

Fragmented.Minimalelectronicmedicalrecordadoption in physician practices



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How Will Retail Clinics Evolve?Retail clinics currently are experiencing explosive growth and moderately

increasing demand or their services. Growth expectations over the nextew years are high, but achievable, given the current environment.

The quest to attain nancial viability and generate a protable numbero visits will continue to drive the retail clinic industry into new

segments and dierent business models. Signicant opportunitieslie ahead or this industry by aggressively entering new markets,disrupting traditional health care nancing schemes, and providing

assistance to the public health sector.

Expanding Scope o CareThe growth o a disruptive innovation depends, in part, on continually

pushing it into new markets with potentially higher protability while alsolimiting the segments o incumbents. Most retail clinic operators currentlyoperate within a very narrow band o services. Expanding into routine(i.e., treatment which ollows standard pathways), preventive and chronic

care could open up signicant markets in terms o overall visits.

Expanding into preventive and chronic care would not only create a new

source o visits or clinic operators, it would also expand consumer accessto these types o care. Consumers may be more likely to get their annualphysical or other routine, preventive diagnostic testing when these services

are so easily accessible. The impact on overall disease prevention anddetection through increased access is potentially signicant.

Service expansion could also positively impact the care o individualswith chronic diseases. The eectiveness o chronic disease management

depends on requent patient touchpoints. Some health plans are turningto customer service representatives (CSRs) to deliver certain componentso disease management programs. Due to the nature o their job,

these CSRs oten have more contact with a member than a diseasemanagement nurse. Similarly, consumers requently visit their localgrocery stores, pharmacies and discount stores, which can acilitate quick,

convenient access to chronic disease management services. (Retail clinicsalready have the nurses and oundations o the technology inrastructure

needed to support the delivery o disease management programs).

The retail clinic concept did not take long to jump rom or-prot

clinic operators to integrated delivery systems and companiesnot traditionally aliated with health care services. A number ointegrated delivery systems have begun to develop their own retail

clinic models. Also, retail giants are setting up their own clinics. Theseretail giants like Target can be market changers. Additionally, discount

stores could ollow the retail giants lead into the clinic space i thediscounters can create similar partnerships with local health providersand established clinic operators, as the retail giants have. This type

o aggressive market entry by multiple discount stores could causeconsumers to view retail clinics as leaning more toward the retail

aspect o operations and less toward the medical clinic. Such a shitin consumer sentiment could erode trust in private-label operators.Discount stores will need to careully balance signicant growth with

maintaining credibility as providers o high-quality health care services.

Leveraging New Financing VehiclesThe two largest retail clinic operators, MinuteClinic and Take CareHealth Systems, are in the unique position o being owned bycombined retail pharmacy/pharmaceutical benet management (PBM)

corporations. CVSs Caremark PBM and the Walgreen Health InitiativesPBM represent signicant market share in both spaces.

These two corporations eectively own nationwide networks o care

delivery centers that will drive specic types o pharmaceutical purchasing.By expanding their services beyond low-acuity and non-urgent conditions,they could gain control o additional care segments, primarily aspectso preventive and chronic care. As discussed earlier, a move into chronic

disease management would be a natural next step. Such expansionwould create single entities that control retail and mail-order pharmacydispensing, which represent signicant aspects o primary care and

chronic disease management services. This package o medication andcare could be bundled, directly contracted and sold in blocks to health

insurance companies or employers, eectively disintermediating physicians(beyond oversight) out o certain segments o care. This type o nancingwould benet both the retail clinic corporations and the purchasers: Retail

clinics would enjoy steady customers with high prescription-drug-attachrates, and purchasers would benet rom lower medical expenditures(though potentially increased drug spend).

Assisting Public HealthThe opportunity or retail clinics to assist public health could be via anexpansion into military and indigent care, to augment the VeteransHealth Administration (VHA) and Medicaids eorts to extend access to

primary care services. VHA is already amiliar with nationwide networkso technologically-integrated care and would be a natural entrant in theretail clinic market. State Medicaid organizations could also augment

their saety net by building alliances with retail health providers tochannel more rontline care away rom Emergency Departments.

A nationwide network o technologically-integrated primary carecenters is a highly desired data repository or epidemiological

surveillance. Large retail clinic operators are in an excellent position to

support public health initiatives with the tremendous data collectionthey routinely perorm each day. Indeed, MinuteClinic already has

approached the Centers or Disease Control and Prevention (CDC) todetermine how they can best utilize the data.9

9 Star Tribune, http://www.startribune.com/business/11828511.html


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Current Consumer Demand or Services and Profle oRetail Clinic UsersBased solely upon the types o conditions currently treated at retailclinics, the growth opportunity or operators is signicant. Overall

consumer demand or these services is high: In 2005, low-acuity andnon-urgent visits comprised over 10 percent o all physician oce

visits and nearly 14 percent o emergency room visits.10

In 2005 (the latest year or which data is available), there were nearly

99 million physician oce visits or conditions which could beconsidered low-acuity; i.e., those where the primary reason care wassought was or coughing, throat symptoms, nasal congestion, eye

examinations, skin rashes, earaches or ear inections.11 Also in 2005(the latest year or which data is available), there were over 16 million

emergency room visits classied as non-urgent; i.e., those or which no

treatment was necessary or at least two hours upon presentation. 12The number o non-urgent emergency room visits is up over 38 percent

rom 2000,13 highlighting the need or additional service locations.

Retail clinics are well-positioned to grab an increasing share olow-acuity cases. While polling data on consumer use o retail clinicsvaries rom year to year and polling sources and conclusions are not

easily drawn, it is likely that the greatly increased number o retail clinicsis driving demand. Harris ound that seven percent o households hadused a retail clinic in 2005.14 Forrester Research ound that number to

be three percent in mid-200615 and an early 2007 Harris poll put thegure at ve percent.16 The Deloitte Center or Health Solutions 2008Survey of Health Care Consumers ound that 16 percent o those polledhad visited a retail clinic. Not surprisingly, retail clinic use appears to haverisen dramatically over the course o 2007; more consumers are being

exposed to retail clinics as openings climb. The same Deloitte Center orHealth Solutions survey ound that 34 percent o those polled would bewilling to use a retail clinic.

Forrester Research has reported extensively on the demographics o retailclinic users, nding that they are younger but do not dier greatly in

health status rom individuals who have not used retail clinics. Forresteround that 63 percent o retail clinic users were taking a prescription

drug. Forrester Research also ound that 84 percent o individuals usingretail clinics had been diagnosed with a disease or medical condition.These rates o drug usage and sickness were similar to non-users o retail

clinics.17 Figures 7 and 8 provide more details about retail clinic users.

Figure 7: Retail Clinic User Demographics

Equalsplitbetweenmaleandfemale

40percentarenon-white(vs.18percentfornon-users)

28percenthavelessthan$40,000householdincome(vs.16percentfornon-users)

30percentarebetweentheagesof19-30(vs.17percentfornon-users)

28percentdonothaveaprimaryphysician(vs.15percentfornon-users)

12percentareuninsured(vs.6percentfornon-users)

MarketStrategies:MinuteClinicTheEvolvingFaceofConsumerismin Healthcare, October 23, 2007

Figure 8: Users of Retail Clinics

Personal

63%

5%6%

5%

41%

Adult familymember

Market Strategies: MinuteClinic The Evolving Face ofConsumerism in Healthcare, October 23, 2007

Child13-18

Child6-12

Childunder 6

10 Imputed rom Centers or Disease Control and Prevention reports cited in ootnotes 8 and 911 Centers or Disease Control and Prevention, National Hospital Ambulatory Medical Care Survey: 2005 Summary, http://www.cdc.gov/nchs/data/ad/ad387.pd12 Centers or Disease Control and Prevention, National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary, http://www.cdc.gov/nchs/

data/ad/ad386.pd13 Centers or Disease Control and Prevention, National Hospital Ambulatory Medical Care Survey: 2000 Emergency Department Summary, http://www.cdc.gov/nchs/

data/ad/ad326.pd14 Harris Interactive, http://www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=98315 Forrester Research, http://www.orrester.com/Research/Document/0,7211,41216,00.html16 Harris Interactive, http://www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=120117 Forrester Research, http://www.orrester.com/Research/Document/0,7211,41216,00.html


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Growth Drivers and ImpedimentsThere are a number o actors that can either drive or disrupt the growth

o retail clinics and the demand or their services. Consumer satisaction,quality o care and regulatory concerns, consumer cost-sharing or retailclinic services, and the nancial viability o the retail clinic model will

likely impact growth trends.

Consumer SatisactionData rom the early 2007 Harris poll ound that consumers are satisedoverall with retail clinics. Satisaction was measured in our areas: cost

(80 percent satised), convenience (83 percent), having qualied sta toprovide care (85 percent) and quality o care (90 percent).18 Somewhat

surprisingly, the only area experiencing a large decrease in satisactionrom 2005 to 2007 was convenience, which had a satisaction rate o

92 percent in 2005 but declined to 83 percent in 2007.19

This may be atroubling trend, as Forrester Research has ound convenience to be theprimary reason that consumers are using retail clinics.20

Quality o Care and Regulatory ConcernsIn addition to convenience, retail clinic operators are heavily ocused

on quality o care, suggesting their marketing research has ound it tobe a signicant concern among consumers. Forrester Research oundthat only 24 percent o retail clinic users actually believe the clinic

oered the same quality as other health care options.21 Apparently,quality has not been the main driver or the pioneer users o retailclinics, but it likely will play a key role in increasing overall consumer

demand going orward.

Retail clinics and industry trade groups appear to be quite committed

to establishing quality as a ocus. MinuteClinic was the rst operatorto become certied by The Joint Commission, an accreditation body

or health care organizations.22 CCA has gone beyond guidelines;adopting 10 standards centered on maintaining relationships withphysicians, emergency rooms and hospitals; the use o technology;

data collection; and inection control. Major operators such asMinuteClinic, Take Care Health Systems and RediClinic have agreed to

principles outlined by the American Association o Family Physicians.23

As clinic operators sought to spread the message to consumers that they

are a sae alternative to traditional primary care settings, the AmericanMedical Association (AMA) initially attacked the saety and quality oretail clinics. At its June 2007 House o Delegates meeting in Chicago,

the AMA stated that a lack o regulation could be creating healthrisks.24 However, neither the AMA nor its state aliates have presented

empirical evidence demonstrating sub-par quality among retail clinics.In act, theAmerican Journal of Medical Qualityrecently published astudy examining quality o care related to treatment o strep throat.

The study evaluated over 57,000 MinuteClinic visits or adherence toguidelines related to antibiotic prescriptions. The results showed thatadherence was in excess o 99 percent.25 The study, co-authored byMinuteClinic employees, was a clear attempt to disprove two key myths:rst, that the quality o care at a clinic is sub-par; second, that aliation

(or in this case, ownership) with retail pharmacies may create adverse

incentives to over-prescribe medications.

Despite a lack o evidence o sub-par quality, the AMA and itsstate aliates have been lobbying to increase regulation o retailclinics. Their infuence has already been elt: In Massachusetts, clinic

openings were delayed by an initial application rejection, reormo the application process, and multiple hearings. Eventually, the

Commonwealth allowed the opening o limited-service clinics butopposition still remains rom the City o Boston itsel.26 In Georgia,increased supervision is required or clinic nurses writing prescriptions.

Finally, in Florida, primary care physicians are barred rom supervisingmore than ve physician-staed oces.27

These policy issues are causing some states to look to the Federal TradeCommission (FTC) or guidance. Massachusetts and Illinois both sought

comment on new statutes specically designed or retail health clinics.Particularly commenting on an Illinois House Bill (HB 5372), the FTCaddressed a key concern related to quality that had been raised by the

AMA and its state aliates: physician supervision. The FTC ound thatstrict limitations on supervision could be considered anti-competitive.28

In addition, the FTC issued comment on other aspects o theregulation, including limitations on retail clinic advertising, dierential

cost-sharing, and co-location o retail clinics inside stores which sellalcohol and tobacco, actors which may infuence quality o care.The FTC commented that strict limitation in these aspects could be

considered anti-competitive, as well.29 The FTCs comments are asignicant win or the retail clinic industry and a blow to the AMA

and its state-level aliates.

18 Harris Interactive, http://www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=120119 Ibid20 Forrester Research, http://www.orrester.com/Research/Document/0,7211,41216,00.html21 Ibid22 CVS Caremark Corporation, http://investor.cvs.com/phoenix.zhtml?c=99533&p=irol-newsArticle&ID=90739223 American Academy o Family Physicians, http://www.aap.org/online/en/home/press/aapnewsreleases/20070201releases/20070201clinicattributes.html24The Chicago Tribune, AMA Takes on Retail Clinics, June 25, 200725 Quality o Care in the Retail Health Care Setting Using National Clinical Guidelines or Acute Pharyngitis, Vol. 22,American Journal of Medical Quality,

No. 6, 457-462 (2007)26The Boston Globe, http://www.boston.com/business/healthcare/articles/2008/01/11/menino_decries_clinics_in_retailers/27 AMAs Backing to Boost Retailer Health Clinics, The Washington Times, December 22, 200728 Federal Trade Commission, http://www.tc.gov/os/2008/06/V080013letter.pd29 Ibid


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More recently, the AMA has broken with some o its state-level

aliates, embracing retail clinics that have agreed to deliver only alimited scope o care.30 It will take time to see i state-level medicalgroups, some o which are opposed to the expansion o retail clinics,

will back down rom their current positions and join the AMA in amore sotened stance.

While the FTC comment will prove useul in preventing over-regulation,the negative sentiment that some state-level groups are attempting

to create among consumers, along with the regulatory tie-ups theycan generate with their signicant lobbying power, could potentiallyhave a negative impact on the growth o retail clinics. The AMAs initial

campaigning also may have caused long-term damage in terms ooverall consumer acceptance o the retail clinic model.

Consumer Cost-Sharing or Retail Clinic ServicesAlong with satisaction and quality issues, the portion o treatment cost

borne by the consumer could be a concern or clinic operators. Whilethe retail clinic model began with cash-only payment models, all othe major operators are now accepting insurance rom the majority o

large carriers, including UnitedHealthcare, Aetna, CIGNA, Humana andMedicare.31 Retail clinic operators also have negotiated contracts with

large regional carriers.

While the early 2007 Harris poll showed that only 54 percent o

insured individuals who visited a retail clinic had some or all o theircosts covered by insurance,32 that percentage is likely to increase as

more partnerships are publicized. Use o retail clinics also is likely torise as consumers become more aware o reimbursement policieswhich require only small co-payments to visit the clinics. Some insurers,

such as Blue Cross Blue Shield o Minnesota, are waiving co-paymentsaltogether to urther drive demand.33 The AMA has lobbied to outlawthe practice o dierential cost-sharing between retail clinics and

traditional primary care settings, citing quality and confict-o-interestconcerns as the primary reasons.34 As mentioned earlier, the FTCs

opinion is that limiting an insurers ability to utilize dierential cost-sharing could be considered anti-competitive.

Financial ViabilityRetail clinics create some o their cost advantage through the use oless-expensive labor inputs, primarily nurse practitioners, and in certain

cases, physician assistants. Combined with hygiene exemptions andthe minimal square ootage required or their operations, retail clinicscan easily provide routine health care services or a lower cost than any

traditional primary care setting.

While these advantages can create pricing pressure, the overall protability

o retail clinics will depend on relatively high demand or services. In2006, xed costs or a retail clinic operating with 450 square eet ospace were estimated at $600,000 per year.35 With most services costing

approximately $59, a retail clinic would need to see more than 10,000patients per year to cover its xed costs. The break-even point would

also have to cover variable costs associated with each visit, primarily labtests and supplies. Since low-cost, portable testing equipment is widelyavailable, variable costs or a retail clinic have been estimated at only 15

percent o overall costs.36 Given total xed and variable costs, most clinicswould need to see 200-230 patients per week to turn a prot.

Details surrounding most retail clinic operators nancials are scarce.Rather than answer the question o which companies are currently

protable, this paper attempts to project how many nancially viable

clinics could be supported under current demand and what the overallprospects or growth may look like.

As stated earlier, there were approximately 800 retail clinics inoperation at the end o 2007. In addition, it was previously estimated

that 115 million visits occur each year to physician oces andemergency rooms or low-acuity and non-urgent conditions. Using

11,000 visits per clinic per year as the break-even point across xedand variable costs, current demand or retail clinic services wouldhave to exceed 8.8 million visits, or between seven and eight percent

o overall demand or those types o services, or across-the-industryprotability. It is unlikely that current retail clinic usage is that high,but it is quickly moving in the correct direction.

Market leader MinuteClinic can be used to test the assumption thatcurrent demand is not enough to generate industry protability. Since

MinuteClinics explosive growth in 2007 occurred primarily in the secondhal o the year, the average operating months per retail clinic or 2007

can saely be assumed at approximately six months. (In the rst twoquarters o 2007, MinuteClinic grew by less than 100 clinics. In the lasttwo quarters, it grew by almost 300 clinics, with nearly 200 coming

online in the 4th quarter alone, or a grand total o 473 clinics at the endo December.) Across all 473 clinics, that equated to 2,838 operating

months. At 915 visits per month as the benchmark, nearly 2.6 millionvisits would have been needed or protability. By MinuteClinics ownmid-2007 estimate, it was expecting one million total visits or 2007. 37

Signicant variation to the underlying assumptions surrounding xedcosts or break-even visit requirements would have to be made to assume

overall protability or MinuteClinic operations in 2007.

30 AMAs Backing to Boost Retailer Health Clinics, The Washington Times, December 22, 200731 Clinic operator web sites: http://www.minuteclinic.com/en/USA/Insurance.aspx; http://takecarehealth.com/RegionListTemp.html; http://www.rediclinic.com/insurance.asp32 Harris Interactive, http://www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=120133CBS News, http://www.cbsnews.com/stories/2007/08/11/health/main3158978.shtml34 American Medical Association, http://www.ama-assn.org/ama/pub/category/17723.html35 Caliornia Health Care Foundation, http://www.chc.org/topics/view.cm?itemID=12321836 Ibid37Managed Healthcare Executive, http://www.managedhealthcareexecutive.com/mhe/article/articleDetail.jsp?id=439158


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CCA has estimated that 5,000 retail clinics could be in operation by the

end o the decade.38 For that type o growth to be immediately protable,it would require approximately 55 million visits, which by 2010 wouldequate to just under 50 percent market share i clinics continue to operate

in the low-acuity and non-urgent bands o care. A number o actorscould support this growth, including the AMA reducing its opposition

and insurers continuing to support reimbursement and drive membershiptoward this lower-cost care option.

It is not necessary or all clinic operators to generate a prot on theretail clinic alone or them to nd value in the model. Those clinicsowned by corporations that also control pharmaceutical dispensing

could prot by attracting new customers to their prescription drugcounters. CVS Caremark, Walgreen and Target could all devisebusiness models around proting rom dispensing ees; in a case

where a consumer came to the store specically to seek care, anyitems they purchase while in the store provides additional value.

Retail hosts such as Wal-Mart and Publix may be willing to lower theirleasing costs or retail clinics i they notice increased attach rates to

prescription drugs or other items. Wal-Mart and Publix have provedsavvy when it comes to keeping consumers in their store via healthcare mechanisms; both showed aggressive moves in pharmaceutical

pricing in an eort to attract and retain shoppers.

How Will Current Industry Stakeholders Adapt?The growth o retail clinics, as part o an overall consumerismmovement, will have ar-reaching consequences or all sectors o theU.S. health care system. There is little doubt that industry stakeholders

including health plans, employers, policy makers, hospitals and medicalgroups will be impacted.

Health PlansInsurers are quickly discovering that the use o retail clinics can createsavings not only through steerage rom emergency rooms but also rom

shiting treatment o minor medical conditions away rom physicianoces and urgent care clinics. As noted earlier, a number o insurers

have decided to waive co-payments in an attempt to shit demand toretail clinics. This is likely based on their cost experience a study byHealthPartners, an insurer operating primarily in Minnesota, ound that

a visit to a retail clinic was, on average, $18 cheaper than a visit to atraditional primary care setting.39

As health insurers attempt to shit demand rom higher-cost outpatient

settings such as physician oces, urgent care clinics and emergencyrooms to lower-cost retail clinics, they should be careul to avoidgenerating additional, un-orecasted demand or health care services.

Pairing the convenience o retail clinics with zero cost-sharing couldpotentially oset a portion o the medical spend savings realized by

higher consumer use o lower-cost care. Health plans should delicatelybalance their desire to encourage member understanding o new careoptions against the possibility o members seeking unnecessary care.

EmployersEmployers are in a bind. Employee health benet costs continue to

increase aster than infation. Companies ace a talent crunch as babyboomers retire. Increasing global competition requires a healthy andproductive workorce to orestall loss o market share. To remain

competitive, employers need to oer cost-eective benets that canhelp them attract and retain employees, and keep employees healthy.

Employers are receptive to disruptive innovations such as retailclinics i they provide quality care or less cost. Employers can take

advantage o retail clinics potential savings by promoting newbenet designs that encourage employees to use the clinics versusmore costly care alternatives.

Retail clinics convenience also could help to improve employee

health and productivity. Employees could stop by the clinic beoreor ater work or during their lunch hour instead o taking time o.Parents would be able to take their child to the clinic or a quick

reerral instead o waiting or an open slot at the pediatriciansoce. Retail clinics also could become an extension o employeroccupational health clinics. Overall employee attendance might

increase, thanks to the peace o mind employees would gain romhaving seen a clinician, rather than worrying about whether or notthey should make a physicians oce appointment.

Policy MakersFederal, state and local policy makers continue to ace tighterbudgets as they try to balance health care cost, access, and qualityor their neediest constituents. This situation is becoming even more

challenging as governments ace budget cuts due to a slowingeconomy and see their tax base erode as a result o allout rom thesubprime mortgage lending crisis.

38 Ibid39USA Today, http://www.usatoday.com/money/industries/health/2006-08-24-walk-in-clinic-usat_x.htm


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Leveraging a convenient, less-expensive primary care setting at stores

in local communities could increase constituents access to healthcare services while also helping to clear the Emergency Departmento inappropriate and more costly utilization. Additionally, retail clinics

paperless operation could help policy makers push or clinicians toadopt EMRs, which are needed to support an e-health inrastructure.

A robust e-health inormation network could provide governmentagencies with electronic surveillance o emerging health threats andsupport pandemic preparedness; oer richer clinical metrics or pay-

or-perormance programs and evidence-based medicine; and detectgaps in care delivery to address saety and quality issues.

HospitalsPhysicians are not the only providers whose operations are beingdisrupted by retail clinics. Hospitals are being impacted, as well.

A number o large health care systems have established their ownretail health care companies to take advantage o this emerging care

model and to expand the continuum o care and control reerrals totheir own physicians, surgical centers, diagnostic acilities, emergencyrooms and hospitals. The Mayo Clinic recently opened its rst retail

clinic in Minnesota to compete with quickly expanding MinuteClinic.Other examples o retail clinics operated by large health care systemsinclude Sutter Express Care, part o Sutter Health in Northern Caliornia;

Geisinger CareWorks, part o Geisinger Health System in CentralPennsylvania; AtlantiCare HealthRite, part o AtlantiCare in New Jersey;and Aurora QuickCare, part o Aurora Health Care in Wisconsin.

The recognizable community brand held by most integrated health

systems should allow them to quickly compete with the major or-protretail clinic operators. Additionally, getting the clinics up and running isbecoming easier or health systems: Indianas Memorial Health Systems

has operated clinics or nearly two years and has agreed to help anotherhealth system establish its retail clinics.40 A turnkey model is also being

developed by AtlantiCare, which is engaged in discussions to assisthealth systems establish retail clinics.41

Medical GroupsWith only 10 percent o retail clinic visits resulting in a reerral,42 it is clear

that the use o retail clinics is diverting patients away rom outpatientsettings such as physician oces, urgent care clinics and emergencyrooms. Health care providers, thereore, likely will experience the most

signicant disruptions rom the emergence o retail clinics.

Traditional primary care will continue to have a virtual monopoly on a

number o services that retail clinics do not oer; however, or overlapping

services, retail clinics are likely to dominate i they can alleviate concernsabout quality. Already, some U.S. physician groups are responding with

increased hours o operation and a renewed ocus on customer service.Similarly, physicians in Britain, through the National Health Service, areembracing the convenience that retail clinics provide: Government doctors

have begun to provide care at a Manchester grocery store during eveningsand weekends. The pilot, called Doctors in Store, is expected to roll out

to additional sites i it proves successul.43

While physicians should be able to compete with retail clinics in thearea o convenience, lowering their costs to the levels o retail clinicswill be dicult. Without competitive pricing, it is likely that insurers

will attempt to shit service delivery o minor health conditions toretail clinics. Urgent care clinics as well as physician oces shouldbe concerned about the direct impact competition will have on daily

patient volume. Both will have to adopt more consumer-orientedmetrics and create dierentiation through their ability to providehigh-quality care. Additionally, as consumers increase their visits to

retail clinics, the use o inormation technology particularly electronichealth records available via the web and electronic prescribing willbecome the expected norm or all providers.

40Hospitals & Health Networks, http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/

data/05MAY2007/070515HHN_Online_Finarelli&domain=HHNMAG41The Journal of Healthcare Contracting, http://www.jhconline.com/article-janfeb2007-touchpoint.asp42 USA Today, http://www.usatoday.com/money/industries/health/2006-08-24-walk-in-clinic-usat_x.htm43The New York Times, http://www.nytimes.com/2008/03/03/business/worldbusiness/03docs.htm


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Stakeholder ResponsesIncreased consumer use o retail clinics creates opportunities and challenges or all participants in the health care system. Each stakeholder must

consider how to respond strategically and operationally to this new market competitor (Figure 9).

Figure 9: Possible Stakeholder Considerations in Response to Retail Clinics

HealthPlans Plansmightpromotetheuseofretailclinicsusingattractiveco-paymentsanddeductibles Theinclusionofretailclinicsinnetworksmightthreatencommunity-basedmedicalpractitionersandhospitals;

outreach by plans could ease tensions Enrolleesatisfactionmightincreasebyincludingretailclinicsinplancoverage Healthplansmightpartnerwithlocalproviderstoofferenhancedpreventiveandprimarycareservicesvia

retail clinics

Employers Employersmightpromotetheuseofretailclinicstoreduceabsenteeismandemergencyroomuse Employeewellnessprogramsanddiseasemanagementservicescouldbeprovidedthroughcontractedretailclinics

Employersmightaddretailclinicsasanoutreachoftheiroccupationalhealthorganization

PolicyMakers Policymakersmightpromoteretailclinicsforbroaderhealthcareaccesstovariouspopulations Policymakerscouldbuildsentineleventtrackingsystemsandpandemicpreparednessprogramsinpartnershipwith

retail clinics Legislativesupportexpandingthescopeofpracticefornursepractitionerswhoprovideclinicalservicesinretail

clinics,alongwithliabilityprotectionforphysicianswhoserveasmedicaldirectors,couldbeconsideredasretailclinicsexpandtolower-incomecommunities

Hospitals ProtmarginsmightbesqueezedasEmergencyDepartmentandUrgentCarepatientmixchangesduetothelossoflow-complexity(andprotable)patients

Retailclinicsmightbebrandedunderacommunityhospitalsname Newnetworkrelationshipswithretailclinicsmightcausefrictionwithtraditionalphysicianreferringnetworks Hospitalsmightengageinajointventurewithcommunity-basedproviderstodevelopretailclinics Primarycareprogramsmightbeatriskforlosingresidencyaccreditationduetolessambulatoryexperience.

Teachinghospitalswillneedtorotateresidentsthroughretailclinicstomaintainoutpatienttraining Hospitalscouldleverageretailclinicsforprimarycareservices,includingcorporatewellnessanddisease

management programs Afocalpointforphysician-hospitalintegrationmightbedevelopmentofacompetitiveretailclinicsysteminthe

community

Medical Groups Traditionaltreatmentofminorconditionsmightbethreatened Physiciansmightbeleftwithlow-margin,chronicallyillpatientsasretailclinicsskimoffhigh-value,low-complexity

patients Ifretailclinicsdiversifytheircareofferingintomoresevereorchroniccare,PCPsandclinicsmightbeinamore

adversarialroleastheycompeteforpatients Competitionforclinicalextendersmightincrease,drivinguplaborcostsfornursepractitionersandphysician

assistants and eroding practice margins



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Final ThoughtsWhen work on this paper began in late 2007, retail clinics appeared to

be a question mark rather than a denitive statement in health care.In less than six months, however, the number o clinics has practicallydoubled, the AMA has altered its position on their viability, and one

company has established market dominance. This activity speaks tothe rapid evolution o the retail clinic model and to the industrys

recognition that retail clinics are not a ad they are a disruptiveinnovation with a sustainable value proposition (price, quality, service)that is welcomed by consumers. Stated simply, retail clinics are an

important and growing part o the U.S. primary care delivery system.

The low number o reerrals by retail clinic personnel suggests that

care provision by nurse practitioners or physician assistants in retail

settings rather than by physicians in oces, urgent care clinics oremergency rooms is a viable option or delivery o certain aspects o

health care. The impact o this trend is potentially signicant: lowercost to all participants, increased access to primary care, and a possible

remedy to the primary care physician shortage. Because these issuesare some o the most troublesome acing the U.S. health care system,the act that the retail clinic model can reduce their pressure speaks to

its potential as a disruptive innovation.

Change is disruptive when it challenges accepted assumptions about the

way things should be. Perceptions about how primary care shouldbe delivered harken back to the image o TVs Marcus Welby a athergure or whom no patient was a distraction and no medical problem

too small. Those days are gone. In their place, health care innovators arending new ways to deliver basic primary care services via retail clinics.

Retail clinics are not a ad; they are a trend being driven by consumerswho seek more value rom the health system. Retail clinics growing

success refects a value proposition accepted by proponents (and,increasingly, some competitors): Health care can be convenient, sae,reasonably priced and achieve high levels o customer satisaction.


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AuthorsWed like to recognize the individuals who contributed their

insights and support to this project. The core team comprised:

Paul H. Keckley, PhDExecutive DirectorDeloitte Center or Health Solutions

[email protected]

Howard R. Underwood, MD, FSA

Senior Fellow & MDPDeloitte Center or Health SolutionsSenior Manager

Deloitte Consulting LLP

[email protected]

Malay GandhiConsultant

Deloitte Consulting [email protected]

AcknowledgementsThanks to the ollowing colleagues or their contributions

and participation: Kara Fleming, Director, Deloitte Consulting LLP andRobert N. Campbell III, vice chairman and U.S. State Government leader,Deloitte LLP.

Contact InormationTo learn more about the Deloitte Center or Health Solutions,its projects and events, please visit www.deloitte.com/

centerorhealthsolutions.

Deloitte Center or Health Solutions555 12th Street N.W.

Washington, DC 20004Phone 202-220-2177Fax 202-220-2178Toll ree 888-233-6169

Email [email protected] http://www.deloitte.com/centerorhealthsolutions

Access this report online along

with other related Center researchTo access a copy o the Retail Clinics: Facts, Trends, and Implicationsreport online please visit: www.deloitte.com/us/retailclinics

To access other research produced by the Deloitte Center or Health Solutionsplease visit: www.deloitte.com/us/centerorhealthsolutions

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