The Case Against Drugstore Clinics

Stopping at the local CVS is often quicker, cheaper, and easier than going to a hospital or primary-care physician, but it also denies patients the quality care that comes from long-lasting relationships with doctors.

Retail clinics—walk-in health clinics within pharmacies or other stores—are proliferating rapidly. There are now more than 1,700 in cities across the United States, a number that has increased more than 20 percent in the last year alone. Today the company with the largest presence in this market is CVS Health, which operates nearly 900 Minute Clinics in 27 states, with plans to open 150 more in the next year. So far, such clinics have served more than 20 million patients. Typical services include diagnosis and treatment of common infections, vaccinations, treatment for minor injuries, and routine lab tests.

But soon the biggest presence among retail clinics may turn out to be Walmart, the world’s largest retailer. At the moment, Walmart operates only about 100 such facilities in 18 states, but it plans to expand in the future. Currently, CVS charges between $79 and $99 for most services, and standard fees for lab tests run between $20 and $40. Walmart has announced plans to charge $40 per patient visit and $8 for routine laboratory tests.

Cost is clearly a major factor in the rapid growth of retail clinics. Most such clinics operate out of existing retail space, employ nurse practitioners or physician assistants instead of physicians, and offer a more limited range of services than a typical doctor’s office. As a result, a visit to a primary-care physician’s office typically costs twice as much as a visit to a retail clinic. Another factor is price transparency. Retail clinics typically post their prices for routine services, so there are no surprises when patients receive their bill.

And these clinics are convenient. Most such clinics see a high percentage of their patients on a walk-in basis, with no appointment needed. Having such a clinic open up in a neighborhood can set new local standards for access and convenience, since many are open 12 or more hours per day, 6 or 7 days per week. While hospital emergency departments have longer hours, their cost of care is generally much higher.

The trade association representing such clinics calls itself the “Convenient Care Association,” presumably to contrast itself with other, more inconvenient forms of care. One driving force behind the establishment of such clinics, which are typically housed in stores that already have pharmacies, is the billions of dollars in direct revenue they can generate. In addition, they generate substantial indirect revenues through other in-store purchases and filling the prescriptions prescribed by their own practitioners.

The downsides of retail clinics are less obvious than the visible cheap prices and clear convenience. One is the fact that they tend to siphon away many of the simpler, quick-to-treat conditions from physicians’ offices and hospitals—these common problems  help keep costs down and keep hospitals in business. If retail clinics handle a growing percentage of the relatively straightforward cases, doctor’s offices and other facilities that offer more complex care will find their average patient becoming more complex, driving up their costs even further.

Another issue is the expertise of those providing care. It is natural for a patient with a common complaint such as a cough, sore throat, or fever to seek the quickest and most convenient treatment option. But common complaints can be signs of less common and more serious medical conditions. And the problem that leads patients to seek care is not always the most serious problem they have.

A recent patient of one of my students illustrates this. A woman with a sore throat went to a retail clinic and received a prescription for antibiotics. After a few days, she hadn’t gotten better, so she went to her family physician. The physician determined that the sore throat was probably due to a viral infection. He also, however, talked to her about her overall health and life. This conversation led to a previously unsuspected diagnosis of clinical depression. The patient is now in treatment and doing much better.

A case like this illuminates three important differences between the retail clinic and the physician’s office. First, the retail clinic prescribed an antibiotic, but in the physician’s judgment the infection was not bacterial. Overusing antibiotics can promote the development of antibiotic-resistant strains of bacteria. Second, the minute clinic focused exclusively on the sore throat. And third, the physician’s more comprehensive evaluation led to a diagnosis with important implications for the patient’s overall, long-term health.

Naturally, retail clinics tend to focus on acute care. They do exactly what most patients want: handle the sore throat or cough. But when this happens, additional equally important opportunities can be missed. For example, counseling by a physician represents one of the best chances for disease prevention and health promotion. When the acute complaint is the focus, opportunities to encourage smoking cessation and weight reduction, for example, tend to be lost.

According to the Convenient Care Association’s quality standards, its members are committed to building “collegial relationships with the traditional health care system and its providers, sharing patient information as appropriate, and ensuring continuity of care.” But the quick and episodic character of many retail clinic visits tends not to foster the kind of long-term, personal relationships to which many primary-care physician visits contribute.

Every time a patient visits a primary-care physician, both parties have the chance to get to know one another better. And that relationship can make a difference in a variety of ways, from making sure the patient’s overall care is well-coordinated to ensuring that families have someone they can count on during serious illnesses and even for end-of-life care.

Problem-based, episodic care does not foster high-quality relationships, a problem that can be exacerbated by high rates of provider turnover, as anecdotally reported by some retail-clinic patients. The patient who restricts her care to such facilities may be able to get a prescription for antibiotics in less than an hour, but she may also suffer for lack of a personal, enduring relationship with a health professional she can turn to in times of need.

In promoting the role of physicians in such care, the American Medical Association has called on retail clinics to “establish arrangements by which their health care practitioners have direct access to and supervision by those with medical degrees,” and “establish a referral system with physician practices or other facilities for appropriate treatment if the patient's conditions or symptoms are beyond the scope of services provided by the clinic.”

The real litmus test for retail clinics is this: Do we want healthcare to be a quick and convenient consumer service, like a 15-minute oil change? Or do we want the kind of healthcare that treats every acute need as an opportunity to build a foundation for more comprehensive care, grounded in a personal, more enduring relationship? While retail clinics can offer affordable, easily accessible care to people who need it, those who can afford to pay for traditional doctors’ visits will often receive a more holistic approach to their health. Behind the choice of care delivery models lies a more fundamental question: Do we want to be treated as healthcare consumers or patients?