RESEARCH

Patients’ view of retail clinics as a source of primary care: Boonfor nurse practitioners?Arif Ahmed, BDS, PhD, MSPH (Assistant Professor of Health Administration)1 & Jack E. Fincham, PhD (Professorof Pharmacy Practice and Administration)2

1 H. W. Bloch School of Management, University of Missouri-Kansas City, Missouri2 School of Pharmacy, University of Missouri-Kansas City, Missouri

KeywordsNurse practitioners; retail clinics; patient

satisfaction; primary care; convenient care

clinics; discrete choice experiment.

CorrespondenceArif Ahmed, BDS, PhD, MSPH, University of

Missouri–Kansas City, 5100 Rockhill Road,

Bloch 308, Kansas City, MO 64110.

Tel: 816-235-2319;

Fax: 816-235-6508;

E-mail: ahmedar@umkc.edu

Received: November 2009;

accepted: January 2010

doi: 10.1111/j.1745-7599.2010.00577.x

Abstract

Purpose: To estimate consumer utilities associated with major attributes ofretail clinics (RCs).Data sources: A discrete choice experiment (DCE) with 383 adult residents ofthe metropolitan statistical areas in Georgia conducted via Random Digit Dialsurvey of households. The DCE had two levels each of four attributes: price($59; $75), appointment wait time (same day; 1 day or more), care setting-provider combination (nurse practitioner [NP]-RC; physician-private office),and acute illness (urinary tract infection; influenza), resulting in 16 choicescenarios. The respondents indicated whether they would seek care under eachscenario.Conclusions: Cost savings and convenience offered by RCs are attractive tourban patients, and given sufficient cost savings they are likely to seek carethere. All else equal, one would require cost savings of at least $30.21 to seekcare from an NP at RC rather than a physician at private office, and $83.20 towait one day or more.Implications for practice: Appointment wait time is a major determinantof careseeking decisions for minor illnesses. The size of the consumer utilityassociated with the convenience feature of RCs indicates that there is likely tobe further growth and employment opportunities for NPs in these clinics.

The retail clinic (RC) is a relatively new, yet rapidlygrowing, nontraditional setting for delivering primarycare in the United States. Also known as convenient careclinics, these walk-in clinics have experienced phenome-nal growth since inception in 2000 (Deloitte Center forHealth Solutions, 2008; Robeznieks, 2007; Sahoo, 2009).In June 2008 there were 971 clinics in 34 states run by40 different operators (Deloitte Center for Health Solu-tions, 2008); the number of clinics grew to 1,214 by theend of 2008 and is expected to go past 2,400 by 2013(Sahoo, 2009). Located in retail settings such as phar-macies, department stores, and shopping malls, RCs aregenerally staffed with nurse practitioners (NPs) or physi-cian assistants (PAs) and offer to patients 18 months orolder a limited set of services that include treatment fora few common acute illnesses, screening tests, and vacci-nations. Prices at RCs are generally less expensive com-

pared to other providers and prominently displayed onthe treatments and services menus as well as the clinicwebsites; patients do not need appointments and rarelyhave to wait more than a few minutes to see a provider.These characteristics, largely absent from the traditionalsettings, make RCs attractive to many consumers.

Background and supporting literature

Public awareness of RCs has increased in recent yearsand a large proportion of healthcare consumers, includ-ing Medicare beneficiaries, are receptive to the conceptof receiving care there (Deloitte Center for Health So-lutions, 2008; Kavilanz, 2009). In a Wall Street JournalOnline/Harris Interactive Health-Care poll (2005), 41%of the respondents indicated that they were somewhator very likely to seek basic medical services at an RC.

193Journal of the American Academy of Nurse Practitioners 23 (2011) 193–199 C©2011 The Author(s)Journal compilation C©2011 American Academy of Nurse Practitioners

Patients’ view of retail clinics A. Ahmed & J.E. Fincham

The level of satisfaction among the users is also gener-ally high (Harris Interactive Poll, 2007; Hunter, Weber,Morreale, & Wall, 2009). A national poll on children’shealth found that 89% of the children that have used anRC have a usual source of care and 70% of the parents ofchildren with a prior RC visit are likely or very likely toseek care for their children at RCs again (C. S. Mott Chil-dren’s Hospital, 2007). Ninety-eight percent of patients of2 RCs in Arizona surveyed by Hunter et al. (2009) indi-cated that they would visit those RCs again for healthcareneeds.

With the widening gap between the demand for pri-mary care services and the supply of primary care physi-cians, there is a growing need for alternative methodsof delivering primary care. The total number of ambu-latory care visits increased by 26% between 1996 and2006, compared to the 11% growth in the U.S. popu-lation during the same period (Schappert & Rechtsteiner,2008). Nearly half of the ambulatory care visits are to pri-mary care physicians in office-based practices. Prolongedtime to appointment and waiting time are already persis-tent undesirable features of the healthcare system (Mur-ray & Berwick, 2003) and, barring any major change inthe healthcare delivery system, likely to get worse withthe increasing demand for primary care services. An im-portant corollary of this is the inappropriate use of emer-gency departments (EDs), including increasing visits toEDs by patients whose usual source of care is a physi-cian’s office (Grumbach, Keane, & Bindman, 1993; Rustet al., 2008; Sarver, Cydulka, & Baker, 2002; Weber et al.,2008). As experienced in Massachusetts following the im-plementation of universal coverage (Massachusetts Med-ical Society, 2008), the need for alternative sources ofprimary care is likely to be further exacerbated as morepeople get healthcare coverage as a result of recent na-tional health reform. By providing alternative means foraccess to minor acute care services, RCs can not only be aremedy for primary care physician shortage and a viableaccess point for the uninsured, but also offer convenienceto the insured.

Although currently located mostly in major metropoli-tan areas, analysts predict significant growth opportunityfor RCs in the future (Deloitte Center for Health So-lutions, 2008). Many major insurers now cover RCservices and almost all RCs accept insurance payment(American Medical Association, 2006; Rudavsky,Pollack, & Mehrotra, 2009; Scott, 2006). Among themajor concerns expressed about care at RCs, particularlyby physician organizations, are their impact on qualityand continuity of care, the possibility of increased pre-scription drug use as a result of location of most RCs inpharmacies, and that patients may be bypassing theirprimary care physicians for the acute conditions and thus

forego necessary preventive care (American Academyof Family Physicians, 2007; American Academy of Pedi-atrics, 2006; Berman, 2007; “Boom in walk-in,” 2007;Halpren-Ruder, 2005). However, these concerns are yetto be substantiated (Bohmer, 2007). Despite the rapidgrowth, the model of RCs is still evolving and provides atremendous opportunity for growth for NPs because theprofession can play a major role in shaping the futureof this industry in the United States. Although most RCshave referral arrangements with physicians or clinics,RCs can be made part of the local system of care throughappropriate partnerships (“Retail clinics in line,” 2009).NPs have a long tradition of successful collaborationwith physicians, patient satisfaction with NPs has beengenerally very high, and several studies have also shownno significant difference between NPs and physicians interms of the quality of care provided (Lenz, Mundinger,Kane, Hopkins, & Lin, 2004; Mundinger et al., 2000;Roblin, Becker, Adams, Howard, & Roberts, 2004). Ananalysis of care provided for acute pharyngitis by NPsand PAs of an RC chain documented a very high rate ofadherence to national clinical practice guidelines (Wood-burn, Smith, & Nelson, 2007). Another retrospectivereview of medical records of an RC concluded that care atRCs compared to regular physician offices do not resultin early return visits, thus suggesting comparable qualityof care for the conditions treated (Rohrer, Angstman, &Furst, 2009). Greater involvement of NPs in developingthese partnerships can address most of the concernsabout RCs described earlier. Additionally, understandingwhy people choose RCs over physician offices andvice-versa will be important in establishing the role ofRCs in the local care delivery system.

Time and cost savings, the two key attributes of RCs,are also important factors in patient satisfaction. Patientsatisfaction with physician visits is generally negativelycorrelated with waiting time (Anderson, Camacho, &Balkrishnan, 2007; Camacho, Anderson, Safrit, Jones, &Hoffman, 2006; Kong, Camacho, Feldman, Anderson, &Balkrishnan, 2007; Probst, Greenhouse, & Selassie, 1997)and time to appointment is one of the strongest pre-dictors of satisfaction with access to care (Jatulias, Bun-dek, & Legorreta, 1997). Although the relative impor-tance of time and cost attributes may vary dependingon the type of illness, people are generally willing totrade between different factors in choosing the methodfor managing minor illnesses; a less preferred manage-ment method may become more attractive with sufficientreduction in wait time and cost (Porteous, Ryan, Bond, &Hannaford, 2006). However, there has been no empiri-cal investigation to quantify the tradeoffs required in theaforementioned attributes to make RC care attractive forusers in the United States.

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A. Ahmed & J.E. Fincham Patients’ view of retail clinics

Discrete choice experiment (DCE) is an establishedmethod of evaluating consumers’ decision-making basedon valuation of healthcare services (Ryan, Bate, East-mond, & Ludbrook, 2001). DCEs allow consumers toeffectively state preferences for choices when exam-ining several discrete options comprised of differentlevels of attributes (characteristics) of a healthcare inter-vention, service, or policy and provide the means to esti-mate consumer utility through willingness to pay (WTP)for changes in the levels of the attributes (Ryan, 2004a,2004b; Ryan et al., 2001).

The estimates of consumer utilities associated with costof care, type of condition for which care is sought, type ofcare setting, and appointment wait time for care-seekingat RCs or physicians’ offices by the nonrural (metropoli-tan statistical area [MSA]) residents of Georgia are pre-sented in this article.

Methods

The study sample was a subset of the fall 2007 round ofthe Georgia Poll—a statewide Random Digit Dial (RDD)survey of Georgians 18 years and older conducted twicea year by the Survey Research Center at the Universityof Georgia. The RDD sample of Georgia households wascomputer generated using a stratified sampling procedurewith probabilities of selection proportional to residentialtelephone numbers in different parts of the state. Withineach area code and exchange (three-digit prefix), the de-sired number of households were called using randomlygenerated telephone numbers. This resulted in inclusionof both listed and unlisted telephone numbers. The per-son in the household, over the age of 18 years, who cele-brated the last household birthday was the person invitedto participate in the survey. This method yielded 1,491 el-igible respondents from 5,448 telephone numbers called.Computer-aided telephone interviews (CATI) were com-pleted with 493 respondents, yielding a 33.1% coop-eration rate [American Association for Public OpinionResearch COOP3 = Interviews/(Interviews + Partials +Refusals)]. Further details about the Georgia Pollmethodology are available elsewhere (The Georgia Poll,n.d.). This analysis is based on the 383 respondents whowere residents of an MSA. Approval of the University ofGeorgia Institutional Review Board was obtained for con-ducting this research.

A full factorial DCE was carried out using 16 ques-tions that were part of the October 2007 Georgia Poll.The poll also contained demographic items (gender, ed-ucation, income, age, and urban/rural status) and addi-tional 50 questions that were not related to the researchreported here. Each of the 16 questions required a “yes”or “no” response from a respondent about the likelihood

of seeking medical care under a specific choice scenario.Two price levels ($59; $75), 2 levels of appointment waittime (same day; wait 1 day or more), 2 types of caresetting-provider combination (NP at an RC; physician at aprivate office), and 2 symptom scenarios of acute illnesses(urinary tract infection [UTI]; influenza) were used to setup 16 choice scenarios in a 2 × 2 × 2 × 2 factorial de-sign. At the time of the survey, services for influenza andUTI were among the most commonly available servicesat RCs. Price levels were set by using the prevailing feeat a large RC chain in Georgia and adjusting for inflationthe median expenditure for primary care physician vis-its reported in the 2004 Medical Expenditure Panel Sur-vey. For each illness type, a preamble statement compris-ing of the description of the symptoms and details aboutthe other attributes was presented to a respondent. It wasfollowed by eight choice scenarios—presented one at atime—comprising all possible combinations of the levelsof the other three attributes. For example, in one of theeight choice scenarios following each of the two pream-ble statements the respondents were asked “if you receivedcare from a supermarket, discount store, or chain pharmacy with

a nurse practitioner and had to wait 1 day or more for care at aprice of $75, would you use this option?” See Table 1 for thepreamble statement and details of the attributes.

Using the respondents’ willingness to seek care undereach choice scenario (“yes” or “no”) as the dependentvariable, a random effects logistic regression was carriedout to quantify preferences for care at RCs and physicianoffices and the contribution of each attribute mentionedearlier in the preferences. Using the indirect method ofestimation, WTP for change in each nonprice attributewas calculated as the ratio between the regression coef-ficient for that attribute and the additive inverse of theregression coefficient for price [β j/(−βprice)] (Ryan, Ger-ard, & Amaya-Amaya, 2008). All analyses were carriedout in STATATM Version 10.0.

Results

The 383 MSA residents that participated in this studywere predominantly white (71.8%) and female (67.4%),with the mean age of 48.86 years. Forty-three percenthad at least a bachelor’s degree and only 4% had less than12 years of education. Total annual household incomewas less than $25,000 for 8.9% and $75,000 or more for43.2% of the respondents, respectively. See Table 2 forcomplete demographic characteristics of the respondents.

The results of the regression analysis indicate that, allelse equal, the respondents preferred to seek care for bothillnesses (α = 6.140 [95% CI 5.031, 7.248], p < .001), hada greater preference for seeking care from a physician ata private office than from a NP at an RC (β = 1.038 [95%

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Patients’ view of retail clinics A. Ahmed & J.E. Fincham

Table 1 Preamble statement, attributes, and levels used in the DCE

Preamble statement

For the next set of items, I would like you to place yourself in the

following situation. . . [symptom scenario]. You have decided to seek

medical care.

The type of care that you can receive is either from a physician at a

private practice OR from a nurse practitioner at a clinic within a

supermarket, discount store, or chain pharmacy. You could either obtain

these services on the same day or wait one day or more. The price you

would pay would be either $59 or $75.

Now I am going to read you hypothetical situations involving where

you might receive care, whether care was received on the same day or 1

day later, and whether the cost of care was $59 or $75 and I would like

you to tell me if you would use the option.

Symptom scenarios� [Influenza] You have high fever, dry cough, and a sore throat. Your

nose feels stuffy, you feel extremely tired, and you have muscle pain all

over your body. The symptoms started to develop 4 days ago, and seem

to have worsened this morning. You have decided to seek medical care.� [Urinary tract infection] Since yesterday morning you have been

having frequent strong urges to urinate that cannot be delayed. Despite

the strong urge very little urine is released each time and you feel a sharp

pain or burning sensation in the bladder or urethra area during urination.

This morning you noticed that the urine is tinged with blood. You have

decided to seek medical care.

Care setting-provider combinations� Physician at a private practice.� Nurse practitioner at a clinic within a supermarket, discount store, or

chain pharmacy.

Price� $59� $75

Appointment wait time� Same day�Wait 1 day or more

CI .875, 1.201], p < .001), and did not prefer to wait 1 dayor more for receiving care (β = −2.859 [95% CI −3.034,−2.685], p < .001). The respondents were less likely toseek care for UTI than to seek care for influenza (β =−.194 [95% CI −.319, −.070]; p = .002) and preferredto spend less (β = −.034 [95% CI −.042, −.027], p <

.001). Furthermore, older respondents were slightly lesslikely to seek care (β = −.008 [95% CI −.017, −.0003],p = .043). There was no statistically significant associationbetween the respondents’ decision to seek care and race,gender, home ownership, marital status, education, andincome.

WTP estimates derived from the regression coefficientsshow that all else equal, the respondents would seek careif the cost is less than $178.64; a cost saving of $30.21would be required for them to seek care from an NP at anRC rather than a physician at a private office; and a costsaving of $83.20 would be required for them to choose towait one day or more. For every 1-year increase in age,

Table 2 Demographic characteristics of the respondents

n (%)

Age Mean 48.86

SD 14.94

Race/ethnicity White 270 (71.8)

Black 90 (23.9)

Asian 3 (0.8)

Hispanic 4 (1.1)

Multiracial 9 (2.4)

Gender Male 125 (32.6)

Female 258 (67.4)

Education Less than 12 years 15 (4.0)

High School diploma/GED 77 (20.3)

Some college/technical 86 (22.6)

school/no degree

2 year college 38 (10.0)

Bachelor’s degree 97 (25.5)

Some graduate work 27 (7.1)

Advanced/professional degree 40 (10.5)

Household income Less than $25,000 25 (8.9)

$25,000–$49,999 69 (24.6)

$50,000–$74,999 65 (23.2)

$75,000 or more 121 (43.2)

Marital status Married 242 (64.2)

Divorced 38 (10.1)

Separated 6 (1.6)

Widowed 31 (8.2)

Never married 60 (15.9)

Home ownership Rent 52 (14.1)

Own 317 (85.9)

WTP for care (likelihood of seeking care) decreased by$0.24. Detailed results of the logistic regression analysisand WTP calculations are presented in Tables 3 and 4,respectively.

Discussion

In this study, we estimated the consumer utility re-lated to common attributes of RCs among the metropoli-tan area residents of a southeastern state that was pene-trated early in the emergence of RC markets in the UnitedStates. The respondents preferred to seek medical care forboth acute illnesses, had a greater preference for physi-cians over NPs, and preferred same-day care. While thesefindings are what one would expect and consistent withthe literature (Tu & Cohen, 2008; Wall Street Journal On-line/Harris Interactive Health-Care Poll, 2005), the quan-tification of consumer utility done in this study allows forthe comparison of relative importance of different factorsassociated with medical care at settings like RCs. The sizeof the WTP for care indicates that there is likely to besubstantial demand for the types of minor illness care of-fered at RCs. Although the respondents showed a greater

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A. Ahmed & J.E. Fincham Patients’ view of retail clinics

Table 3 Results of the random effects logistic regression and willingness to pay (WTP) estimates

Variable (reference category∗) β SE z p> |z| 95% CI

Symptom scenario (urinary tract infection) −0.194 0.064 −3.06 .002 −0.319 −0.070

Appointment wait period (1 day or more) −2.859 0.089 −32.08 <.001 −3.034 −2.685

Age −0.008 0.004 −2.02 .043 −0.017 0.000

Provider-care setting (physician at private office) 1.038 0.083 12.5 <.001 0.875 1.201

Fee −0.034 0.004 −8.64 <.001 −0.042 −0.027

Race (White) 0.012 0.066 0.018 .853 −0.117 0.142

Gender (male) −0.081 0.135 −0.6 .549 −0.347 0.184

Home ownership (owned home) −0.064 0.061 −1.05 .296 −0.184 0.056

Marital status (married) −0.012 0.046 −0.29 .771 −0.104 0.077

Education (high school or less) −0.011 0.040 −0.27 .787 −0.090 0.068

Income 0.007 0.031 0.24 .812 −0.053 0.067

Constant 6.140 0.566 10.85 <.001 5.031 7.248

Likelihood ratio test of ρ = 0: χ2 = 556.41, p = 0.000.∗Variables listedwith reference categorieswere entered in the regression as dichotomous variables (presence or absence of the reference characteristic).

preference for seeking care from a physician than froman NP, the WTP for the convenience feature of RCs (sameday care) is more than two times larger than the WTP forcare from a physician. This is consistent with the find-ings of Hunter et al. (2009) that the majority of patientscite convenience as the reason for seeking care at an RC;furthermore, 95% of the participants in that study werevery satisfied or satisfied with the care provided at RCsand 98% expressed their willingness to seek care thereagain. These results bode very well for RCs as an alterna-tive delivery point for limited primary care services andthe growth of professions like NPs who typically staff RCs.Expansion of the RC market will not only expand thepractice/employment opportunities for NPs, it will alsoincrease their interaction with the public and likely en-hance appreciation and acceptance of NPs as primary careproviders. Both RC operators and primary care physicianpractices will find the results valuable for service plan-ning, rate setting, and staffing decisions.

It has been suggested that the fullest potential of RCscan be achieved by making them an integral part ofthe local system of care delivery (“Retail clinics in line,”2009). It behooves the RC operators to take advantageof the fact that NPs are used to working collaborativelywith physicians and other healthcare providers and can

play a significant role in coordinating care. The poten-tial impact of RCs on overall utilization and operationof outpatient primary care services in the United Statesis still unknown. In the face of competition from RCs,some primary care practices have made changes in theirscheduling system to accommodate same day care, ex-tended their operating hours, and publicized fees for rou-tine procedures on their websites (Bachman, 2006). Fur-thermore, the demand for primary care services is likelyto increase with the expansion of health insurance cov-erage under the Patient Protection and Affordable CareAct of 2010. Given the current supply of primary carephysicians, there will be greater need for alternative de-livery models like RCs. It is not possible to predict fromour study the impact of RCs on access to and overall costof care. However, most RCs are currently located in largemetropolitan areas, offer a limited set of services, and27–30% of the RC users are uninsured (Rudavsky et al.,2009; Sahoo, 2009; Tu & Cohen, 2008). Although thereis concern in some quarters that RCs may drive up pre-scription drug spending, early evidence suggests the con-trary and the costs of care for episodes initiated at RCsare lower than those initiated in physician offices, urgentcare centers or EDs (“Boom in,” 2007; Mehrotra et al.,2009).

Table 4 Calculations of willingness to pay (WTP) estimates

Variable/attribute (Choice) Coefficient (β) WTP calculation βj/(−βprice) WTP ($)

Fee (price) −.0343697 – –

Provider-care setting (Receive care from physician at private office) 1.038238 1.038238/.0343697 30.21

Appointment wait period (Wait 1 day or more) −2.859446 −2.859446/.0343697 −83.20

Age −.0083769 −.0083769/.0343697 0.24

Constant (Seek medical care) 6.139829 6.139829/.0343697 178.64

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This is the first quantification of urban consumers’preferences related to RC use in the United States. ThisDCE assumes out-of-pocket cost of $59 and $75 for RCsand physician offices, respectively. With many insurancecompanies reimbursing for RC care now, the out-of-pocket costs are likely to be lower for many RC usersand thus may change the WTP estimates. The providerchoice in our study was limited to only physicians andNPs; however, RCs are also staffed by PAs and it is there-fore unknown whether the WTP estimates would remainthe same if PAs were included as a choice. The utility val-ues should not be applied to NPs working at care settingsother than RCs because attributes not considered in thisstudy may affect those valuations. Readers should alsoexercise caution in applying the utility values becausethose are based on residents of one state and only two ofthe several types of services offered at RCs. Furthermore,as some RCs add chronic disease care in their menu ofservices, utility values are likely to be different for thoseservices as well (Merrick, 2009).

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