decided whether to participate or submit testimony on theirexperience of the PolyHeme trial.

“We have a conundrum in this country,” said Gould, ChiefExecutive Officer of Northfield. “It’s the balance between theneed to respect patients’ rights and the need to conductrigorous scientific studies in emergency life-threateningsituations. Those are the opportunities for some of the greatest

advances in care, and yet it is virtually impossible to do themwith the traditional approach to informed consent.”

Maryn McKenna is a freelance journalist and a Henry J. KaiserFamily Foundation Media Fellow studying emergency departmentstress. She lives in Atlanta and Minneapolis.

doi:10.1016/j.annemergmed.2006.09.008

ONE STOP HEALTH CARE SHOPPING?THE RISE OF “MCCLINICS” AND THEIR IMPACT ON EMERGENCY CARE

George FlynnSpecial Contributor to Annals New and Perspective

In the last year or so, shoppers at supermarkets or drug anddiscount stores began noticing the hype for a not-so-traditionaltype of staple debuting near aisles once reserved for cereal,laundry soap or birthday cards:

“You’re Sick. We’re Quick!”“Convenient Care When Your Doctor’s Not There!”“Get Well. Stay Well . . . Fast!”By late 2006, nearly 200 health care clinics had been added

to grocery and merchandising giants such as Wal-Mart, Target,HEB, CVS, Kroger, and Piggly Wiggly. Their size and businessmodels varied, but the clinics uniformly touted the advantagesof speedy and economical treatment administered by nursepractitioners for common ailments.

That’s just the start of what some doctors refer to as the“McClinics” or even “Doctor Starbucks.” Ambitious expansionplans call for the retail clinics to spread faster than a flu virus,with more than 1,000 by the end of 2006, and twice that manynext year.

The Madison Avenue-like pitches for clinic patients havespawned national media buzz. The New York Times, Los AngelesTimes, Time Magazine, USA Today, and other publications haveweighed in with largely favorable coverage on this newest trendin medical care.

Emergency physicians generally welcome the retail clinics asanother point of access for medical care, but those surveyed stopfar short of accepting contentions that the clinics could bring acure to the longstanding problems of emergency department(ED) crowding.

Dr. Michael Bishop, an emergency physician and chiefexecutive officer of the Bloomington, Indiana-based UnityPhysician Group, said retail clinics have had no measurableimpacts on the patient loads at the 10 EDs staffed orcoordinated by Unity. They have about 270,000 combinedvisits annually.

“Obviously, any time there is another provider around, thereis the potential to have an impact,” he said. Urgent care centersand primary care physicians may feel the effects of the clinics, he

said, “but I really don’t think it is going to have a great deal ofimpact on emergency departments.”

A QUESTIONABLE IMPACT ON EDS

Bishop explained that the bulk of emergency patients—whobelieve they have serious medical problems—will continue torush to EDs rather than Wal-Marts. Most of the other EDvisitors, especially at the safety net sanctuaries of publichospitals, won’t find retail clinics to be a viable alternative.

“Most of those [clinics] want cash, or if not cash, then atleast insurance,” Bishop said. “They aren’t going to be of help atall to the uninsured and the under-insured cases that occur inemergency medicine.”

That assessment also came from Dr. Wesley Crowley, anemergency physician who is president of California EmergencyPhysicians group, which staffs more than 50 EDs.

Asked about the retail clinic movement, Crowley said, “Idon’t think that it is a bad thing, but I don’t think that it isanything more than probably another point of entry ofconvenience” in the health care field. “I don’t think it is abusiness model that is necessarily going to fundamentallychange medicine or anything like that.”

Crowley also said patient numbers at EDs served by hismedical group had been unaffected by the onset of retail clinics.He also questioned the news media’s extensive and largelyunchallenged coverage of the clinics’ claims of significantconsumer savings over hospital or physician’s office costs, and offaster and more efficient care.

Articles on the retail clinics mostly overlook the trend bymany hospitals and EDs to reduce wait times throughinnovative programs that expedite treatment, such as theCalifornia Emergency Physicians’ Rapid Medical Evaluationplan, Crowley said.

“I really take issue with the subject of cost,” Crowley said.While the bill for serious injuries or illnesses is obviously high inEDs, “for a minor treatment, the cost is low in an emergencyroom,” he said.

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As both physicians noted, studies and experience haveconcluded that non-urgent patients are not responsible for thelong waits encountered by patients in EDs.

‘HIGH TOUCH, LOW TECH’Despite the concerns, Crowley said he welcomes retail clinics

as another form of care providers. Having personal attention bya nurse practitioner is a plus for people with relatively minorproblems, he said. Crowley added that the usefulness of clinicsare limited by the absence of an on-site physician and the spacerestrictions for diagnostic tools and testing equipmentcommonly found at hospitals.

“So, essentially, retail clinics are high touch but low tech,”Crowley said.

Crowley described an overall spectrum of medical care thatstarts perhaps with a mother’s or grandmother’s care and runsupward to specialized treatment by a neurosurgeon or board-certified emergency physician. He said retail clinics fit in justabove telephone advice by medical call centers, and just belowthe physician-supervised attention received at urgent carecenters.

Clinic operators countered the concerns by saying they donot compete with but complement the established medicalcommunity.

Indiana-based MedPoint Express, with 3 locations and plansfor two more, is an affiliate of Memorial Health System. TheAtlantiCare system already includes hospitals, a primary carephysician network and urgent care centers. It plans to open achain of HealthRite retail clinics in New Jersey.

Barrett Cook, a spokesman for Florida-based Solantic retailclinics, said some hospital EDs have started handing outSolantic materials to patients with non-urgent conditions toencourage them to use that service to reduce ED crowding.Solantic, however, is one of the few chains with on-sitephysician staffing.

ANOTHER POINT OF CARESeveral other clinic companies said they have formed

cooperative agreements to refer patients to primary physiciansfor follow-ups or treatments not provided in the limited scopeof services of the retail clinics. Likewise, some doctors havedirected patients to the retail clinics for treatment when theiroffices are closed during the evenings or weekends.

Clinic officials also said their nurse practitioners are welltrained for the variety of care and treatment offered tocustomers. Those typically include ear and eye infections, sorethroats, seasonal allergies and various muscle aches or sprains.Their menu of available services also features standardscreenings, physical exams and vaccinations.

Limiting services has a side benefit of reducing medicalmalpractice insurance premiums to reduce overhead.

A report this year by the California HealthCare Foundation(CHCF) estimated that most clinics could cover their expenses

with as few as 2 customers hourly. The report showed that aclinic charged about $100 (medication included) on the averagefor strep throat, a condition that usually cost consumers $122 ata doctor’s office and nearly $330 at an ED.

CLINICS AS COST-CUTTERS?Cost factors were hardly limited to consumer pocketbooks.In late 2005, Wal-Mart was embarrassed by the leak of

portions of a confidential memo outlining suggestions to cutemployee benefits. It stated in part that the addition of clinics toits stores, along with “innovations” to reduce the price of retailclinic visits, “could become an important part of our health carestrategy, especially as a substitute for emergency room visits.”

Low overhead for now stems primarily from the use of nursepractitioners, although the demand for their services is pushingtheir pay scales toward those of some physicians. The nursepractitioners are uniformly required to have supervisingphysicians; the regulations vary among states. In Texas, forexample, those off-site physicians must be on call during clinichours, and are required to visit the clinics a minimum of every10 days, and review at least 10% of the patient charts.

Many clinics have proprietary software to help guide thenon-physicians through the examination process withcomputerized prompts and electronic recordkeeping.

Eileen Ansel Conery, a spokeswoman for the Houston-basedRediClinic chain, explained that the standard layout ofRediClinics “is quite adequate for the services offered at theclinic. If there is a medical issue or a concern regarding aRediClinic patient that falls outside the scope of services offered,they will be referred to a physician as appropriate. The clinic isnot meant to replace one’s primary care physician.”

“Continuity of care is extremely important and RediClinicsupports this,” Conery said.

NPS VERSUS FPS

However, there are those in the retail clinic field whoquestion whether nurse practitioners are most appropriate to beheading the on-site care.

Cook, the Solantic spokesman, said his company’s “model isto use board certified or board eligible family practice physiciansin all of our centers.” Staffing by physicians is financially viable,and has led to contracts with “every major managed careorganization in the country, based primarily on the fact that wedo staff with physicians . . .. That was one of the big sellingpoints.”

Solantic considered using the nurses. Cook said there wassome “backlash” by the public over it, so they stayed with thephysicians. “You know the old adage, ‘If it ain’t broke, don’t fixit,’” he said.

Most major physician organizations, including the AmericanCollege of Emergency Physicians, have largely stayed out ofdirect debates on retail clinic issues.

However, in June the American Academy of FamilyPhysicians (AAFP) and the American Medical Association

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voiced concerns about the consistency of care at the clinicswhen they issued guidelines—“desired attributes”—for theclinics’ models of care.

The recommendations were basic and outwardly applaudedby clinic operators. Among the guidelines were calls for in-storeclinics to adhere to standardized medical protocols, to be linkedto physicians for continuity of care, to keep recordselectronically, and to clearly define available services.

AAFP president-elect Rick Kellerman said that familyphysicians typically find and treat 3 more health problems forpatients who come in for care on a separate medical problem.“Patients simply cannot get this top-quality, customized care ata retail clinic,” he said.

In response to the arrival of the clinics, some familyphysicians and general care providers were reported to haveexpanded office hours and reduced daily appointments to helpcompete with the speed and convenience of care for patients atclinics.

AN AMBIVALENT PUBLICThe public appeared to reflect the mixed feelings about the

clinics in an Interactive Harris poll conducted in 2005 withabout 2,500 respondents.

About 78% of the consumers in the poll believed the clinicscould be a convenient, fast avenue for basic medical needs,although a nearly equal number–75%– also registered concernsover the quality of medical care provided by the clinics. Of the7% of respondents who had used the clinics, about 90%reported satisfaction with their visits.

Results of another survey by the CHCF suggested that retailclinics may have a limited niche for some patients who reporteda lack of accessibility to physicians’ offices and other health careproviders. However, that study also indicated a strong relianceby those visitors on EDs.

The foundation surveyed 170 emergency physicians, 400primary care physicians and 1,400 ED consumers in California.The final report, which concentrated on potential solutions forED crowding, was scheduled to be released in late 2006,although CHCF shared some of the findings early.

Maribeth Shannon, CHCF’s director of hospital and nursinghome program, said part of the study focused on insuredpatients who described their health problems as non-urgent, yetthey were going to EDs during regular working hours. “Wethought, well, those people have access to a lot of other healthcare alternatives; why are they showing up at emergencydepartments?”

Of that ED visitor group, 46% could have been handled by aprimary care provider, yet they reported that they “had troublegetting an appointment at their primary doctor’s office or[otherwise] getting access to their physicians, even over thephone,” Shannon said. She noted that the results don’t meanthat 50% of that patient segment could be treated at retailclinics, because of the clinic’s narrow scope of services, “Butsome would be candidates” for clinics, she said.

Shannon said emergency physicians and primary careproviders were both surveyed on how effective various proposalswould be in reducing the number of ED patients who could betreated elsewhere.

Of the primary care doctors, 31%—compared to 20% of EDphysicians—thought increased availability of alternative facilitieswould be effective. Results showed the same split on the question ofthe effectiveness of extending hours for urgent care centers.

There was agreement—by roughly 20% of both physiciangroups—that there would be some effectiveness from fast trackprograms and financial incentives for primary care physicians tosee patients after-hours or on weekends.

Six percent of the ED physicians thought nurse advicetelephone centers would help, compared to 17% of the primarycare physicians. Only 4% of the ED physicians believed bettercommunity education about proper ED use would be effective,while 12% of the primary care physicians believed that.

“The thought we had as we were going through this was thatemergency medicine physicians rarely felt like you could offloada lot of the population they are seeing,” Shannon said. Shelaughed briefly as she said, “I don’t know if that’s just a kind ofdenial, or because they knew what [visitors] needed, and theycouldn’t be treated at a retail clinic, or what.”

EDS AS FIRST AND LAST RESORTEighty percent of the customers said they knew that urgent

care centers were open in their areas, but “people reported thatthey tended to use the emergency rooms because they knew theywere there,” Shannon said.

Her conclusion: “When people are in pain, their firstthought is often the emergency department because it is there,and they know it is available. So the 24-hour, seven-day-a-weekaccess of the emergency department is always going to havepeople beating a path there.”

Retail clinics will need broad operating hours and access, aswell as heavy marketing to alert customers to their presence, shesaid. Otherwise, the clinics will find it difficult to penetrate thehealth care market, Shannon said.

Marketing appears to be a strong suit in the backgrounds ofmajor players in the retail clinic push.

Michael Howe, the chief executive officer of the retail clinicpioneer MinuteClinic, previously held that same top position forArby’s restaurant group. After establishing more than 80 clinics, thecompany announced in July that it would be acquired by one of itsprimary tenants, the CVS drug store chain.

Take Care Health Systems, headquartered in Pennsylvania,drew $77 million in financing in mid-2006 and plans to have1,400 clinics in place by 2009.

Richard L. Scott went from the helm of the vast Columbia-HCA Healthcare hospital empire to run Solantic. RediClinic’sgeneral manager, Sandra Kinsey, had been the executive overmarketing for pharmacies for Wal-Mart, and her boss isprevious AOL chairman Stephen Case.

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Case has traced his inspiration for the clinics to a 4-hour waitin an ED a few years ago, when he unsuccessfully tried to get hisdaughter treatment for her earache.

Clinic entrepreneurs are credited with innovative foresightin creating the clinic models, although veteran emergencyphysicians said the clinics appear to be largely a sequel toanother trend of 2 decades ago–urgent care clinics.

THE ECHO OF URGENT CARE CLINICS“There is the same buzz,” Crowley said. “It is almost exactly

what happened when the urgent care centers were introduced.”That trend was chilled because they couldn’t accept healthmaintenance organization payments and “insurance companiesdidn’t want to pay for them. So a lot of people just paid out ofpocket . . . and didn’t worry about it, because they enjoyed theconveniences. Essentially, you’ve got the same thing happeningall over again.”

Bishop recalled the references to urgent care centers as “Docin the Box,” making the retail centers of discount supergiantsthe “Doc in the Big Box.”

About the retail clinics, he said, “I think a few of them willbe here to stay. I don’t think there are going to be as manythousand as everybody thinks, because it is going to bedifficult.” While some retailers may favor them for the lucrativeprescription traffic they generate, the relatively high overheadof the clinics may make them noncompetitive with othercommercial enterprises and merchandise.

The fittest of the urgent care clinics survived, Bishop noted,but the same may not be true for the nurse-run retail clinics.“I don’t know if these places will become part of the medicallandscape or not, because most of them don’t have physiciansin them.”

doi:10.1016/j.annemergmed.2006.09.009

Call for Resident Papers

The �Residents’ Perspective� is soliciting ideas from emergency medicine residents for future articles. If you have an idea,an issue, or an experience about which you would like to write, submit an abstract (limit 250 words, double-spaced)outlining your idea. Give the names of your coauthors, if any. If your idea is chosen, you will be asked to write an article forthe �Residents’ Perspective� section.

Submit your abstract to Kalev Freeman, MD, PhD, Resident Fellow, Annals of Emergency Medicine, 1125 Executive Circle, Irving,TX 75038-2522. E-mail: kalev@ecomail.org.

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