In reform era, retail clinics become part of the healthcare delivery system

A contract between Detroit-based Henry Ford Health System and MinuteClinic, a division of CVS Caremark Corp., is one example of how retail clinics are becoming a larger part of the healthcare delivery system in Southeast Michigan to meet an expected increase in patient demand next year under the Patient Protection and Affordable Care Act.

Under the contract, Henry Ford provides at least five physician medical directors to 14 CVS MinuteClinics in metro Detroit to oversee clinical operations and supervise nurse practitioners. CVS plans to add three or four more MinuteClinics here and more than 150 nationally next year.

"Our physicians serve as medical directors to meet with nurse practitioners at MinuteClinics on a regular basis to review quality," said Paul Szilagyi, Henry Ford's vice president of primary care and medical centers. "They are a phone call away if the nurse practitioner has a question about a patient."

The contract also allows patients of the Henry Ford Medical Group to use the MinuteClinics as if they were one of the 27 Henry Ford-owned medical centers and nine affiliated physician offices.

Two years ago, officials at Henry Ford Health System recognized they needed additional access points for patients and others seeking care from Henry Ford doctors.

"The only way to get into the Henry Ford Health System was through (hospital) emergency departments or our ambulatory care clinics," Szilagyi said. "We wanted to create more doors to enter the system."

Henry Ford considered creating retail clinics on its own, he said, but concluded it would be better to seek an established company.

Because Woonsocket, R.I.-based MinuteClinic already had contracts with more than two dozen other health systems and physician group practices, including the Cleveland Clinic—and evidence showed that MinuteClinic quality was high and medical malpractice incidents low—Henry Ford decided to join forces with the retail clinics.

"CVS had already made a commitment to Detroit, and we felt they had the same commitments to access, quality and connections (to primary care doctors) as we did," Szilagyi said.

Another bonus for Henry Ford patients, Szilagyi said, is that MinuteClinic offers expanded evening and weekend access to care and affordable primary care prices.

Dr. Sylvana Yalda, a family medicine doctor at Henry Ford Medical Center-Troy and a MinuteClinic medical director, said the delivery of care has been convenient and high-quality.

"The nurse practitioner sees the patient, and we do chart reviews," Yalda said. "They call me for consultations and a second opinion if they have questions about a patient.

"Nurse practitioners are very good at following (national clinical care) guidelines, but some situations require a doctor's point of view."

Since January 2012, when Yalda became a MinuteClinic medical director at the Waterford Township, Rochester Hills and Southfield CVS centers, some of her patients have been seen by nurse practitioners at MinuteClinics, she said.

Nurse practitioners fax patient encounter notes to primary care physicians, Yalda said.

"I have received quite a few," she said. "It is very helpful to know the care my patients have received."

To improve the sharing of patient records with primary-care doctors, Henry Ford Health and MinuteClinic are working to link electronic medical record systems, Szilagyi said.

Next year, Henry Ford should have MinuteClinic fully integrated with the health system's Epic electronic medical records, Szilagyi said, which will provide visit tracing and opportunies to do chronic disease management.

Because of health insurance expansion and the need to offer lower primary care costs, the number of retail clinics is projected to double over the next five years in the U.S. to 3,000, said Tine Hansen-Turton, executive director of the Philadelphia-based Convenient Care Association.

Hansen-Turton said the Affordable Care Act is stimulating growth because 40% to 50% of the people who use retail clinics don't have a primary care physician, and many are uninsured.

"We expect to increase services as people become insured and seek lower-cost options of retail clinics," Hansen-Turton said. Costs for comparable services at retail clinics are 40% lower than in physician offices and urgent care centers and 80% less than emergency departments, she said.

"People will be more cost-sensitive because they will have higher out-of-pocket costs before they hit their deductibles," she said.

Like retail clinics, urgent care centers—which provide higher levels of care than retail clinics but less than hospital emergency departments—are also growing in numbers in Southeast Michigan to accommodate expected demand, said Dr. Mohammed Arsiwala, president of the Lansing-based Urgent Care Association of Michigan.

Under the Affordable Care Act, over the next several years, nearly 900,000 uninsured people in Michigan are expected to either purchase private health insurance through healthcare.gov or qualify for Medicaid.

"We won't see much more growth in the next year," Arsiwala said. "But the second year, 2015, we will start to see growth" in patient volumes at urgent clinics, he said. It will take time for newly insured patients to learn how best to access the healthcare system.

One concern has been that the influx of newly covered patients will overload the primary care delivery system. Primary care physicians, hospitals and other providers have been ramping up care recently for the expected increase in volume.

Besides CVS, pharmacies including those inside Walgreen Co. and Rite Aid Corp. stores have started retail clinics in various ways to take advantage of national changes in healthcare that are projected to add 16 million privately insured patients and 16 million Medicaid beneficiaries starting in 2014.

In a 2-year-old pilot program that began in Detroit, Rite Aid has established virtual NowClinics in nine stores in Michigan. NowClinic uses computers and telemedicine to link customers with remotely based advanced-practice nurses and physicians.

"Our online clinics have computer kiosks adjacent to the pharmacy in a private room with a computer," said Ashley Flower, senior manager of public relations for Camp Hill, Pa.-based Rite Aid.

Flower said customers can talk with nurses for free, but a 10-minute consultation with a physician costs $45. Customers also can consult with medical providers using their home computer, she said.

While Deerfield, Ill-based Walgreen doesn't currently operate its Take Care retail clinics in Michigan, the nation's largest pharmacy chain operates more than 400 clinics in 21 states—including Illinois, Indiana, Ohio and Pennsylvania—as well as the District of Columbia, said Jim Cohn, a Walgreen spokesman.

The company also has contracted with 15 health systems to integrate its clinics with system hospitals. Those health systems include Baltimore-based Johns Hopkins Health System and Indianapolis-based Community Health Network.

Retail clinics are positioned to meet the needs of people who don't have a doctor or can't get a convenient appointment, Cohn said.

But Arsiwala of the Urgent Care Association of Michigan cautioned that retail clinics are limited in the types of care they can provide.

"Urgent care centers offer comprehensive medical care for people who need it urgently and cannot be seen by primary care doctors," said Arsiwala, who also is CEO of 10-center Michigan Urgent Care Centers.

"Pharmacy retail clinics are a very commercial side of the business," Arsiwala said. "They have nurse practitioners working for them. They don't have X-rays or comprehensive testing. They treat very minor complaints like earache or sore throats."

Dr. Nancy Gagliano, MinuteClinic's chief medical officer, said retail clinics can take on a large range of basic primary care services. Those include treating strep throat, bladder infections and pink eye and offering vaccinations for flu, pneumonia, pertussis and hepatitis.

Gagliano said patients do a good job deciding the appropriate care location for their medical issue.

"We send patients to ERs every once in a while," she said, "but working with health systems like Henry Ford helps us deliver the type of care that patients need. Doctors are seeing MinuteClinics as a place to augment primary care."

Gagliano said retail clinics stay within the boundaries of what nurse practitioners and physician assistants can do.

Yalda, the Henry Ford doctor and MinuteClinic medical director, said nurse practitioners at the clinics are well-trained in established clinical guidelines and refer more complicated patients to physicians or hospital emergency departments.

"If there is a sore throat and it is complicated, they will be referred," she said. "They know if a patient is not appropriate for the guidelines. They refer them right away. I get calls from them."

Although MinuteClinics lack the sophisticated diagnostic equipment found in hospitals and urgent care clinics, nurse practitioners can perform diabetic evaluations that include simple foot examinations to check for circulation problems or infections and can conduct blood sugar and blood pressure tests, Yalda said.

Gagliano said 50% of patients who come to a MinuteClinic do not have a primary care physician, and 50% of those patients visit during evening or weekend hours.

"Patients tell us if it weren't for us, they would go to an emergency department," Gagliano said. "We are reducing overall healthcare downstream costs."

"In era of health reform, retail clinics become part of the healthcare delivery system" was originally published in Crain's Detroit Business.