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Filling the Gap

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In the weeks leading up to the October 1 opening of individual enrollment for insurance under the Affordable Care Act, professionals associated with retail health clinics pondered what it could mean for the well-being of their organizations — and the industry at large.

Asked about the overall mood toward the impending implementation of Obamacare, responses ranged from “cautiously optimistic” to “genuinely eager,” with pretty much everything in between. There’s as much dissension, excitement and “we’ll have to wait and see” as within the general population.

For most people, not much will change during the period of enrollment, which continues through March 31, 2014. Tom Charland, CEO of Merchant Medicine — a Minnesota-based organization that offers research and consulting services to “walk-in medicine” outfits — doesn’t expect much change afterwards, either. In retail health, he says, those who anticipate a large uptick in new customers as the previously uninsured enter an already-burdened system may be wrong.

“Starting on January 1, there will be people who may have been uninsured but now carry insurance cards,” Charland says. “But when they walk into a retail clinic, they don’t represent new patients or new business, because they’ve already been patients. I believe we’ll see a slight uptick in patient volume, but it’s not like 30 million people will be new customers of retail clinics. They’ve been there the whole time.”

Preparing through growth
The Affordable Care Act is only one part of a complex overall shift, one moving toward accountable care organizations, direct primary care and team-based patient-centered “medical homes” — and potentially away from fee-for-service payment models. The current definition of who or what a health care “provider” is may even be up for grabs.

Meanwhile, representatives of the retail clinics speak of opportunities to fill gaps and to work in tandem with the traditional health care system rather than compete with it. Formal affiliations between retail clinics and major health systems are already on the rise — lending not only increased credibility, but also increased opportunities for reimbursement for services offered.

Dr. Andrew Sussman, MinuteClinic president and senior vice president/associate chief medical officer for CVS Caremark, says the organization is now officially affiliated with 28 health systems across 19 states, including Cleveland Clinic, UCLA Health System, Emory Healthcare and UMass Memorial Health Care. MinuteClinic continues to work on integrating electronic health records with these systems for more congruent and efficient responses to patients, in addition to incorporating more screenings, chronic disease management and wellness-type programs.

“MinuteClinic is evolving into being a part of the more traditional health care system at a time when the system needs more capacity,” Sussman says. “And our model of providing walk-in access and high quality using evidence-based guidelines has really helped to facilitate that. I think the important message here is that we’re growing, we’re accelerating our rollout of new clinics and seeing ever-more patients in an environment where we think there’s going to be tremendous need.”

As the nation’s largest retail clinic provider, MinuteClinic has seen 17 million patients since the company’s inception — 10 million over the past three years alone. (CVS acquired MinuteClinic in 2006.) MinuteClinic has more than 700 sites, and is in the midst of adding 150 in 2013. The objective, Sussman says, “is to get to 1,500 [clinics] by 2017.” To put that in perspective, there are fewer than 1,500 retail health clinics in the United States right now. Healthcare Clinic at select Walgreens (known as Take Care Clinics before a recent rebranding) is second on the list, followed by Kroger’s The Little Clinic.

“The basic issue is that the need for affordable, accessible care is only going to grow,” Sussman says. “We talk about a medical home model, but there are going to be a lot of medically homeless people. There already are — 40 to 50 percent of the patients we see don’t have a primary care physician, so that problem is likely to worsen as more people get coverage. The kinds of activities we’re undertaking include giving patients a list of primary care physicians in their area who are accepting new patients. … We are actually an important portal of entry into the traditional health care system.”

Focusing on trends
Heather Helle, divisional vice president of Walgreens’ Take Care Health Systems consumer solutions group, reports it’s been “a fantastic year.” The company’s Healthcare Clinics at select Walgreens stores now number nearly 400; partnerships with clinical affiliations also have increased, as have new services like chronic condition management. The rebranding, announced in July, aligned all of the drug store chain’s health care assets and affiliations under a single umbrella. In keeping with the goal of transforming the role of community pharmacy — including more comprehensive options and delivering a “differentiated patient experience” — Walgreens has formed several accountable care organizations and expanded its Medicare Part D programs.

“We’re looking at the marketplace and the trends happening in health care broadly,” Helle says. “Our focus is really there versus what’s happening in the political arena. Unfortunately in this country today, we’re facing an epidemic of obesity and chronic disease. We’ve got an aging population, we have a number of Americans set to become insured at the beginning of 2014, and all of this is happening at a time when we’re facing a primary care physician shortage. So we’re looking at those trends, and how we can help be part of the health care solution for this country.”

Like Sussman, Helle believes every walk-in clinic patient should have a primary care physician. But the clinics still have the opportunity, she says, to “serve on the front lines of health care,” in addition to helping build and support the health care networks in the communities where they operate. The Healthcare Clinics at select Walgreens represent only a portion of the company’s overall transition from traditional drug store to health and daily living store, she says; other changes include new store formats and the addition of fresh foods and community rooms.

Technology’s role
In the past, retail clinics fought battles for acceptance, in addition to enduring challenges regarding the scope of services offered and appropriate reimbursement schedules. But there seems to be progress on all fronts. Affordable Care Act or not, the future offers even more opportunities for advances and greater popularity. Those might include the increased use of telemedicine between clinics, so that a walk-in patient at a busier site could be seen in short order by a medical practitioner at another location, as well as mobile apps that will show wait times at individual clinics.

“We are starting to see the evolution of queuing technologies where people, based on their geo-location, can look up urgent care centers [or] retail clinics and find where the closest ones are,” Charland says. “What’s missing is, ‘What’s the queue at the one in this direction versus the one in that direction?’ Once we have that technology in place, there will be almost automated load balancing, because people will choose based on the shortest wait time.”

Such load balancing could eventually help retail clinics participate in the direct bill approach, Charland says, likening it to delivering primary care services in much the way a health club membership works. For a set fee per month, patients would be able to see the doctor whenever needed, with a high deductible for anything more serious.

Access to advice
Independent community pharmacies are also facing some uncertainty in the changing landscape. John Norton, director of public relations for the National Community Pharmacists Association, which represents some 23,000 privately owned pharmacies across the country, expects an increased number of newly insured patients visiting pharmacies not only for medicine, but for medical advice.

The Affordable Care Act has much to say about more collaborative care, Norton says, “and we hope and think that if a pharmacist is part of that team you’ll see better results. It’s definitely an opportunity from that perspective. We’re clinically trained medication experts, but we’re not fully utilized — and certainly not fully compensated — for that. If we’re better utilized, we’ll see better results.”

Community pharmacists — regardless of whether a clinic is attached to the facility — are constantly fighting the perception that they’re just “dispensers of pills,” Norton says.

“We provide much more. Think about it this way: If you want to talk to a doctor, you get an appointment, but it might be a day or week from now. With a pharmacist, if you have a question, you can call them up, and they may be able to answer that question on the phone.

“We’re a lot more accessible and offer a lot of consultation,” he says.

Other unique services might include compounding of drugs, home delivery or working directly with long-term care facilities.

NCPA continues to fight for “provider” status for pharmacists, especially in terms of reimbursement for services rendered or programs like Medicare.

“It’s something we’ll have to advocate for, whether at the state or federal level,” Norton says. “The system is what it is. Ultimately, all we can do is make our case and help the decision-makers understand that their decisions impact our ability to help patients.”