Vous êtes sur la page 1sur 8

Social Science & Medicine 75 (2012) 1134e1141

Contents lists available at SciVerse ScienceDirect

Social Science & Medicine


journal homepage: www.elsevier.com/locate/socscimed

From cottage industry to a dominant mode of primary care: Stages in the diffusion
of a health care innovation (retail clinics)
John B. McKinlay*, Lisa D. Marceau
New England Research Institutes (NERI), Institute for Health Services and Disparities Research, 9 Galen Street, Watertown, MA 02472, USA

a r t i c l e i n f o a b s t r a c t

Article history: Primary health care is essential to population health and there is increasing need for it, especially with an
Available online 25 May 2012 aging population with multiple comorbidities. Primary health care in the U.S. is widely considered in an
ever-deepening crisis. This paper presents a detailed case study of the recent rise of a “disruptive
Keywords: innovation” e retail clinics e which have the potential to transform the face of primary health care in the
Convenient care clinics US. We describe six stages in the diffusion of retail clinics, from cottage industry to a dominant mode for
Retail clinics
the delivery of primary health care, and consider sociopolitical influences that facilitate and impede their
Primary care
emerging potential. Retail clinics may provide a strategic opportunity to re-engineer the primary health
Nurse practitioners
Health policy
care system, although they may also produce worrisome unanticipated consequences. Discussion
USA concerning the potential threats and opportunities posed by retail clinics occurs in the absence of sound
evidence concerning their comparative effectiveness and quality-of-care. This case study identifies the
sociopolitical influences and processes that determine whether health care innovations rise or fall, and
highlights critically important points along the pathway to health system change.
Ó 2012 Elsevier Ltd. All rights reserved.

Introduction when the alternative for large segments of the population may be
no primary care at all? Are retail clinics likely to produce an
This paper presents a case study of the emergence of retail unanticipated negative consequence e a two-tier primary health
clinics and identifies 6 stages in the diffusion of a “disruptive care system with the relatively advantaged receiving care from
innovation” in the US health care system, identifying critically physicians and specialists while others obtain care from a retail
important issues for health services researchers and policy experts, clinic? Would such a development and the clinical outcomes it
and highlighting a development overlooked in most discussions of produces be different from the current situation? These and many
the challenges facing primary health care in the US (Lee, other related issues are raised by the recent rapid growth of retail
Bodenheimer, Goroll, Starfield, & Treadway, 2008; Scheffler et al., clinics.
2008). Given well-documented, ever-widening health care dispar-
ities, evidence of subpar management of chronic diseases and the Conceptual framework
increasing shortage of primary care physicians (PCPs), can other
health care workers (Nurse Practitioners and/or Physicians Assis- Clayton Christensen’s widely used theory of “disruptive
tants) be enlisted to help fill the gap and receive appropriate innovation” provides a compelling explanation for the sequenced
recognition and reimbursement? Can one historically powerful stages we describe with respect to the evolution of retail clinics and
professional group continue to obstruct the emergence of the accommodative responses of dominant U.S. health care inter-
competing groups able to perform most of the same tasks as ests. The theory was first introduced by Bower and Christensen
effectively and cost efficiently? To date, there is no well-designed (1995) when they defined a disruptive innovation as an improved
study of the comparative effectiveness or quality of care provided product or service designed for a new set of customers, typically at
by retail clinics. Is opposition to retail clinics on the grounds of a lower price, that the market does not expect. “Generally,
quality and safety credible in the absence of any reliable data, and disruptive innovations were technologically straightforward, con-
sisting of off-the-shelf components put together in a product
architecture that was often simpler than prior approaches”
* Corresponding author. Tel.: þ1 617 972 3012; fax: þ1 617 926 4282. (Christensen, 1997, p. 16). Christensen identifies two types of
E-mail address: Jmckinlay@neriscience.com (J.B. McKinlay). technologies: sustaining and disruptive. Sustaining technology relies

0277-9536/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2012.04.039
J.B. McKinlay, L.D. Marceau / Social Science & Medicine 75 (2012) 1134e1141 1135

on incremental improvements to an already established tech- diagnosed and treated at retail clinics. Care is provided by certified
nology. Because they are new, disruptive technologies initially Nurse Practitioners (NPs) and Physician Assistants (PAs), with
appeal to a limited audience and often result in poorer product assistance from proprietary technology, especially electronic
performance, at least in the near term. They are generally “cheaper, medical records (EMRs).
simpler, smaller, and, frequently, more convenient to use” (p. xv). The average start-up cost for a retail clinic is around $75,000
Disruptive technologies occur less frequently, but when they dollars excluding salaries and corporate overhead costs. The
emerge may cause the failure of established entities, which are average annual salary for an NP was $89,579 (median $85,000) in
more committed to sustaining technologies. Because they often do 2009 (Rollet, 2009) while primary care physicians earned twice
not initially satisfy the demands at the more established end of the that amount, with a median annual average compensation of
market, the value of disruptive technologies may be dismissed by $186,044 (Bureau of Labor Statistics, 2011). A retail clinic must
large companies only to be blindsided as the technology matures, process 17e23 patients a day and stay open eighteen months to two
gains a larger audience, expands its scope of work, becomes prof- years to break even (Schroeder, 2008) and the cost for a visit ranges
itable and threaten the status quo. Disruptive technologies often from $15 to $116, depending on the nature of the visit (Kluger,
eventually surpass sustaining technologies in satisfying market 2009; Mehrotra et al., 2009). These costs are lower than primary
demand with lower costs. Larger enterprises which do not invest in care visits or visits to the ER (Marquand, 2008; Mehrotra et al.,
or adapt to the disruptive technology are eventually left behind. 2009). Health insurance companies, Medicare and Medicaid cover
Christensen has refined the original formulation of his theory in most of the cost of visits to a retail clinic, with patients responsible
several subsequent books, The Innovator’s Dilemma (1997) and The for any co-pay. Retail clinics should be distinguished from so-called
Innovator’s Solution (2003) and it provides a useful explanation for urgent care clinics, which are usually stand-alone enterprises
the emergence of retail clinics in the context of the U.S. health care staffed by physicians and other providers and represent a half way
system. While Christensen’s theory is not a common sociological house between a physician’s office and a hospital emergency room.
approach to explain the patterning of organizational innovations, it Some key differences between retail clinics and traditional primary
is one of the most widely employed theories in the related fields of care physician offices are summarized in Table 2.
management and public administration and provides a particularly Retail clinics appear to have filled a national need, their conve-
good fit for the emergence of retail clinics. nience and affordability caught on and they now operate in all but
five states (Howard, 2011; Mehrotra et al., 2009). More than 3.4
What is a retail clinic? million Americans have used the approximately 1200 retail clinics
located in drug stores, grocery chains and even airports across the
Distinguishing features of retail clinics are summarized in country (Tu & Genna, 2008). There were about 1200 retail clinics in
Table 1. Retail clinics are located in large commercial settings and 2008, with annual revenue of $545 million; by 2013 the total is
consist of one or two private exam rooms with a waiting area, estimated to reach 2400, with revenue about $2 billion (Kavilanz,
occupying 200e500 hundred square feet, and equipped with the 2009). After slow growth in 2009 and 2010, they increased by 11.2
basic equipment and facilities characteristic of any medical percent to 1355 in 2011 (Japsen, 2012). Sensing the opportunity
outpatient office. Most operate seven days a week, twelve hours provided by health care reform in the US, CVS Caremark announced
a day, during the workweek and eight hours on Saturday and plans to open 500 additional retail clinics over the next 4 years. It’s
Sunday. Many open on public holidays. Their hours are usually chief executive (Mr. Merlo) stated, “we believe our plans to double
more convenient than a traditional doctor’s office. Retail clinics are our clinic count over the next several years will position us well to
busier on weekends, in the evening and at lunchtime, reflecting play an important role in providing care to the 32 million newly
their convenience and consumer-focus. Willingness to use retail insured beginning in 2014” (Japsen, 2012).
clinics tends to be greater among the uninsured and women, and
are also more likely to be used by younger patients (Leppel, 2010). Table 2
Visits generally take 15e25 min for diagnosis and treatment. Retail Some differences between retail clinics and primary care doctors.

clinics prominently display the services provided and their cost. Characteristics Retail clinics Primary care
Statutory limitations restrict the range of conditions that can be physicians
Site Retail outlets Physician offices
Table 1 (e.g., pharmacies, and hospital
Distinguishing features of retail clinics. big-box discount emergency
stores and grocery departments
 Open 7 days
stores)
- 12 hours during week
- 8 hours on weekend days Current focus Acute, non-serious Chronic, acute
- No appointments necessary of care conditions and preventive
 Treats limited list of conditions, provides vaccinations,
Appointments Walk-in Depends on
conducts physical exams
and scheduling physician availability
 Do not cover lab tests, EKG, treat chronic disease or diagnosis
serious medical conditions Diagnosis or Immediate, less Defined by physician
 Routine visit lasts 15 min treatment pathway than 15 min or health professional
 Costs 30e80% less than other health care (ER, urgent care, availability
community clinics)
Labor input Nurse practitioner Physicians
 Accepts most major health insurance plans
or physician assistant
 Nurse practitioners have Master’s degrees
 Have local referral network of health care providers if Cost per encounter $50e$75 with the $55e$250
diagnosis is made requiring physician care majority of services
 Clinical staff collaborate with local medical directors priced at $59
(phone or pager) for feedback about treatment and prescriptions
 Utilize Electronic Medical Records to improve long term quality Technology input Portable diagnostic Fragmented. Minimal
of care equipment and electronic medical
 Pricing is prominently displayed electronic medical record adoption in
records physician practices
Source: Convenient Care Association, 2008.
1136 J.B. McKinlay, L.D. Marceau / Social Science & Medicine 75 (2012) 1134e1141

Stage I: conditions conducive to the emergence of retail clinics (47 million), or underinsured (25 million), who appear in poorer
health and are the heaviest utilizers of health care (Link & McKinlay,
Retail clinics started in 2000 when Rick Krieger could not get his 2010). Second, there are widening health care disparities which
son into a doctor for a strep throat test. As he recalls, greatly affect those who are most in need of accessible, affordable,
quality health care, especially racial and ethnic minorities, the
“We started talking about why there was not a way to just get
elderly, and rural populations. Third, PCPs have been slow to adapt
a simple question answered or a simple test, like strep throat,
to the changing health care landscape and medical practices
done....Wasn’t there some way to get care in a timely manner for
generally remain organized for the convenience of providers
a relatively simple illness? A quick, convenient way to diagnose
(Costello, 2008). Most physicians’ offices are typically closed at
without waiting in the ER for two hours? We’re not talking about
night, on weekends and public holidays (Alexander, 2008). From
diabetes, cancer, or heart disease! We’re talking about colds and
a managerial perspective physicians continue to embrace an inef-
throat and ear infections.” (Scott & Scott and Company, 2006, p. 8)
ficient business model d “if they had a better business model, may
With a business partners (one of whom was a family physician) be these (retail clinics) wouldn’t have taken off” (Hancock, 2008). A
and in cooperation with a local grocery chain (Cub Foods), he Commonwealth Fund Study found only two in five US doctors had
started the first Retail Clinic charging a flat fee of $35 (cash only) for arranged their practices so that patients could see a nurse or doctor
rapid testing, diagnosis and prescriptions for common illnesses like after regular hours. By contrast, 76e95 percent of doctors in six
strep throat, influenza, ear infection, pink eye and seasonal allergies other industrialized countries provided after-hours care (Costello,
(Scott & Scott and Company, 2006). 2008; Schoen et al., 2006). One national survey found that 7 out
Several factors combined to create an environment conducive to of 10 parents who had used a retail clinic for their children said they
the emergence of retail clinics (See Fig. 1). They appear to have been initially considered taking them to a doctor’s office. But 40 percent
a response to increasing consumer discontent with the organiza- said they could not get an appointment, and 46 percent said they
tion and financing of primary care in the US. First, there was the wanted to take care of their child’s problem more quickly (C.S. Mott
ever-increasing number of people either without health insurance Children’s Hospital, 2008).
Fourth, many employers, especially small businesses with
modest profit margins, pass on the increasing costs of health
insurance by asking workers to pay more of their health insurance
premiums with costlier co-payments and deductibles. Such cost
shifting has been exacerbated by the lengthy recession in the U.S.
which is encouraging people to search for more cost effective
alternatives, like retail clinics. Fifth, studies repeatedly reveal major
chronic diseases, like diabetes, asthma and hypertension, are poorly
managed within the US health care system (Rothman & Wagner,
2003; Wagner, 1998). Conditions conducive to the start-up of
retail clinics to care for relatively minor (but not unimportant)
acute illnesses appear also to favor their eventual expansion into
major chronic diseases, which appropriately trained NP’s are fully
able to effectively diagnose and manage. Broader cultural devel-
opments may also contribute to the perceived anachronism of
much office-based primary care. Consumerism has become
a dominant force in American society, advanced by the so-called
“me generation”, which views health care as just another
commodity to be purchased wherever it is sold. Mehrotra argues,
“what’s really important to consumers is convenience and price.
They don’t care so much about the doctorepatient relationship.”
(Mehrotra, Wang, Lave, Adams, & McGlynn, 2008). Elsewhere, it is
suggested that patients today “value the convenience of the clinics
more than the continuity of care a private physician can offer”
(Japsen, 2008a).
Accumulating evidence over 50 years shows nurses can provide
primary care that is as effective and has similar outcomes as that
provided by physicians (Ettner et al., 2006; Horrocks, Anderson, &
Salisbury, 2002; Mundinger et al., 2000). Some argue that appro-
priately trained NPs may provide effective care for everyday
medical problems, perhaps up to 80 percent (Carter & Chochinov,
2007), but caution they are ill-equipped to manage complex
medical issues requiring the expertise of more extensively trained
physicians. However, for a broad range of complex chronic medical
conditions NPs have been shown to be as effective as physicians.
There are approximately 200,000 NPs involved in patient care in
the US (American College of Nurse Practitioners, 2011). The range of
services they provide approaches 90% of what PCPs provide
(Hooker, 2006). Emergency department (ED) overcrowding is
considered a serious problem in the U.S. and retail clinics may offer
Fig. 1. From cottage industry to the dominant form of primary health care e 6 stages in some relief from their inappropriate and costly utilization. Of an
the emergence of retail clinics. estimated 14 million visits to hospital EDs in the US annually, only
J.B. McKinlay, L.D. Marceau / Social Science & Medicine 75 (2012) 1134e1141 1137

12.9% are considered emergent. Carter and Chochinov (2007) A majority of patients using retail clinics report high levels of
report 60e80% of ED patients presented with non-urgent prob- satisfaction with almost every facet of their care: convenience (92
lems. Weinick, Burns, and Mehrotra (2010) estimated between 13 percent satisfied), quality of care (89 percent), staff qualifications
and 27 percent of all ED visits could take place at either an Urgent (88 percent), and cost (80 percent). Interestingly, of the 93 percent
Care Center or at retail clinics, with potential savings of $4.4 billion who had not used a retail clinic, 41 percent reported they were
annually. likely or somewhat likely to use a retail clinic if they or someone in
A large proportion of the everyday illness presented in their family needed basic medical care for everyday problems
primary care can be considered “routine” and does not require (Sullivan, 2006). The substantial cost savings make retail clinics an
a physician. Hancock (2008) suggests, “devoting 10-plus years of attractive alternative. Ahmed and Fincham (2010) found that
college, medical school and residency to treating earwax, poison appointment wait time and cost savings offered by retail clinics
ivy and athlete’s foot isn’t the most efficient use of resources for were important in care-seeking decisions and conclude,
the doctor or the patient.” Recognizing this, many existing “Appointment wait time is the most important factor in care-
primary care practices already delegate what can be termed seeking decisions and should be considered carefully in setting
“routine illnesses” to appropriately trained nurse practitioners. appointment policies in primary care practices.” (p. 1). According to
One observer notes that “95 percent of the time, patients will Kissinger (2008), “a myriad of patient dissatisfaction issues stem-
receive identical care in a retail clinic as in their doctor’s office” ming from antiquated approaches to primary care access are
(Peterson, 2008). resulting in the establishment of retail health clinics (RHCs)
throughout the country.” (Abstract).
Stage II: growing public acceptance In addition to high levels of patient satisfaction, support for
retail clinics has come from segments of the nursing community,
Following the success of the first retail clinics in the especially nurse practitioners (NPs) and physician assistants (PAs)
Minneapolis-St Paul area they quickly expanded across the US in in settings that permit professional recognition and more autono-
grocery stores, drug stores and shopping malls, eventually resem- mous practice (Meyers, 2008). Retail clinics signify organizational
bling a cottage industry. Entrepreneurial interests, who had not recognition of results from numerous studies showing that, for the
traditionally been providers of health care, saw an economic majority of everyday illnesses, NPs are able to provide care that is as
opportunity to invest in an area of consumer demand (Pollert, effective, and often more efficient and with higher levels of patient
Dobberstein, & Wiisanen, 2008). satisfaction, as that provided by primary care physicians.
Mehrotra et al. (2008) found that 90 percent of visits to retail
clinics are for 10 simple acute conditions, such as sinusitis, bron- Stage III: professional resistance and capitulation
chitis and urinary tract infections, or preventive care (screening or
blood tests or immunizations). These clinical problems constitute While retail clinics are opening up long-awaited opportunities
13 percent of adult PCP visits, 30 percent of pediatric visits, and 12 for professional development and public recognition for nurses
percent of adult PCP visits. Forty-three percent of retail clinic they also resurface dormant inter-professional struggles over turf
patients were between the ages of 18 and 44 years and over 39 (Nelson, 2007). Disparaging terms are used to characterize retail
percent reported having no primary care physician (compared with clinics: “drive through care”, “express lane medicine”, “Jiffy Care”,
80 percent nationally). One-third of retail clinic patients did not to name a few. Several groups have expressed opposition to retail
have health insurance. An estimated 10.6% of the total US pop- clinics. Perhaps understandably, physicians and their professional
ulation and 13.4% of the urban US population lives within a 5-min associations mounted the strongest opposition to retail clinics. One
driving distance of a retail clinic, whereas 28.7% (total) and 35.8% observer considers their reaction “traditional turf protection by
(urban) live within a 10-min driving distance (Rudavsky, Pollack, & a regulated industry worrying about innovative upstarts. Just as
Mehrotra, 2009). During early stages in their development it was lawyers excoriate even basic legal education (a nonprofit group
thought retail clinics would attract lower income individuals distributes basic contract forms for free) as quackery, organized
without health insurance or established relationships with physi- physicians want to retain their licensed monopoly” (Hancock,
cians. The extent to which retail clinics provide access to care for 2008).
underserved populations was investigated by Pollack and Bachman (2006) observes that those opposing retail clinics
Armstrong (2009) who found census tracts with retail clinics had provide no data to support their expressed concerns, and even
a lower black population percentage, lower poverty rates, and ignore evidence arguing for retail clinics as a viable new model for
higher median incomes and were less likely to be medically the delivery of primary health care. Some concerns appear to apply
underserved areas/populations compared with census tracts as much to those raising them as they do to retail clinics. Hancock
without retail clinics. Because retail clinics are currently located in (2008) remarks, “AMA talk of conflicts of interest would sound
more advantaged neighborhoods, they may in fact be less acces- more convincing if the group took a tougher stand on physician-
sible for those with higher medical needs. Rudavsky and Mehrotra owned specialty hospitals or drug company emoluments for
(2010) described the socioeconomic characteristics of the doctors. The conflicts of interest in those situations are far worse.”
communities in which retail clinics operate. Compared with the Reports of physician conflicts of interest culminated in public
rest of the urban population, people living within a retail clinic hearings convened by Senator Charles Grassley to expose the
catchment area had a higher median household income ($52,849 vs magnitude of the problem throughout the health care system
$46,080) are better educated (32.6% vs 24.9% with a college degree) (Harris, 2008; Kassirer, 2005). Such exposures make it difficult for
and are as likely to be uninsured (17.7% vs 17.0%). Retail clinics may physician groups to argue convincingly that the professional
offer a form of health care delivery that is socio-culturally appro- independence of retail clinics is undermined by potential conflicts
priate for Hispanics, because it mirrors the way health care is of interest.
delivered in Latin countries (Dolan, 2008). Physician-written Opposition to retail clinics revolves around five concerns which
prescriptions for medications are generally not required in Latin largely reflect reactions identified in Christensen’s theory of
counties, where people often go to a pharmacy instead of to disruptive innovations. First, that they will drive patients away
primary care physicians and to avoid overburdened emergency from their primary care physicians, disrupt the continuity of the
rooms. doctorepatient relationship, cause serious underlying conditions to
1138 J.B. McKinlay, L.D. Marceau / Social Science & Medicine 75 (2012) 1134e1141

go undetected or untreated and they will produce a need for more States vary by the extent to which they regulate the advanced
early return visits. Second, there are suggestions retail clinics may practice professionals that typically staff retail clinics, such as NPs.
be unsafe. Third, that retail clinics will eventually expand their Nearly half of all states do not require any physician oversight (Scott
scope to include more complex and life-threatening chronic & Scott and Company, 2006), which give some retail clinics the
medical problems. Finally, there is frequently expressed concern of option of being managed entirely by NPs and PAs. Sensing
fragmentation and the quality of care provided in retail clinics. increasing competition physician groups have attempted to restrict
Variations on these concerns have been advanced by three the activity of retail clinics at the state level. For example, New York
physician organizations e the American Medical Association State regulators investigated whether retail clinics are being used
(AMA), the American Academy of Family Practitioners (AAFP) and improperly to simply increase business, or to steer patients to the
the American Academy of Pediatrics (AAP). The AMA and the AAFP pharmacies in which the retail clinics are located. The Illinois
have proposed policies designed to circumscribe the scope and legislature considered a bill that would bar retail clinics from being
practice of NPs in retail clinics. However, such practice restrictions in any location that sold tobacco products or alcohol. However, the
are already legally and professionally defined by Nurse Practice Acts FTC ruled in May, 2008 that provisions in the proposed bill would
in each state, as well as by professional nursing organizations such restrict the clinics’ growth “to the detriment of Illinois health care
as the American Nursing Association, American College of Nurse- consumers.without offering countervailing consumer benefits”
Midwives and the American Academy of Nurse Practitioners (Costello, 2008). Faced with the rapid growth of retail clinics,
(Klein, 2006). The AMA called for investigations into waivers of documented high levels of consumer satisfaction, evidence
state regulations for retail clinics, of the requirement by insurance dispelling most of the major concerns and unfavorable rulings from
companies of copayments and also the possibility of conflicts of the FTC, professional associations began to take an “if you can’t beat
interest as described above. In June 2008 the Federal Trade ‘em, join ‘em” approach to the retail clinic movement (Costello,
Commission (FTC) declined the request of the AMA to increase 2008). Christensen’s theory anticipates this accommodative
regulation of retail clinics by requiring permits, curbing their response to a disruptive innovation. Just 5 years ago the AMA House
advertising campaigns, and requiring “more physician involve- of delegates passed a vote criticizing retail clinics in general, and
ment” (Japsen, 2008b). Complaints against insurance companies as, CVS, Walgreens and Walmart in particular, for owning or hosting
such as Blue cross/Blue Shield of Minnesota, for waiving copay- such clinics. In 2012 the Journal of the American Medical Associa-
ments altogether for retail clinic visits in order to drive demand tion (JAMA) published an article by Dr Christine Cassel, President
were also rejected by the FTC on the grounds that, “Limiting an of the American Board of Internal Medicine, suggesting that
insurer’s ability to utilize differential cost-sharing could be retail clinics may provide a solution to the problems of access to
considered anti-competitive” (Deloitte Center for Health Solutions, healthcare and a shortage of primary care physicians by providing
2008, p.12). patients with timely, convenient and cost-effective access to health
The AAP proposed a set of “principles to guide retail-based care-‘.the retail clinic phenomenon could be transformative for
health clinics”: they included referring retail clinic patients to a vast number of patients in the U.S.’ (Cassel, 2012).
pediatricians or primary care physicians, ensuring prompt Increasing competition with retail clinics is having an impact on
communication with the patient’s physician within 24 h (incor- traditional office-based primary care provided by physicians who
rectly assuming retail clinic patients had such a physician), using are extending evening and weekend availability, implementing
evidence-based medicine, and not waiving or lowering co-pays open-access scheduling, and providing same-day consultations for
which could provide a financial incentive not to visit a physi- relatively simple illness conditions, such as are treated by retail
cian. The AAP strongly endorsed the medical home model, which clinics. They are increasingly offering more convenient options for
ensures a central role for pediatricians and family practitioners communication between patients and practice staff (e.g., telephone
(Weinick, Pollack, Fisher, Gillen, & Mehrotra, 2010). Pollack, call-in hours and online consultations).
Gidengil, and Mehrotra (2010) discuss the fundamental tension
between a patient-centered medical home and retail clinics. The Stage IV: institutional recognition
AAFP Board of Directors proposed a list of desired attributes of
retail health clinics which cover scope of service (it should be By this stage in the diffusion process retail clinics were emerging
well-defined and limited), evidence-based medicine, the need for throughout the US and resembled a vibrant cottage industry. It was
an inclusive team-based approach and electronic medical records. estimated that about 2.3 percent of the total population (Mehrotra
Sullivan (2006) reports that the major retail clinic groups have all et al., 2009; Tu & Genna, 2008), have used a retail clinic with some
indicated strong support for these AAFP attributes. In 2008, three estimates suggesting this comprises10% of all children (Hopson,
retail clinic companies, Minute Clinic, RediClinic and Take Care 2007). Nurses and their professional organizations viewed retail
Health, announced that they all supported AAFP clinical stan- clinics as providing new employment opportunities and a long-
dards. They agreed to use evidence-based approaches to care, awaited chance to practice more autonomously. After first fiercely
offer only a limited range of medical services and ensure that resisting the threat of retail clinics, physicians and their profes-
each clinic site has a formal connection with a physician in the sional organizations eventually realized they were becoming an
community. In 2006 the Convenient Care Association was formed established part of the primary care landscape and that cooperation
and has been instrumental in promoting operational standards and adaption were required if primary care doctoring was to
for retail clinics and approved the quality and safety standards survive.
promulgated for them by other physician-led groups (Convenient Institutional recognition of retail clinics came from three main
Care Association, 2008). While clearly not addressing all concerns, sources. First, employers saw advantages in retail clinics, particu-
this appeared to allay fears of competition and essentially dissi- larly in cost savings and increased worker availability as employees
pated physician resistance to retail clinics. Retail clinics are now do not have to take as much time off work to go to a doctor’s office.
developing referral relationships with nearby physician practices, Black and Decker reported that for the typical retail clinic visit the
urgent care centers and emergency departments so that referrals company saved 40 percent, compared with treating the same
are beginning to flow both ways as overworked physicians send ailment in a doctor’s office. This did not include the additional
patients with quick simple issues to retail clinics (Finarelli & Pillai, discount employees received on their portion, or the time and
2007). aggravation saved (Hancock, 2008).
J.B. McKinlay, L.D. Marceau / Social Science & Medicine 75 (2012) 1134e1141 1139

Second, insurers were increasingly enthusiastic about retail primary care (Hauer et al., 2008). The level of workplace discontent
clinics because they achieved two major objectives at once, among primary care physicians in the US, and in many other
increased member satisfaction and considerable cost savings. countries, has reached alarming levels (McKinlay & Marceau, 2011).
Third, major institutional support for retail clinics has come Barken’s Out of Practice: Fighting for Primary Care Medicine in
from the state: a visit to a retail clinic can now be charged to America (2011) provides a first-hand account of the forces driving
Medicare and Medicaid. While support from employers and primary care physicians from US medical care. The American
insurers considerably strengthened the position of retail clinics in Medical Association estimates there will be a shortage of 85,000
the health care system, official recognition from the state, in the doctors in primary care, cardiology, oncology and general surgery
form of reimbursement, constitutes the most significant source of by 2020 (AcademyHealth, 2009).
institutionalization, and more importantly, legitimation. The impending shortage of primary care physicians in the U.S.
combined with convincing evidence that minor illnesses
Stage V: concentration of ownership consuming much of a physician’s time can be treated effectively
and less expensively by NPs and PAs will likely fuel the continued
Many factors have made retail clinics an attractive target for expansion of retail clinics, even making them a standard compo-
heavy capital investment. Demography (the rapid aging of the nent of first-line primary health care in many US communities. It is
population with multiple co-morbidities) underscores the need for possible that retail clinics will become a major organizational mode
a strong primary care system in the US. A vibrant profitable cottage for the delivery of primary care in the US, not because there is
industry of retail clinics was established in communities throughout evidence as to their comparative effectiveness and cost efficiency,
the country. Patients appear to be more satisfied with retail clinics although such data are sorely needed, but because nearly all
than with traditional care provided by physicians. Initial profes- doctors in training prefer to be specialists. Primary care doctors as
sional resistance to retail clinic dissipated and many physicians an occupational category will continue to decline over the next
began forming partnerships with retail clinics. With employers, several decades (McKinlay & Marceau, 2008). Such observations
insurers and especially the state in support through reimbursement, concerning the future of US health care and the potential role of
retail clinics are an irresistible target for large institutional investors. retail clinics must be considered speculative at this point in time
Hospitals, health systems and even physician groups began to (McKinlay & Marceau, 2011) e time will tell whether they are
acquire retail clinics (Landro, 2006; Robeznieks, 2007). The cost of prescient or perhaps preposterous.
setting up a retail clinic is increasing quite rapidly and is probably
a major reason why much of the future growth in retail clinics is Conclusion and some implications for the future
expected to come from larger investors with deep pockets, and from
hospital systems already well-known in a community (Schroeder, Christensen’s theory suggests that innovations over time
2008). That the Government is prepared to pay for the costs of become more acceptable and begin to extend their reach
care received from retail clinics and that insurance companies are (Christensen, Roth, & Anthony, 2004) and expand their activities to
also covering these costs means that their profitability is essentially include a broader range. This is already occurring. Having demon-
underwritten by third parties. This is a highly desirable situation for strated their effectiveness, cost-efficiency and high levels of patient
private investors e to have Government and the Blues guarantee satisfaction with clearly circumscribed minor illnesses, a next
that health care bills will be paid. Given these attractive features, logical step would be for retail clinics to assume care for major
retail clinics were formed in Wal-Mart, Target and local grocery chronic conditions like hypertension, diabetes and asthma, espe-
stores. Larger organizations quickly acquired the smaller players cially since there are glaring deficiencies in chronic disease
(like SmartCare Health Clinics, Corner Care Clinics and Checkups management in the US (Gogoi, 2006; Wang, 2009a,b). Retail clinics
USA) which earlier gave the appearance of a vibrant cottage are already following established protocols for the minor illnesses
industry. In 2006 CVS/Caremark acquired 83 clinics owned by which currently fall within their purview. Since there are well-
Minute Clinics; Walgreens acquired the Take Care system in 2007; established protocols for the management of most major chronic
and Wal-Mart has recently partnered with RediClinic. Eventually, illnesses it would be relatively easy for retail clinics to gradually
hospital systems, physician groups and managed care companies adopt these as well, achieving outcomes no different from those
entered the market, often partnering with large retail outlets. Only achieved by physicians (McKinlay & Marceau, 2008). Walgreens are
12% of retail clinics are owned by hospital systems of physician pilot testing a 5-city program in which people with Type 2 diabetes
groups, while 73% are now owned by CVS, Walgreens, or Target consult with pharmacists and nurse practitioners concerning the
(Ferris, McAndrew, Shearer, Donnelly, & Miller, 2010). management of their disease. There are plans to take the program
nationally and if it is successful to possibly expand it to cover other
Stage VI: a dominant form of primary care conditions, like asthma, high cholesterol and obesity (Martin,
2010). Similarly, CVS has announced plans to aggressively expand
It would appear we are now entering a sixth and possibly final the workscope of their retail clinics to cover these chronic condi-
stage in the development of retail clinics in the US. The unexpected tions. We agree with the suggestion that theories proposing stages
rise of retail clinics within less than a decade appears to have are overly linear and static, and do not suggest all innovations pass
coincided with the crisis in US primary care and some erosion in the through each and every one of the stages described in this paper.
position of PCPs within the US health care system. Elsewhere we While outlining 6 stages for heuristic purposes only, we view the
have traced structural reasons for the erosion of primary care emergence of retail clinics as a dynamic sociopolitical process,
doctoring in the US (McKinlay & Marceau, 2002) and more recently involving competition, conflict and accommodation between well
outline what we believe to be a realistic future scenario for primary entrenched interest groups which are understandably resistant to
care doctoring in the US (Marceau & McKinlay, 2008; McKinlay & change.
Marceau, 2008), around which there is healthy debate concerning Health services researchers sometimes refer to the three issues
the likely future of primary care doctoring in the US (Timmermans, of cost, access and quality as the “iron triangle” of health care
2008). Nearly all US medical students now choose to specialize (Bachman, 2006). To date and with respect to retail clinics, atten-
rather than pursue careers in primary care: recent estimates indi- tion remains heavily focused on: a) possible cost-savings associated
cate that only 5 percent of US medical graduates plan to practice with retail clinics; and b) the reported high levels of retail clinic
1140 J.B. McKinlay, L.D. Marceau / Social Science & Medicine 75 (2012) 1134e1141

customer satisfaction, of which both appear considerable. Unfor- Ettner, S. L., Kotlerman, J., Afifi, A., Vazirani, S., Hays, R. D., Shapiro, M., et al. (2006).
An alternative approach to reducing the costs of patient care? A controlled trial
tunately, there has been no well-designed comparative effective-
of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Medical
ness study of the quality of care delivered by retail clinics (Costello, Decision Making, 26(1), 9e17.
2008). Ferris, A. H., McAndrew, T. M., Shearer, D., Donnelly, G. F., & Miller, H. A. (2010).
It is possible that retail clinics could help ameliorate serious Embracing the convenient care concept. Postgraduate Medicine, 122(1), 7e9.
Finarelli, M., & Pillai, N. (2007). Walk-in clinics present an opportunity for hospitals
problems confronting primary health care in the US e like physi- to capture new customers. Hospitals and Health Networks, May 15. Retrieved
cian shortages, inaccessibility, escalating costs and underutilized 16.10.08 from. http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?
nursing talent. However, it is also possible that retail clinics could dcrpath¼HHNMAG/Article/data/05MAY2007/070515HHN_Online_
Finarelli&domain¼HHNMAG.
produce an unanticipated and worrisome consequence: a two Gogoi, P. (July 17, 2006). Drugstore clinics are bursting with health. Business Week,
tiered health care system in which the relatively advantaged Retrieved 16.10.08 from. http://www.businessweek.com/investor/content/
receive primary care from a physician (most likely a specialist) jul2006/pi20060717_240148.htm.
Hancock, J. (September 13, 2008). Convenient mall walk-in clinics fill an
while others, possibly the relatively deprived, receive their primary unmet need. Baltimore Sun, Retrieved 16.10.08 from. http://articles.
care from retail clinics. While some health services researchers and baltimoresun.com/2008-09-13/business/0809120152_1_walk-in-clinics-clinics-
policy makers would consider this an unfortunate development, are-staffed-physicians.
Harris, G. (October 3, 2008). Top psychiatrist didn’t report drug makers’ pay. The
others may consider it to be simply a perpetuation of existing New York Times, Retrieved 16.10.08 from. http://www.nytimes.com/2008/10/04/
injustices, in which some groups are already known to receive health/policy/04drug.html.
better care than others. Hauer, K. E., Durning, S. J., Kernan, W. N., Fagan, M. J., Mintz, M., O’Sullivan, P. S.,
et al. (2008). Factors associated with medical students’ career choices regarding
internal medicine. Journal of the American Medical Association, 300(10),
Acknowledgment 1154e1164.
Hooker, R. S. (2006). Physician assistants and nurse practitioners: the United States
experience. The Medical Journal of Australia, 185(1), 4e7.
For their assistance during the preparation of this paper we Hopson, K. (April 18, 2007). More children expected to seek care at retail clinics,
gratefully thank Sharon Frazee, Jay Friedman, Sandra Ryan, Lauren U-M experts find. C.S. Mott Children’s Hospital National Poll on Children’s Health,
Smith, Christina Yantsides, and Julia Coleman. There is no impli- Retrieved 16.10.08 from. http://www2.med.umich.edu/prmc/media/newsroom/
details.cfm?ID¼576.
cation that they share, or are responsible for, any of the views Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether
expressed. nurse practitioners working in primary care can provide equivalent care to
doctors. British Medical Journal, 324(7341), 819e823.
Howard, P. (February 2011). Easy access, quality care: the role for retail health
References clinics in New York. Medical Progress Report No. 12. Manhattan Institute For
Policy Research, Retrieved March, 2011 from. http://www.manhattan-institute.
AcademyHealth. (2009). Will the United States have a shortage of physicians in 10 years? org/html/mpr_12.htm.
Changes in Health Care Financing & Organization (HCFO). Retrieved March, 2011 Japsen, B. (2008a). Retail clinic users lack personal doctors. Chicago Tribune,
from. http://www.academyhealth.org/files/publications/HCFOReportDec09.pdf. September 25, 2008. Retrieved 16.10.08 from. http://articles.chicagotribune.
Ahmed, A., & Fincham, J. E. (2010). Physician office vs retail clinic: patient com/2008-09-25/business/0809241875_1_retail-clinics-doctor-patient-
preferences in care seeking for minor illnesses. Annals of Family Medicine, 8(2), relationship-medical-care.
117e123. Japsen, B. (2008b). FTC: clinic rules not what doctor ordered. Chicago Tribune, June
Alexander, K. J. (2008). Health plans embrace retail clinics. Managed Care, 17(3), 14, 2008. Retrieved March, 2011 from. http://articles.chicagotribune.com/2008-
32e34, 43. 06-14/business/0806130465_1_retail-clinics-clinic-rules-ftc.
American College of Nurse Practitioners. (2011). American college of nurse Japsen, B. (January 9, 2012). More health clinics pop up inside retailers. The New
practitioners. Retrieved January, 2011 from. http://www.acnpweb.org/i4a/pages/ York Times, Retrieved February, 2012 from. http://prescriptions.blogs.nytimes.
index.cfm?pageid¼1. com/2012/01/09/more-health-clinics-pop-up-inside-retailers/.
Bachman, J. (2006). What do retail clinics mean for family medicine? Family Practice Kassirer, P. (2005). On the take: How medicine’s complicity with big business can
Management, 13(5), 19e20. endanger your health. Oxford University Press.
Barken, F. M. (2011). Out of practice: Fighting for primary care medicine in America Kavilanz, P. B. (April 13, 2009). Wal-Mart wants your rash and strep throat.
(the culture and politics of health care work). Ithaca: Cornell University Press. CNNMoney.com, Retrieved March, 2011 from. http://money.cnn.com/2009/04/
Bower, J. L., & Christensen, C. M. (1995). Disruptive technologies: catching the wave. 13/news/economy/healthcare_retailclinics/index.htm.
Harvard Business Review, JanuaryeFebruary 1995. Kissinger, M. (2008). Retail health clinics drive innovation into primary care
Bureau of Labor Statistics, U.S. Department of Labor. (2011). Occupational outlook practices [abstract]. Journal of Medical Practice Management, 23(5),
handbook, 2010e11 edition, physicians and surgeons. Retrieved March, 2011 314e319.
from. http://www.bls.gov/oco/ocos074.htm. Klein, T. A. (2006). In a retail clinic: what nurse practitioners need to ask. Topics in
C.S. Mott Children’s Hospital. (2008). Retail clinics: an emerging source of health Advanced Practice Nursing eJournal, 6(3), Retrieved 16.10.08 from. http://www.
care for children. National Poll on Children’s Health, 4(3), Retrieved 16.10.08 medscape.org/viewarticle/544422.
from. http://health.med.umich.edu/workfiles/npch/20080811_clinic_report.pdf. Kluger, J. (September 1, 2009). Drive-thru medical: retail health clinics’ good marks.
Carter, A. J., & Chochinov, A. H. (2007). A systematic review of the impact of nurse Time, Retrieved March, 2011 from. http://www.time.com/time/health/article/
practitioners on cost, quality of care, satisfaction and wait times in the 0,8599,1919754,00.html#ixzz1HG2phT3r.
emergency department. Canadian Journal of Emergency Medicine, 9(4), Landro, L. (July 26, 2006). The new force in walk-in clinics. The Wall Street Journal,
286e295. Retrieved 03.08.06 from. http://online.wsj.com/article/SB115387157235517194.
Cassel, C. K. (2012). Retail clinics and drugstore medicine. JAMA, 307(20), 2151e2152. html.
Christensen, C. M. (1997). The innovators dilemma: When new technologies cause Lee, T. H., Bodenheimer, T., Goroll, A. H., Starfield, B., & Treadway, K. (2008).
great firms to fail. Boston: Harvard Business School Press. Perspective roundtable: redesigning primary care. New England Journal of
Christensen, C. M., & Raynor, M. E. (2003). The innovator’s solution: Creating and Medicine, 359(20), e24.
sustaining successful growth. Boston: Harvard Business School Press. Leppel, K. (2010). Factors influencing willingness to use convenient care clinics
Christensen, C. M., Roth, E. A., & Anthony, S. D. (2004). Healing the 800-pound among baby boomers and older persons. Health Care Management Review,
gorilla. Seeing what’s next: Using theories of innovation to predict industry change 35(1), 13e22.
(pp. 179e206). Boston: Harvard Business School Press. Link, C. L., & McKinlay, J. B. (2010). Only half the problem is being addressed:
Convenient Care Association. (2008). Fact sheet: Convenient care clinics: Providing underinsurance is as big a problem as uninsurance. International Journal of
high-quality, accessible health care 2008. Retrieved March, 2011 from. http:// Health Services, 40(3), 507e523.
www.ccaclinics.org/images/stories/downloads/factsheets/cca_factsheet_ Marceau, L., & McKinlay, J. B. (2008). The blindness of those who will not see: on the
quality_care.pdf. replacement of primary care doctors in the 21st century. A response to
Costello, D. (2008). A checkup for retail medicine. Health Affairs (Millwood), 27(5), Timmermans. Social Science & Medicine, 67(10), 1497e1501.
1299e1303. Marquand, B. (2008). Using insurance at retail-based clinics. Insure.com, Retrieved
Deloitte Center for Health Solutions. (2008). Retail clinics: Facts, trends and impli- March, 2011 from. http://www.insure.com/articles/healthinsurance/retail-
cations. Retrieved March, 2011 from. http://www.deloitte.com/assets/Dcom- based-clinics.html.
UnitedStates/Local%20Assets/Documents/us_chs_RetailClinics_230708%281% Martin, T. W. (January 13, 2010). Walgreen to test diabetes services. The Wall Street
29.pdf. Journal, Retrieved March, 2011 from. http://online.wsj.com/article/
Dolan, P. L. (2008). Retail clinic targets Hispanic populations, cultural differences. SB10001424052748704586504574654630471968964.html.
Retrieved 16.10.08 from. http://www.ama-assn.org/amednews/2008/09/22/ McKinlay, J., & Marceau, L. (2002). The end of the golden age of doctoring. Inter-
bisc0922.htm. national Journal of Health Services, 32(2), 379e416.
J.B. McKinlay, L.D. Marceau / Social Science & Medicine 75 (2012) 1134e1141 1141

McKinlay, J., & Marceau, L. (2008). When there is no doctor: reasons for the Rudavsky, R., Pollack, C. E., & Mehrotra, A. (2009). The geographic distribution,
disappearance of primary care physicians in the US during the early 21st ownership, prices, and scope of practice at retail clinics. Annals of Internal
century. Social Science & Medicine, 67(10), 1481e1491. Medicine, 151(5), 315e320.
McKinlay, J., & Marceau, L. (2011). New wine in an old bottle: does alienation Scheffler, R., Bodenheimer, T., Lombardo, P., Starfield, B., Morris, W., Treadway, K.,
provide an explanation of the origins of physician discontent? International et al. (2008). The future of primary careethe community responds. New England
Journal of Health Services, 41(2), 301e335. Journal of Medicine, 359(25), 2636e2639.
Mehrotra, A., Liu, H., Adams, J. L., Wang, M. C., Lave, J. R., Thygeson, N. M., et al. Schoen, C., Osborn, R., Huynh, P. T., Doty, M., Peugh, J., & Zapert, K. (2006). On the
(2009). Comparing costs and quality of care at retail clinics with that of other front lines of care: primary care doctors’ office systems, experiences, and views
medical settings for 3 common illnesses. Annals of Internal Medicine, 151(5), in seven countries. Health Affairs (Millwood), 25(6), w555e571.
321e328. Schroeder, M. (May 21, 2008). Hiccup for convenient care: 3 local failures
Mehrotra, A., Wang, M. C., Lave, J. R., Adams, J. L., & McGlynn, E. A. (2008). Retail show challenges for retail clinics. The Journal Gazette, Retrieved March, 2011
clinics, primary care physicians, and emergency departments: a comparison of from. http://www.journalgazette.net/apps/pbcs.dll/article?AID¼/20080521/
patients’ visits. Health Affairs (Millwood), 27(5), 1272e1282. BIZ/805210358/-1/BIZ09.
Meyers, E. (2008). A nurse’s perspective on retail health clinics. Frontiers of Health Scott, M. K., & Scott and Company. (2006). Health care in the express lane:
Services Management, 24(3), 29e32. The emergence of retail clinics. Oakland, CA: California HealthCare Foundation.
Mundinger, M. O., Kane, R. L., Lenz, E. R., Totten, A. M., Tsai, W. Y., Cleary, P. D., et al. Retrieved 16.10.08 from. http://www.mcms.org/downloads/
(2000). Primary care outcomes in patients treated by nurse practitioners or HealthCareInTheExpressLaneRetailClinics.pdf.
physicians: a randomized trial. Journal of the American Medical Association, Sullivan, D. (May 16, 2006). Retail health clinics are rolling your way. Family Practice
283(1), 59e68. Management, Retrieved 16.10.08 from. http://www.aafp.org/fpm/2006/0500/
Nelson, R. (2007). Retail health clinics on the rise. NPs are finding new job p65.html.
opportunities, but with some old turf issues. American Journal of Nursing, 107(7), Timmermans, S. (2008). Oh look, there is a doctor after all: about the resilience of
25e26. professional medicine: a commentary on McKinlay and Marceau’s ‘when there
Peterson, E. (May 28, 2008). Would you like a prescription with that? Medill News Service, is no doctor’. Social Science & Medicine, 67, 1492e1496.
Retrieved from. http://news.medill.northwestern.edu/chicago/news.aspx?id¼90585. Tu, H., & Genna, R. (December 2008). Checking up on retail-based health clinics: is
Pollack, C. E., & Armstrong, K. (2009). The geographic accessibility of retail clinics the boom ending? The Commonwealth Fund, Issue Brief. Retrieved March, 2011
for underserved populations. Archives of Internal Medicine, 169(10), 945e949, from. http://www.commonwealthfund.org/usr_doc/Tu_checkinguponretail-
discussion 950e943. basedhltclinics_1199_ib.pdf?section¼4039.
Pollack, C. E., Gidengil, C., & Mehrotra, A. (2010). The growth of retail clinics and the Wagner, E. H. (1998). Chronic disease management: what will it take to improve
medical home: two trends in concert or in conflict? Health Affairs (Millwood), care for chronic illness? Effective Clinical Practice, 1(1), 2e4.
29(5), 998e1003. Wang, S. (2009a). Can treatment for chronic diseases boost use of retail clinics?
Pollert, P., Dobberstein, D., & Wiisanen, R. (2008). Jumping into the healthcare retail The Wall Street Journal, September 10, 2009. Retrieved March, 2011 from. http://
market: our experience. Frontiers of Health Services Management, 24(3), 13e21. blogs.wsj.com/health/2009/09/10/can-treatment-for-chronic-diseases-boost-
Robeznieks, A. (2007). Look who’s buying retail. Hospitals, health systems, and even use-of-retail-clinics/.
physician groups are getting involved in the latest wave of ‘convenient-care’ Wang, S. (2009b). Retail clinics set to roll out new services. The Wall Street Journal,
clinics. Modern Healthcare, 37(46), 26e28. June 5, 2009. Retrieved March, 2011 from. http://blogs.wsj.com/health/2009/
Rollet, J. (2009). 2009 national salary & workplace survey: good news in troubled 06/05/retails-clinics-set-to-roll-out-new-services/.
economy. Advance for Nurse Practitioners, 18(1), 24e26, 29e30. Weinick, R. M., Burns, R. M., & Mehrotra, A. (2010). Many emergency department
Rothman, A. A., & Wagner, E. H. (2003). Chronic illness management: what is the visits could be managed at urgent care centers and retail clinics. Health Affairs
role of primary care? Annals of Internal Medicine, 138(3), 256e261. (Millwood), 29(9), 1630e1636.
Rudavsky, R., & Mehrotra, A. (2010). Sociodemographic characteristics of Weinick, R. M., Pollack, C. E., Fisher, M. P., Gillen, E. M., & Mehrotra, A. (2010). Policy
communities served by retail clinics. Journal of the American Board of Family implications of the use of retail clinics. Retrieved February, 2012 from. http://
Medicine, 23(1), 42e48. www.rand.org/pubs/technical_reports/2010/RAND_TR810.pdf.