American Medical News
By — Posted Aug. 12, 2013
Convenience trumps loyalty when parents seek treatment for nonemergencies for their children. This desire for quick, easy-to-access care is leading many to take their children to retail clinics instead of the pediatrician's office.
A study posted online July 22 in JAMA Pediatrics examined why some parents seek care for children at retail clinics — even though they have an established patient relationship with a pediatrician. Despite the retail clinic market not growing as quickly as initially predicted, some doctors are still concerned about such clinics having a negative impact on their practices and their patients.
With parents seeking convenience at retail clinics, some physicians say quality of care may suffer due to fragmentation and a lack of continuity.
The JAMA Pediatrics study found that once adults become familiar with retail clinics, they are more likely to take their children to them. Of the 1,484 parents surveyed for the study, 37.4% had used a retail clinic for themselves and 23.2% had taken their children to one. Respondents were interviewed at pediatric practices in the St. Louis area and had a patient relationship with a pediatrician.
Study lead author Dr. Jane Garbutt, a research associate professor of medicine and pediatrics at Washington University School of Medicine in St. Louis, said researchers wanted to see how use of retail clinics by parents contributed to a decline in pediatric visits. She cited previous research that found the pediatric services sought at retail clinics equate to about 30% of what a pediatrician might see daily.
Ateev Mehrotra, MD, a researcher at Harvard Medical School's Dept. of Health Care Policy and RAND Corp., said the study shows the groups most likely to use retail clinics — more educated, older and affluent parents — also are the ones that have the best access to care. “But they are choosing this as a real alternative to their primary care pediatric practice,” he said.
Numerous studies published about five years ago predicted that the retail clinic market would grow from less than 1,000 locations at the time to more than 6,000. The actual growth has not met expectations. As of July 1, there were 1,443 clinics operating in the U.S., according to Tom Charland, CEO of Merchant Medicine, a walk-in medicine market research and consulting firm based in Shoreview, Minn. An August 2012 RAND report showed that use of retail clinics continues to climb, with a fourfold increase in visits between 2007 and 2009, to reach nearly 6 million.
Early on, when retail clinics started opening, there was concern among primary care physicians that the clinics would take business from their practices. Those fears were mostly unfounded for adult primary care practices, but pediatric practices are another story, said Joe Zickafoose, MD, a pediatrician with the University of Michigan Health System in Ann Arbor.
“There are more general pediatricians per child than there ever have been in the United States,” said Dr. Zickafoose, adding that there may be isolated areas in the U.S. where this is not the case.
A 2004 Journal of Pediatrics study predicted that the number of general pediatricians would expand by 64% between 2000 and 2020, and the child population was projected to expand by only 9%. A January 2011 Journal of Pediatrics study indicated that the predictions might be on target. It found that between 1996 and 2006, the general pediatrician and family physician work forces expanded by 51% and 35%, respectively, and the child population increased by only 9%.
Another concern that physicians have with retail clinics relates to continuity of care.
Unless a retail clinic is part of a larger health care system, there are no shared records beyond the clinic sending a care summary to a physician's office after a visit. That approach could be problematic if a child gets a sports physical and the nurse practitioner conducting the exam doesn't know that the child had two concussions last year, said pediatrician Anne Francis, MD.
“It makes it a little bit difficult to really say that this is quality medicine,” said Dr. Francis, who works in an eight-physician pediatric practice in Rochester, N.Y.
Dr. Francis was a member of the American Academy of Pediatrics Retail-Based Clinic Policy Work Group that wrote the academy's policy statement on retail clinics. The policy spells out a set of principles for retail clinics, including that they support the medical home model and refer patients back to a primary care office for future care. The American Medical Association has similar policy that supports protocols ensuring continuity of care.
Dr. Zickafoose said he is less concerned about treatments for minor issues such as a sore throat in otherwise healthy children. But Dr. Francis said every visit to a retail clinic is a lost opportunity for a pediatrician to bond with that patient. “A lot of what we do is relationship building,” she said.
Knowing that convenience is driving many patients to retail clinics, offering expanded hours may seem like an easy fix for physicians trying to get those patients back into their offices. But many have found it's not that simple.
In recent years there has been an increased focus on the patient-centered medical home concept, which promotes convenience and access. Dr. Zickafoose said pediatricians were among the first to expand office hours, add weekend appointments and make themselves or their staff available via email and telephone 24 hours a day. Yet many patients still view retail clinics as more convenient.
A study in the June issue of the Journal of Pediatrics found many parents were unaware of the after-hour services offered by their pediatricians. Dr. Zickafoose, lead author of the study, said he often reminds patients of his own after-hour services.
He added that even though many practices offer extended hours, patients still must make an appointment and likely will face a wait once they get there. The JAMA Pediatrics study found that 57.5% of respondents who used a clinic reported a wait time of less than 30 minutes. It also found that 74% first considered going to a pediatrician's office, but 25.2% couldn't get an appointment.
“If a pediatric practice is going to try to compete with a retail clinic by trying to improve convenience, they have to make it really convenient,” Dr. Mehrotra said. “In other words, telling a busy, well-educated mother, 'Well, you still have to wait three hours, or we'll get you in, but you may have to wait a while,' may not be a viable alternative.”
Physicians also can talk to patients about their use of retail clinics, Dr. Garbutt said. Only 2% of the surveyed patients in the JAMA Pediatrics study said their physicians had raised the topic.
Dr. Garbutt said many practices are addressing the issue by affiliating themselves with retail clinics with which they share an electronic health record.
“It's not a good business model for the pediatricians to all be working until 9 o'clock at night, so it makes sense that they would form some sort of shared resources that they could recommend their patients go to after hours if they needed to be seen,” she said.