The “one stop shop” of convenience care offered by walk-in retail medical clinics has become popular with consumers and health insurers alike. This new model of care has been embraced by discount superstores like Walmart and Target, also known as big-box stores, and chain pharmacies such as CVS. While big-box retailers own and operate the majority of retail clinics nationwide, hospitals and health networks increasingly operate them, too, and some are operated jointly between retailers and traditional healthcare providers.1Healthcare risk managers need to keep abreast of new delivery models like convenience care, be prepared to manage the risks and potential liabilities they present, and also be able to support the community service and business opportunities they offer.
Background
Convenient care began as an industry in 2000 with the opening of the first walk-in clinics in Minneapolis-St. Paul. Since then, several companies formed through acquisition of these and similar clinics by retailers and healthcare organizations. While initially the clinics accepted only cash for very basic health services, most now have contracts with health insurers and/or employers.
The Convenience Care Association (CCA) uses the term “convenience care clinics” and notes that its membership includes more than 1,900 clinics throughout the U.S. According to CCA, its members’ clinics are located in convenient locations such as drugstores, food stores and other retail settings...making it easier and more convenient for patients to get the right level of care, in the right place, at the right time.2According to critics of this care model however, this amounts to “commercialized” healthcare provided by for-profits as a marketing strategy for their other high margin products.3 Some state legislators have enacted or proposed regulations to increase control over retail clinic operations. While there may be regulations promulgated that could reduce number of new retail clinics, there is no evidence that this sector is shrinking; rather, it is projected to grow exponentially. For a summary of state legislation and laws for retail clinics, see the National Conference of State Legislatures website http://www.ncsl.org/.
What are convenient care (aka walk-in) clinics and what are the risks?
The most common conditions treated at walk-in retail clinics are low-acuity problems like cold symptoms and flu, sinus infections, minor injuries (cuts and sprains) and illnesses (strep throat, allergies, poison ivy, etc.). Health services typically include immunizations, sports and driver physicals, health screenings, laboratory testing and blood pressure monitoring. However, some big-box retailers’ clinics are moving into more chronic care management 4 _ a concern for primary care providers who cite the potential for ineffective communication and care coordination issues that arise among multiple care providers. For example, in a March 2014 policy statement, The American Academy of Pediatrics noted that they view “retail-based clinics as an inappropriate source of primary care for pediatric patients, as they fragment medical care and are detrimental to the medical home concept of longitudinal and coordinated care.”5
Most retail clinics are staffed by nurse practitioners or physician assistants. Risk managers whose organizations provide retail clinics should ensure that the mid-level providers’ scope of practice, which is governed by state regulations, fits the range of services provided by the clinic and that careful due diligence is carried out for provider credentialing/re-credentialing and/or employment contracting.6 If the clinics are providing primary care or chronic care management, it is especially important that risk, quality and safety monitoring encompass the effectiveness of care coordination and communication among providers, along with standard monitoring, evaluation and improvement processes.
Liability risks and mitigation strategies
Top liability risks for retail walk-in clinics include:
- Failure or delay in diagnosis, or misdiagnosis
- Communication, care management/coordination of care
- General liability (e.g. retail traffic hazards, falls, equipment related issues)
Strategies to mitigate these risks and reap the benefits of a retail walk-in clinic as a service to the community and a new business opportunity for the healthcare enterprise include the following:
- As noted above, careful provider selection, credentialing and monitoring of clinical practice to avoid errors in diagnosis are key loss prevention strategies; use of clinical decision making systems and algorithmic software may also assist with prevention of diagnostic errors
- Use of electronic health records and information systems is a must, not only for billing and payment, but for communicating with primary care providers, reporting laboratory and other diagnostic tests and referrals, and coordinating patient care and follow up; failure to track and follow up on diagnostic tests are major contributors to liability in any ambulatory setting
- Standard loss prevention strategies for any walk-in clinic should include assessing the physical environment, implementing infection prevention and emergency response plans, and developing general safety procedures to avoid injuries from falls or equipment
References
- Freudenheim M. Hospitals Begin to Move Into Supermarkets. The New York Times. May 2009.
- Convenience Care Association website – http://ccaclinics.org/about-us/history-of-theindustry
- Hupfl A. City & State: Big Box Healthcare. January 2015.
- Appleby J. Walgreens Becomes 1st Retail Chain to Diagnose, Treat Chronic Conditions.Kaiser Health News. April 4, 2013.
- AAP Policy Statement. AAP Principles Concerning Retail-Based Clinics Pediatrics. Vol. 133, No. 3. March 1, 2014.
- Gaffey A. Nurse Practitioners and Physician Assistants: Managing Potential Liability in the Physician Office. Professional Liability Risk Resource. First Edition 2015. Sedgwick website.
Kathleen Shostek, RN, ARM, FASHRM, CPHRM, CPPS, Vice President, Healthcare Risk Management