Alternative Healthcare Delivery and the Rise of Convenient Care Clinics

Alternative Healthcare Delivery and the Rise of Convenient Care Clinics

Challenges Facing U.S. Healthcare Fragmentation High costs Healthcare disparities Primary care shortage Aging and sicker population

The Harsh Reality 50 million Americans are uninsured, including 1 in every 8 children.¹ For those who are insured: ~70% have private insurance¹ ~30% have public insurance (Medicare/Medicaid)¹ 29% of Medicare recipients (11.6 million people) have a hard time finding a PCP who accepts their insurance.² About half of all emergency room visits were non-emergent in nature or otherwise treatable in primary care settings.³ ¹ US Census Bureau, 2010 ² Commonwealth Fund, 2007 ³ Desypher Analytical Services, Analysis of Emergency Room Use with NYU ED Algorithm, 2010

Healthcare Access is in Crisis Limited access to routine and preventive care. Millions of consumers do not have an established physician relationship or health insurance. Health care costs are rising at unsustainable rates. Consumers are increasingly pressed for time and are demanding convenience. These issues will worsen as the primary care physician shortage grows.

Innovating Out of Crisis Non-physician led healthcare and alternative delivery settings are expanding primary care capacity. Nurse-Managed Health Centers School-Based Health Clinics Urgent Care Centers Retail-based Convenient Care Clinics

Nurse-Managed Health Centers NMHCs are, nurse-practice arrangements, managed by advanced practice nurses, that provide primary care or wellness services to underserved or vulnerable populations and are associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency. 1 The majority of care is provided by nurses a team of Nurse Practitioners and Nurse Midwives (Advanced Practice Nurses/APN) and other health professionals. Direct access to APN care. Dominant theme: nurses control their own practice and provide the patient/client care. ¹Affordable Care Act Section 5208

Types of Nurse-Managed Health Centers NMHC practice models are diverse and date back to early part of the 20 th Century in U.S. Community health visionary Lillian Wald Nurse Midwife Mary Breckenridge Today s NMHC models include: Birthing Centers Mobile Vans School-based Centers Wellness centers Academically affiliated NMHCs

Services Provided in NMHCs Primary Care Mental/Behavioral Health Family Planning Prenatal Services Disease Prevention Health Promotion

School-Based Health Centers School-based health centers (SBHC) are health centers located on school premises. (A small number are also mobile.) There are nearly 2,000 in the U.S. Primarily operated by NPs and physician assistants who care for students of the school. Some also serve the community. Services include: primary care, behavioral health, dental, health education, substance abuse counseling among others. All services are provided regardless of ability to pay. The number of ER visits for children with SBHCs in Cincinnati decreased 33.5% an estimated savings of nearly $1,000 per child. 1 1 Guo, JJ, Jan R, Keller, KN, McCracken, et al., Impact of SBHCs on Children with Asthma. Journal of Adolescent Health. 37(4) (October 2005): 266-274.

Urgent Care Centers 9,300 stand-alone, walk-in urgent-care centers; 700-800 clinics open every year Strategic Objective Hospitals and Health Systems Expands ambulatory brand catchments, captures new patients for downstream referrals, and leverages provider relationships Strategic Objective Payers Creates point-of-network access, while reducing ER utilization. Some offer co-pay differentials in benefit plan designs and education for members on when it s appropriate to use urgent care. Strategic Objective Private Equity Opportunity to create improved patient access in light of a primary care physician shortage and rising health care demand. Investment focus: underserved urgent-care markets. Sources: Urgent Care Association of America American Academy of Urgent Care Medicine

Convenient Care Convenient Care has been termed a disruptive innovation for the impact it has had on thinking about healthcare.

What are Retail-based Convenient Care Clinics? Healthcare facilities located in high-traffic retail outlets like retail pharmacies, grocery stores and big box retailers. Staffed primarily by NPs and PAs. Clinicians evaluate, diagnose, treat and write prescriptions as necessary for minor and acute illnesses and chronic disease conditions. Clinics also provide wellness services (immunizations, physicals and programs like weight management and smoking cessation).

Retail Clinic Services Services include¹¹: Evaluation, treatment, & education of patients from 18 months through 65+ Acute care Immunization Wellness/preventive services School, camp and sports physicals DOT physicals EpiPen Instruction and Prescription Medication reconciliation Minor office procedures Chronic disease care Prescribe medications as necessary ¹¹ Convenient Care Association

Clinical Service Expansion Clinic services are expanding to include chronic disease care for conditions such as : Diabetes Hypertension Hyperlipidemia Asthma/COPD Chronic disease care is done in collaboration with PCPs in local physician groups or health systems for nonhospital operators and PCPs within the health system for hospital clinic operators. Promotes quality Promotes continuity and coordination of care

Clinical Service Expansion Additional education and wellness services Smoking Cessation Weight Management Diabetes Education Hypertension Evaluation Lifestyle Modification & Coaching

The Value and Solution Accessibility Affordability Quality

Introduction to the CCA Founded in 2006, we are the national trade organization representing the convenient care industry. Our membership includes over 97% of all clinics in operation. CCA membership is diverse, representing many companies, health systems, and others around the country.

Where We Started At our founding ~150 clinics open. Concept was very novel. Clinics were mostly cash-only, offered a very limited scope of services, and were nearly all operated or owned by corporations. Many questioned the viability and legitimacy of the model. Early opposition tried to beat industry back.

Our Role CCA works to enhance and sustain the growth of convenient care through: Sharing best practices, common standards of operation, resources, experiences and ideas; Giving a united voice to advance the needs of convenient care clinics, providers and patients; Reaching out to the existing medical community to create partnerships; and Building relationships with policymakers, researchers, employers, other trade organizations, related professions, and other stakeholders to positively position and advance the cause of convenient care for the benefit of patients.

Major Achievements Creation of Quality and Safety Standards and Recommended Practices; Implementation of independent certification program for CCA members; Successful advocacy against legislation and regulation that would harm convenient care clinics, providers and patients, including, in 2010, Colorado, Kentucky and New Hampshire; Gaining visibility in the media and among third-party researchers as a valuable source; Founding National Convenient Care Clinic Week; Launching the CCA Clinician Portal to support and engage clinic providers; Establishing partnerships with major national publications; Strategically engaging with federal government agencies and major national organizations; and Successfully integrating convenient care into the national dialogue about healthcare and healthcare reform.

Where We Are Today More than 1,800 retail clinics in 43 states and D.C. Greater acceptance publicly and support for an emphasis on patientcentered care. Operators include: hospitals/health systems and corporations Growth rate highest among hospitals and health systems. The majority of individual clinics still operated by 5 non-hospital companies versus 75 hospitals/health systems Affiliations between non-hospital operators and major health systems Increases access to care and enhances clinical quality Provides service expansion opportunities for chronic disease care

How Things Are Evolving More people insured = more need for access points. Greater prioritization of wellness and preventive care. Technology will increase access to and management of healthcare through innovation.

What The Research Shows Clinics improve access. Clinics lower cost. Clinics are high-quality.

Retail Clinics Improve Access Fill Primary Care void: Nearly 40% of clinic patients report not having a PCP.¹ Create Point of Entry: Some hospital systems report their retail clinics are the an entry point into their healthcare system. Clinical affiliations between nonhospital operators and health systems include a referral process. Reduce ED Traffic: 12 to 14% of all ED visits can be seen at convenient care clinics.² Convenience: Nearly 30% of the U.S. population lives within 10 minutes of a clinic.³ ¹ Mehrotra, Ateev, and Judith R. Lave. Visits to Retail Clinics Grew Fourfold From 2007 To 2009, Although Their Share of Overall Outpatient Visits Remain Low. Health Affairs, 31, No. 9, (2012). ² Weinick, Robin M., Rachel M. Burns, Ateev Mehrotra. (2010) Many Emergency Department Visits Could be Handled at Urgent Care Centers and Retail Clinics. Health Affairs, 29, No. 9 (2010): 1630-1636. ³ Rudavsky, R, Craig Evan Pollock, Ateev Mehrotra. The Geographic Distribution, Ownership, Prices, and Scope of Practice at Retail Clinics. Annals of Internal Medicine, 151, No. 5 (2009):321-328.

Retail Clinics Improve Access Create Point of Entry: Some hospital systems report their retail clinics are an entry point into their healthcare system. Clinical affiliations between non-hospital operators and health systems include a referral process and enhance clinical quality. Most non-hospital clinic operators have clinical affiliations and/or partnerships with health systems and/or physician groups.

Clinical Affiliations/Partnerships CVS Caremark/MinuteClinic - UCLA Health System, Sharp HealthCare, Dignity Health, Cleveland Clinic FL, Emory Healthcare Walgreens/Healthcare Clinic at select Walgreens - Johns Hopkins Medicine, The Valley Health System, Memorial Health, LSU Healthcare Network The Little Clinic The Ohio State University Wexner Medical Center, University of Louisville Physicians RediClinic - Memorial Hermann Healthcare System, Methodist Healthcare System, St. David's HealthCare Target Clinics Duke University Medical Center

Retail Clinics Lower Costs Retail clinics offer a quick, affordable alternative for patients with pressing, non-emergency medical needs. CCCs prominently display their healthcare services and pricing, so patients know costs up-front. CCCs may reduce health care costs by providing preventive care (e.g., flu shots) and facilitating earlier access to care. CCCs demonstrate significant cost savings for both consumers and third-party payers. Retail clinics reduced ER use and costs for pediatric population, and reduced admissions and outpatient costs for patients with chronic illnesses.⁵ ⁵ Parente, Stephen T., Retail Clinics as Key Performers for Successful Bipartisan Health Reform (Presentation), May 2012.

Retail Clinics Lower Costs Costs of care at a convenient care clinic are significantly lower than those at an urgent care center, primary care office, or emergency department.⁵ Average costs for treatment: Convenient Care Clinic - $60 Emergency department - $356.00 Urgent Care - $124.00 Physician Office - $127.00 Blue Cross and Blue Shield of Minnesota eliminated co-pays for enrollees who used a clinic, citing $1.2 million in cost savings. ⁶ Thygeson, Marcus, Krista A. Van Vorst, Michael V. Maciosek, and Leif Solberg. Use and Costs of Care In Retail Clinics Versus Traditional Care Sites. Health Affairs, 27 No. 5 (2008): 1283-1292. ⁷ BlueCross BlueShield Association, July 29, 2008

High-Quality Standards Convenient care clinic providers adhere to evidence-based practice guidelines.⁸ Quality scores and rates of retail clinics for acute and preventive care are better than other delivery settings such as urgent care centers and EDs.⁹ ¹º 92.72% compliance with quality measure for appropriate testing of children with pharyngitis vs HEDIS average of 74.7%; 88.35% compliance score for appropriate testing of children with URI vs HEDIS average of 83.5%.⁸ Return visit rate comparable to standard medical offices; care quality does not generate excessive follow-up utilization.¹¹ ⁸ Jacoby, Richard, Albert G. Crawford, et al. Quality of Care for 2 Common Pediatric Conditions Treated by Convenient Care Providers. American Journal of Medical Quality. 2010. ⁹ Mehrotra, Ateev, Llu Hangsheng, John L. Adams, et al. Comparing Costs and Quality of Care at Retail Clinics with that of Other Medical Settings for 3 Common Illnesses. Annals of Internal Medicine.151 no. 5 (2009):321-328. ¹⁰ Shrank, William H., Krumme, Alexis A., et al. Quality of Care at Retail Clinics for 3 Common Conditions. American Journal of Managed Care. 20, No. 10 (2014):794-801. ¹¹Rohner, James E,, Kurt B. Angstman, et al. Early Return Visits by Primary Care Patients: A Retail Nurse Practitioner Visit Versus Standard Medical Office Care. Population Health Management, 15, No. 4 (2012):216-219.

High-Quality Standards CCA member retail clinics use electronic health records (EHRs), and at the patient s request, these can be shared with a patient s primary care provider in order to facilitate continuity of care. The use of EHRs in the clinics monitor evidence-based practice performance. CCA s Quality and Safety Standards were developed with input from leading nursing, medical and quality organizations and are more stringent than those recommended by the American Medical Association, American Academy of Family Practitioners and American Academy of Pediatrics.

High-Quality Standards CCA members follow OSHA, CLIA, HIPAA, ADA and CDC requirements and guidelines. CCA members are committed to monitoring quality and safety on an ongoing basis including: Peer review and collaborating physician review; Aggregating, collecting and reporting data on quality and safety outcomes; and Monitoring patient satisfaction, which generally exceeds 90 percent. 100% rate of clinic certification or accreditation.

Retail Clinic Growth & Opportunity Visits grew four-fold between the years 2007 and 2009.¹² Accenture Research projects health clinics to grow 25% to 30% annually, doubling the number of clinics from 1,400 to more than 2,800. MinuteClinic to open 100-150 new clinics each year, for next five years. Retail clinics significantly help to address capacity constraints at hospitals and PCP offices.¹³ ¹² Mehrotra, Ateev, and Judith R. Lave. Visits to Retail Clinics Grew Fourfold From 2007 To 2009, Although Their Share of Overall Outpatient Visits Remain Low. Health Affairs, 31, No. 9, (2012). ¹³ Accenture Report, June 2013.

Retail Clinics Role in Increasing Healthcare Workforce For NPs, PAs, NP/PA students and NP/PA faculty, retail clinics offer: Clinical training sites (with access to most illness/conditions seen in primary care offices). Autonomous advanced practice provider operated clinical experience. Exposure to a patient-centric model with advance practice leadership. Opportunity to provide care in an evidenced-based practice environment. Opportunity to collaborate with interprofessional care teams. Exposure to a career path that includes leadership opportunities. Opportunities for research, project, and DNP Capstone.

Retail Clinic Policy Then & Now Concerns raised by retail clinic opposition: Quality of care. Continuity of care. Conflict of interest. Lack of regulation and standardization.

Counterarguments to concerns: Retail Clinic Policy Then & Now Quality of care NPs and PAs are excellent providers; evidence-based medicine; internal P&Ps; collaboration Continuity of care EHRs; record sharing; registries where available Conflict of interest firewalls; 3 rd -party research; patient anecdotes re: antibiotic Rx Lack of regulation and standardization regulated like other healthcare entities; certification and accreditation; provider licensure Also importance of maintaining an open and competitive marketplace; FTC advisory opinions

States are the real battleground

Areas that have been targeted Related to the provider s practice. Related to the clinic facility. Related to the business model. Related to the retail host.

How we have been successful Arguing for increasing access. Supplementing ERs and overbooked physician practices. Demonstrating our quality. Demonstrating our affordability and cost-effectiveness. Good for market competition. Identify your allies. Be willing to negotiate and play by the local political rules. Clinic site visits often have a strong impact. Work together when we can to avoid legislation (e.g., CO AAP chapter).

Industry s Recent Policy Work Scope of practice battles continue in all the states. Texas NP & PA scope of practice improvements. Nevada NP full authority. States are updating Medicaid law, but not updating the Medicaid delivery infrastructure. Improve Medicaid Facility credentialing Improve Medicaid Provider credentialing

Industry s Recent Policy Work Telehealth laws are appearing in every state, often ripe with the possibility for unintended consequences. Ensuring providers are not defined out. Working towards direct reimbursement New Industry Principles on Telehealth: Telehealth care should be provided through means that uphold the highest standards of patient care and protect patients private health information. A telehealth definition should be written broadly to allow telehealth services to be provided across multiple settings through multiple providers. State law should strongly encourage payment for telehealth services to improve healthcare access.

Summary Alternative healthcare settings like retail clinics are key Physician shortage is predicted to continue Greater access to high-quality, affordable healthcare is needed Increase in retail clinic collaborative partnerships Health systems, physician groups, nurse-managed health centers, school-based clinics Care coordination Expanded services in retail clinics Chronic disease care Telehealth services Preventive health and wellness

Thank you! Questions? Tine Hansen-Turton, MGA, JD, FCPP, FAAN Executive Director Convenient Care Association Centre Square East 1500 Market Street, 16 th Floor Philadelphia, PA 19102 www.ccaclinics.org tine@ccaclinics.org