Retail Walk-In Clinics Provide Easy Access to Low-Cost Primary Care Services

Problem Addressed

Description of the Innovative Activity

• Locations and hours: MinuteClinic facilities are located within CVS Pharmacies, large corporate campuses, and select malls. All retail locations also have a pharmacy and sell over-the-counter medications. The typical retail clinic operates 7 days a week, from 8:30 a.m. to 7:30 p.m. on weekdays, from 9 a.m. to 5:30 p.m. on Saturdays, and from 10 a.m. to 5:30 p.m. on Sundays. As a subsidiary of CVS, MinuteClinic will place most new clinics within CVS stores.  
• Marketing to consumers and employers: MinuteClinic uses a public relations firm to promote new and existing clinic locations through a variety of means, including print and electronic media, billboards, and radio. MinuteClinic also works with local employers to advertise the clinic’s existence to employees.
• Physical space: Most new clinic locations are built-in, permanent facilities that house one or two private examination rooms roughly 100 square feet each. Some older locations use stand-alone kiosks of the same size. The typical clinic has an electronic sign displaying hours, services, prices, ages served, and other relevant information. Outside each clinic is a sign-in table, with an electronic touch-pad kiosk. Each clinic has a computer terminal and chair for the nurse practitioner, two chairs for a patient and family member or friend, a countertop for testing and vaccine administration, and built-in cabinetry and a refrigerator for storage. Many newer clinics include a custom-designed fold-down examination table and sinks.
• Staffing and physician oversight: The vast majority of clinics are staffed with one nurse practitioner or physician assistant at a time, with each individual working a 12-hour shift. During high-demand times, (e.g., flu season), both rooms in a side-by-side clinic may be staffed. In every market, local doctors serve as collaborating and/or supervising physicians to the nurse practitioners and physician assistants. These physicians are available for telephone consultation during clinic business hours, and also perform routine reviews of patient charts as a form of quality control (see below for more details). 
• Focused set of services: Each clinic offers a limited set of well-defined services to patients 18 months of age or older (24 months and older in Massachusetts); services are designed to be offered during a visit of approximately 15 minutes in length. Services (some vary by state) include the following:
  • Diagnosis and treatment of common illnesses, skin conditions: Illnesses include allergies, bladder infections, bronchitis, ear infections, flu, mononucleosis, pink eye and styes, sinus infections, strep throat, ear infections, and swimmer’s ear. Skin conditions include athlete’s foot, cold sores, deer tick bites, impetigo, minor burns, minor skin infections and rashes, minor sunburn, poison ivy, ringworm, shingles treatment, and wart removal. Some services are not available to certain age groups (e.g., children, the elderly) or to those with certain pre-existing conditions. These individuals are directed to another appropriate health care facility.
  • Vaccinations: Vaccinations include diphtheria, tetanus, pertussis (DTaP and Tdap), flu and pneumonia (offered seasonally), hepatitis A and B for adults and children, meningitis, polio, and measles, mumps and rubella. In Massachusetts, MinuteClinic does not provide any childhood immunizations other than the flu vaccine.
  • Prevention, wellness, and other services: In most markets, clinics offer general health screenings and pregnancy tests, along with cholesterol, diabetes, hypertension, and obesity screenings. Clinics also provide suture removal services. 
• Referrals for other services: One important function of retail clinics is to connect patients who have out-of-scope conditions and those who need ongoing care with local providers who can meet their needs.¹ At MinuteClinic, patients who cannot be appropriately treated are referred to their primary care provider, an urgent care center, or an ED as appropriate. Roughly 2.3 percent of visits result in triage to an ED or physician's office, with the most common reason being that the patient's presenting problem fell outside the scope of protocols used at the clinic.² In addition, patients who do not have a regular primary care provider (up to 60 percent in some areas) are given a list of local physicians accepting new patients. Each clinic also has a list of community clinics that accept uninsured patients. 
• Pricing and insurance: As of early 2009, most basic visits cost $62, while vaccinations range in price from $30 to $112. The only additional charges are for tests sent to an outside laboratory, such as a culture for a strep throat test. MinuteClinic works with most major insurers.
• Technology and guidelines to support improvement: Each clinic has access to an electronic medical records system that helps clinicians proceed logically through the medical examination, providing prompts and checklists created in response to patient-specific data entered by clinic staff. Providers at any MinuteClinic location can access the system. The software is based on established national clinical practice guidelines, including those developed by the American Academy of Family Physicians, the American Academy of Pediatrics, and the Institute for Clinical Systems Improvement. 
• Ongoing quality control: Under the direction of the corporate physician medical director and with the assistance of local, contracted physicians, MinuteClinic reviews 17 percent of all charts nationwide, evaluating adherence to evidence-based practices by clinic location and individual provider. Individuals providing suboptimal care are approached in a nonconfrontational, nonpunitive manner, with a focus on education. In addition, a corporate-based nurse practitioner leads the overall clinical quality improvement process under the direction of the chief nursing officer.

References/Related Articles

• Scott MS. Health Care in the Emergency Lane: The Emergence of Retail Clinics. Prepared for the California HealthCare Foundation by Mary Kate Scott of Scott & Company; July 2006.
• Bohmer R. The rise of in-store clinics—threat or opportunity? N Engl J Med. 2007 Feb 22;356(8):765-8. [PubMed]
• Freudenheim M. Attention Shoppers: Low Prices on Shots in the Clinic Off Aisle 7. The New York Times National Edition; May 14, 2006.
• Hansen-Turton T, Ryan S, Miller K, et al. Convenient care clinics: the future of accessible health care. Available at: http://www.acnpweb.org/files/public/CCAWhitePaperFINAL.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software.).

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Results

• High quality and patient satisfaction: An internal survey that generated 26,273 responses in November 2005 found that 93 percent of MinuteClinic patients rated the quality of care as “excellent,” with the remainder ranking it “good.” Nearly every patient surveyed (99.6 percent) indicated they would use the service again, while 98.6 percent suggested they would recommend it to a family member or friend. A 2008 Harris Interactive Survey found high levels of satisfaction with various aspects of retail clinics, including quality (with 90 percent being satisfied), qualifications of staff (88 percent), convenience (93 percent), and cost (86 percent).  
• Enhanced access to care: More than 60 percent of survey respondents are drawn to the clinic's convenient location and the ability to minimize time away from work. In the absence of the clinic, 64 percent would have gone to their primary care provider, 14 percent to an urgent care facility, and 9 percent would have foregone care.
• Lower costs: Several studies have documented the cost savings generated by MinuteClinics. For example:
  • A Health Affairs study found that the adjusted mean pharmacy, medical, and total costs per episode of care were lower at MinuteClinic locations than at an ED, physician office, or urgent care center. For example, total costs per episode averaged $104 at MinuteClinic locations, compared to $383 in the ED, $159 in a physician's office, and $155 in an urgent care center.¹
  • A 2005 study conducted by Mercer on behalf of Black & Decker found that MinuteClinic visits saved more than 50 percent versus the same type of visit at a primary care clinic; a Blue Cross Blue Shield of Minnesota study from June 2004 to June 2005 found similar results.³ 
  • Preliminary analysis of 1 year of claims data by HealthPartners (a large health plan in the Minneapolis area) found that MinuteClinic episodes were 15 percent less expensive than those initiated in a physician’s office or urgent care setting.⁴
• Strong adherence to evidence-based care: Available data suggest that MinuteClinics adhere to evidence-based guidelines. 
  • Sore throat: A study of 57,311 MinuteClinic patients complaining of a sore throat found that 99.15 percent of them received proper treatment.⁵ Separate reports from the Minnesota Community Measurement Project found that Minneapolis-area MinuteClinic locations treated 91 percent of children with sore throats according to evidence-based guidelines in 2008, above the overall clinic average of 86 percent.
  • Colds: The 2008 Minnesota Community Measurement Project report found that area MinuteClinic locations complied with evidence-based guidelines for the treatment of colds 91 percent of the time, above the overall clinic average of 86 percent.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Working with local practitioners: Whenever MinuteClinic opens a new location, the Medical Director for Physician Management sends a letter to practitioners in the local community to alert them of MinuteClinic’s intention to open a facility within the market. The physicians are invited to become a part of the clinic’s referral list. Local physician acceptance continues to improve, particularly as physicians begin to understand MinuteClinic's very limited focus and its potential to be a source of referrals.
• Training: Clinic staff undergo 2-week training sessions before beginning work. Training focuses on professional, operational, and clinical skills. Each trainee must have his or her competency verified at the conclusion of the session, and then be recertified in each module on an annual basis.
• Consumer focus groups: MinuteClinic conducts periodic focus groups with consumers to gain a better understanding of the services they would like to receive. During the most recent set of focus groups, conducted in March 2007, consumers expressed a desire for greater assistance with smoking cessation counseling; travel-related medicine (e.g., education about safe travel overseas, immunizations for specific disease such as malaria); and routine physicals for schools, camps, sports, and employers. MinuteClinic reviews the results of these focus groups as a part of its planning for new services. 
• New market team and market research: An expansion team evaluates the merits of a particular site before new locations are chosen. These teams evaluate a variety of factors, including consumer demographics, existing supply of services, logistical issues (e.g., ease of building, availability of parking), and zoning and licensing regulations and restrictions. MinuteClinic also makes use of CVS’s market research capabilities to identify the best sites for new locations.

Resources Used and Skills Needed

• Staffing: Each clinic has roughly two full-time equivalent nurse practitioners or physician assistants. Staff members often work additional part-time jobs at local primary care practices, urgent care centers, or EDs.
• Costs: A study by the California HealthCare Foundation found that the typical costs for developing a retail clinic (not necessarily a MinuteClinic) are as follows:⁴
  • $20,000 to $100,000 for a retailer to make the space ready for retrofitting.
  • $25,000 to $145,000 for physical retrofitting, depending on the size of the clinic and the number of examination rooms; average setup costs are $50,000.

Funding Sources

MinuteClinic (subsidiary of CVS)

Tools and Other Resources

Getting Started with This Innovation

• Invest in rigorous staff training: Training must require the demonstration of competencies. While many practitioners have been trained generally on a broad range of primary health care services, they often have limited experience in the retail health care setting.
• Set up systems to monitor quality: Build in evidence-based standards and retrospective quality review to ensure adherence to those standards. The goal should be to engineer variability out of the system.  
• Collaborate with provider community: Work closely with the local provider community to minimize resistance to the building of a new retail clinic. Make special efforts to refer those who do not have a regular primary care doctor to local practitioners interested in taking on new patients.

Sustaining This Innovation

• Periodically review the evidence: Keep up to date on the latest evidence and guidelines, including those related to any new services under consideration. Any new service must be amenable to standardized treatment algorithms that can be embedded within the information system.
• Offer competitive compensation: Pay a competitive salary and benefits, as attracting and retaining practitioners can be difficult in some markets.