The Clinic Connection

Walmart wants to play an important role in American health care. The giant retailer has leased space to third-party health care providers for clinics inside its stores since 2005, but last year embarked upon a pilot program to create its own in-store Walmart Care Clinics.

"Walmart wants to be a health-care destination," says Jennifer LaPerre, senior director for health and wellness for Walmart. "We have really strong pharmacies, vision centers and now clinics. We have a lot of opportunities to be an affordable health-care destination for our customers and associates."

The Little Clinic is a chain of 154 clinics in Kroger stores and affiliated banners.

Walmart's Care Clinics are the most ambitious retail clinics now emerging, since they are designed to become the primary-care provider for clients who do not currently have one. However, several other models, featuring various relationships with local health care systems, are evolving, including: clinics owned by retailers in partnership with local health-care providers; clinics owned by health-care organizations, and clinics run by third-party providers that lease space in the stores.


Walmart's design to offer primary-care services to patients in place of an established relationship with a family physician contrasts with practice at most other retail clinics, which encourage patients to establish such relationships with outside physicians.

"Across the country, regardless of what state, any patient who comes to a MinuteClinic who does not have a primary-care physician gets a list of local physicians accepting new patients," explains Dr. Nancy Gagliano, chief medical officer of MinuteClinic, which is owned by CVS Health and operates 970 clinics inside CVS locations in 31 states and the District of Columbia. "So we encourage every patient to be connected with a medical home."

"Patients are educated about the importance of having a relationship with a PCP and encouraged to establish one."


Convenient Care Association

Tine Hansen-Turton, executive director of the Convenient Care Association (CCA), a trade group for retail-based clinic operators headquartered in Philadelphia, says CVS's practice is typical. "Patients are educated about the importance of having a relationship with a PCP and encouraged to establish one," Hansen-Turton says.

It's not that Walmart Care Clinics don't do that if asked. LaPerre says the nurse practitioners that staff the clinics help patients establish such relationships with outside physicians if requested. But patients may opt to consider Walmart their primary care provider, something that typically does not happen at other clinics.

"We made a decision that Walmart could make a difference in health care," LaPerre says. "Our model is a basic primary-care model."

The primary-care focus is not the only difference between Walmart Care Clinic and other retail clinics. LaPerre calls Care Clinic a "disruptive" model and notes three distinctions: the clinics serve customers and Walmart employees and their families; the clinics are highly affordable ($40 per visit for customers; $4 per visit for employees and their dependents); and the clinics help patients control chronic conditions, rather than just treating minor health complaints.

"We felt it was important to try to tackle where the greatest costs exist from the primary-care perspective, which is chronic condition management," she says. "We take care of cough, colds, and flu, but we feel very strongly in controlling the chronic conditions that create 75 percent of health-care costs, such as high blood pressure and diabetes."

Walmart Care Clinics are staffed by a nurse practitioner that practices under the supervision of a local physician. Neither is a Walmart employee; the physician works under a contract, and the nurse practitioner is employed by QuadMed, a business based in Sussex, Wis., that operates employer on-site clinics.

Seventeen Walmart Care Clinics currently exist, all in Texas, Georgia and South Carolina. LaPerre says those locations are considered pilots, and it's too early to predict whether Walmart will expand the model.


States promulgate many health-care regulations, so CVS MinuteClinics operate a number of different models, depending on the regulations in the 31 states it operates in.

"In its simplest form, every single clinician in a MinuteClinic has a collaborating physician in the community who provides education and monthly meetings, and is available for backup," Gagliano says. "That is standard across the country."

One typical model that MinuteClinic employs is an affiliation with a local health-care system; it has these relationships with 51 health systems across the states it covers. In this model, CVS still owns and staffs the MinuteClinic, while the affiliated health-care system provides some resource such as the list of physicians who are taking new patients, services of the physicians who can collaborate with the MinuteClinic clinicians, and opportunities for joint clinical programs.

Because of regulations, in 13 states in which MinuteClinics operate, the clinics are owned by a local physician or physician group. "In that relationship, the physician oversees the clinical quality, and MinuteClinic's role is more administrative," Gagliano explains.

One area in which MinuteClinic excels is its integration of electronic health records across the country and with local providers. This allows patients to seamlessly move from their family doctor, to a MinuteClinic, to a specialist, for example.

"Let's say an affiliated physician sends a person to a MinuteClinic on a Saturday because of a sore throat. On Monday morning the physician has that note on the medical record," Gagliano says. "We feel the integrated electronic health record is important in terms of clinical collaboration."


The Little Clinic, a wholly owned subsidiary of Kroger, operates 154 clinics in Kroger, Fry's, King Soopers, and JayC stores in nine states. All practitioners at The Little Clinic are employees.

Like MinuteClinic, The Little Clinic encourages patients to develop relationships with primary-care providers in the community, rather than count on the clinic for primary care.

"With our health system affiliations, we have set up processes for ease of access to a [primary-care physician]."


The Little Clinic

"The Little Clinic believes that patients should establish a medical home for their preventive, ongoing and changing health care needs," says Eileen Myers, vice president of affiliations and patient centered strategies for The Little Clinic. "With our health system affiliations, we have set up processes for ease of access to a PCP. For example, [the clinician can say] 'We can provide you a list of nearby doctors, or we can contact our health system affiliation and help you make the appointment right now.' When a patient needs to be seen more urgently than establishing a PCP relationship, we provide the care coordination to set up the appointment."


FastCare is another model of retail clinic. Rather than being owned by a retailer, the business is a division of Bellin Health Care Systems in Green Bay, Wis. FastCare operates retail clinics inside ShopCo Pharmacies in Green Bay and cobrands with other retailers and health systems to run 35 FastCare clinics in other areas.

In all cases, the clinics are actually owned by the local health care system. FastCare holds the master lease with the retailers, and subleases the space to the health-care organizations when a deal is struck. FastCare builds out the clinic, counsels the clinic operator on marketing, and provides creative services for billboards and advertising on radio and TV and in print publications.

"The health system looks at the clinics as a low-cost access point into their system, thus building their primary care base."



"The health system looks at the clinics as a low-cost access point into their system, thus building their primary care base," says Steve Lazzari, director of development for FastCare. Lazzari says that of the 40 to 50 percent of patients who use a retail clinic who do not already have their own PCP, between 10 and 15 percent become regular patients of physicians affiliated with the parent health care organization.

"Retail clinics are targeting a new class of customers who have not been properly treated by current doctors' offices and hospitals."


Clayton Christensen Institute


Retail clinics are businesses, whether they make money directly from the services they offer, feed clients to a health-care system, or attract customers who visit the grocery aisle after visiting the clinic. Nevertheless, leaders of the clinics also see their businesses as contributing to the U.S. health-care system in general.

"Retail clinics are targeting a new class of customers who have not been properly treated by current doctors' offices and hospitals," says Spencer Nam, senior research fellow for health care at the Clayton Christensen Institute for Disruptive Innovation, a San Francisco-based think tank that looks at health care and other issues. "Those who are 'toughing out' their minor illnesses, seeking basic blood testing, avoiding vaccination for flu, or experiencing a sudden attack of fever can now seek immediate care from retail clinics that are conveniently located and have little to no wait time."

Not only are the clinics serving clients who previously "toughed out" minor illnesses, they also are seeing clients who previously visited the emergency department for those problems.

"The Little Clinic provides that access point for care when a patient cannot see their physician or if it is after normal business hours. By treating these non-emergency issues, the Clinic allows the ERs to focus on true emergencies," Myers explains.

But do the hospitals worry about losing the income from those ER patients? Not really, Nam says.

"Patients who considered going to the ER but instead headed to retail clinics is a revenue loss for the ER, but not necessarily a profit loss, especially if the ER is overcrowded," Nam explains. "Overcrowding is a major problem with hospitals, particularly ERs, because they're not well equipped to run faster than they are designed to be. When overcrowding occurs, ERs will try to run faster, and that's when bad things happen such as misdiagnosis, medical errors and failed responses."

A major push of health-care reform is to evolve America's health care system from treatment-based to prevention-based. The accountable care organization (ACO) model that is being implemented in some areas pays health-care organizations more when utilization goes down. Retail clinic operators hope they are part of that equation.

"There are things MinuteClinic can provide to an ACO that add value," Gagliano says. "One thing CVS does well is focus on adherence, making sure patients pick up the prescriptions and take the medicine. In an ACO model you really care about the overall health of the population and make sure they are treated well and chronic disease is kept under control. So providing access to care through MinuteClinic is very valuable in the ACO model."

In the end, retail clinics aspire to be part of the overall health-care reform solution.

"As members of the Convenient Care Association, we believe that retail clinics are an integral part of the health-care delivery system," Little Clinic's Myers says. "Through the partnerships and utilization of technology, retail clinics continue to meet the needs of patients and help to fill in the gaps from the primary-care provider shortage."

Ed Avis is a freelance writer and editor in Chicago who has written for many the consumer and trade publications.