Not long ago, I received a phone call from a relative in the Twin Cities about a child's illness. It was Saturday afternoon. I felt uncomfortable treating it on the phone and described the options: a visit to an emergency department, a visit to the urgent care facility or, for $50 dollars, a visit to a nurse practitioner at the local Target store. Given those options, what would you have done?

Cost, quality and access have been called the “iron triangle” of health care. Reduced cost, improved quality and increased access will certainly be the measures of improvement as primary care programs evolve. The recent development of “retail clinics,” health care facilities that offer care by midlevel providers in retail stores, reflects an awareness of the importance of these dimensions. (See the article "Retail Health Clinics Are Rolling Your Way" in this issue.) The corporations behind most of these “retail clinics” have been shown to be successful and are rapidly growing. How do the clinics measure up against the iron triangle?

Improved access. Generally these facilities operate in discount department stores and drug stores. They are open during most of the hours the host store is open, so evenings and weekends are staffed. Patients go to the store and register at a kiosk, where the conditions cared for and the cost of each kind of visit are clearly posted. The patient may then wait or take a pager and shop until it is his or her turn to be seen. In a recent Wall Street Journal Online/Harris Interactive poll, 83 percent of respondents felt these clinics could provide basic medical services when doctors' offices were closed, and 78 percent felt they offered fast, easily accessed medical services.¹ The degree to which employers and other large organizations like this kind of access can be seen, for example, in the fact that MinuteClinics operate at the Best Buy corporate office and the main campus of the University of Minnesota.

Improved quality. A recent Rand report on the quality of health care in America², which reviewed 439 parameters involving 30 medical conditions, found that patients received 54.9 percent of recommended care – and this was for more than 6,000 individuals in 12 major metropolitan areas. The study was summarized in the March 27 issue of Business Week as “Equally Lousy Treatment for All.” We clearly have room for improvement in providing medical care.

While the retail clinics are too new to have much of a track record, the signs point to quality. Several of the corporations opening retail clinics use expert panels to assemble evidence-based protocols. The corporations then provide electronic medical record (EMR) systems and collect data digitally for analysis. In many of the facilities, the nurse practitioner uses an EMR that can be audited and has the ability to prevent prescribing errors that result from drug interactions. In at least one chain, patient satisfaction is documented in as many as one in 10 visits and nurse practitioners are given incentives for high patient-satisfaction scores. In some facilities each patient receives a follow-up telephone call the next day. Patients judged too sick for the facility are referred to local physicians, who receive fax reports of the encounters.

The kind of support these corporations are giving their providers should promote quality care. A review of the literature comparing nurse practitioners to primary care physicians shows that their outcomes are similar.³ It is not hard to imagine that, in a model of health care delivery that uses electronic support, limits the number and severity of conditions treated, and has a system or protocol for referrals, these retail clinics could provide care superior to that offered by a busy, paper-based primary care office.

Decreased costs. The savings for employers can be substantial. Linda Hall Whitman, until last year CEO of MinuteClinic, said, “A service that costs $40 at a clinic costs as much as $109 at a doctor's office, about $120 at an urgent care facility and $325 at a hospital emergency room.” A patient may learn the cost of the clinic's services by checking its Web site. Many clinics accept insurance, and often insurance companies forgive the co-pay because a visit to a retail clinic is less costly than a visit to an emergency department or an urgent care facility.

The future

Clayton Christensen, DBA, has outlined the effects of the “disruptive technology” of nurse practitioners in the book Seeing What's Next.⁴ Christensen's argument is that technology allows people with less skill to do more and that innovations tend to come in areas that are poorly served and overpriced. While the innovations are crude to begin with, they tend to be refined and to extend their reach. From Christensen's point of view, the most likely scenario is that the nurse practitioner facilities will thrive and expand their roles. A logical future step for the facilities is to tackle hypertension or even diabetes care, because chronic disease management is handled poorly in the United States.^5–6 By following protocols, the retail clinics could very well achieve excellent outcomes. And if they can provide laboratory work on site so people can have tests done on the weekend, the appeal would be strong.

The physician reaction

Responses to retail clinics from physicians and physician organizations have ranged from the relatively undisturbed to the strongly negative. Although some have urged caution about this model, they provide no data and ignore a considerable number of studies of nurse practitioner outcomes. Larry Fields, MD, president of the AAFP, calls retail clinics “something to use in a pinch or in a hurry or when you're not too sick. They are not a medical home.” At the negative extreme, some physicians feel that an appropriate response is to boycott stores that provide this service.

In Minneapolis/St. Paul, physicians have moved on to compete by extending hours and providing a rapid consult for simple problems. Competition with the retail clinics is spurring positive changes in physician practices. Family Practice Management has published several articles on same-day scheduling and other topics that might help physicians compete. Interestingly, though, Christensen would argue that family physicians would not be successful in competing against these retail clinics, at least in part because the clinics thrive on physicians' least remunerative patients. He would suggest family doctors instead do work that subspecialists are now doing. For example, colonoscopy does not require a highly paid surgeon or gastroenterologist. Family physicians might look at this as an opportunity to improve access, decrease cost and improve quality. Another possibility is to look at virtual visits. Group Health Cooperative of Puget Sound (Washington), Kaiser Permanente, the Department of Veterans Affairs, Cleveland Clinic and several other groups are showing this to be a reasonable way of providing improved access, better quality and lower cost.

Whatever we do in response, it seems that retail medicine has a place in health care as long as it is able to improve access, decrease costs and improve quality. In case you are wondering what I recommended to the relative with the sick child, I said, “Take the kid down to Target.”