My wife Aimee and I both work.  When one of our kids wakes up complaining of a sore throat, we begin a ritual stare-down to determine which of us is gonna have to wait for the doctor's office to open, call them, wait on hold, schedule an appointment, which will inevitably be in the middle of the day, take off work, pick the kid up from school, wait in the waiting room surrounded by other sick kids, get seen, get the rapid strep test, find out if the kid's infected, and then take them either to a pharmacy and home or back to school before returning to work.

OR one of us could just take the kid to a retail clinic on the way to work or school and be done in 30 minutes.  The undeniable convenience and reliability of retail clinics is the topic of this week's Healthcare Triage.

(Intro)

Strep throat is incredibly easy to treat.  Penicillin still works great.  There's a simple and very fast test for it.  Moreover, physicians are really bad at diagnosing some of these common illnesses clinically.  A study found that a doctor's guess as to whether a respiratory infection is bacterial or viral is right about 50% of the time.  No better than flipping a coin.

The point is, you need to get the rapid strep test every time regardless, whether at your doctor's office or at a clinic.  Aimee and I choose the retail clinic every time.  Why?  Convenience is the biggest reason.  Many doctors' offices are only open on weekdays and during business hours.  This also happens to be when most adults work and most kids go to school.

A 2010 survey of 11 countries found that Americans seek out after-hours care or care in an emergency department more often than citizens of almost any other industrialized nation.  More than 2/3 of Americans with a below average income did so, but this isn't just a problem for the poor.  About 55% of those with an above average income did so as well.  We complain all the time that people use the emergency department for primary care, but that's not always about insurance.  It's about access.  The emergency department is open when people can actually go get care.  It's likely one of the reasons that emergency department use has gone up, not down, since the passage of the Affordable Care Act.  More people have insurance and now can afford the care available to them when they need it.

That care is also coming from retail clinics.  Between 2007 and 2009, retail clinic use increased ten-fold.  It turns out that my wife and I represent America pretty well.  About 35% of visits to retail clinics for kids are for pharyngitis or sore throat.  Add in ear infections and upper respiratory infections and you've accounted for more than 3/4 of visits for kids.  

Parents bring their kids to retail clinics to take care of quick, acute problems.  Swap out ear infections for immunizations and you've got the main reasons adults use retail clinics, too.  Another study published in The American Journal of Medical Quality talked to patients who sought out care at retail clinics.  Patients who had a primary care physician but still went to a retail clinic did so because their primary care doctors were not available in a timely manner.   A quarter of them said if the retail clinic wasn't available, they'd go to the emergency room.

It's understandable why physicians' groups might be opposed to retail clinics.  Above and beyond the obvious economic loss to a clinic or office when a patient goes elsewhere, many primary care physicians correctly point out that retail clinics often lack the knowledge and experience that comes from continuity of care.  For many years, experts have argued that medical homes are comprehensive set-ups to care for kids in many domains are the optimal way to care for children, especially those with chronic conditions.  Retail clinics are pretty much the opposite.

The American Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association have all released policy statements or guidelines that oppose or at least advise that use of retail clinics be restricted to very few domains.  That doesn't seem to have deterred many patients.

Research hasn't borne out many of the physicians' concerns though.  A 2009 study in The Annals of Internal Medicine examined the cost and quality of care delivered at retail clinics compared to physicians' offices and urgent care centers.  Turns out that aggregate quality scores were similar in all three settings, as were patients' receipt of preventive care.  The cost of visits, however, was significantly less in retail clinics, $110 versus $166 and $156 respectively.  

This has led some to believe that these clinics are a viable way to reduce spending in the United States healthcare system.  After all, if we can achieve the same quality, improve access, and spend less, we will have achieved the triple aim that everyone wants but that some, including me, have argued is apocryphal.

A very recent study in Health Affairs would seem to support my beliefs though.  If retail clinics just allowed people to substitute less expensive visits for more expensive ones, they might help us to spend less overall, but if they induce new healthcare visits that otherwise wouldn't have happened, they could raise spending.  It turns out the latter is occurring.

Researchers used insurance claims from Aetna for more than 13 million enrolees from 2010 to 2012.  They found that 58% of visits to retail clinics were for low acuity conditions that represented new utilization.  Retail clinic use was associated overall with an increase in spending of $14 per person per year.

It's possible that many of these visits were unnecessary.  For example, upper respiratory infections, for the most part, don't need a clinical visit at all.  If we improve access and maintain a focus on quality, it may cost more.  Many who use retail clinics might be willing to make that trade-off.  If physicians want to reclaim that business, they will likely have to offer the same benefits of scheduling and efficiency that retail clinics do, but if we're looking for ways to reduce our national healthcare spending, retail clinics may not be the prescription we need.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation.  We'd especially like to thank our research associate Joe Sevits and our surgeon admiral Sam.  Thanks Joe!  Thanks Sam!  More information can be found at patreon.com/healthcaretriage. (?~5:54)