Surprise: Retail Health Clinics May Increase Healthcare Use, Spending

Rather than decreasing healthcare spending, retail health clinics actually modestly increase spending by $14 per person per year, according to an analysis of Aetna insurance claims data for 11 health conditions typically treated at retail health clinics.

Policy makers and insurers typically view use of these retail clinics—of which there are now more than 2000 across the country that see more than 6 million patients per year—as a way to decrease healthcare spending by substituting less expensive clinic visits for more expensive emergency department (ED) or physician office visits.

However, the new analysis published in Health Affairs by J. Scott Ashwood of RAND and colleagues found that retail clinics may actually increase spending by driving new healthcare utilization rather than offering a substitute for more expensive care. Roughly two-thirds of retail clinic visits in the study represented substitution; the other three-fifths represented new utilization. Of the visits that represent substitution, the authors estimate that 93.1% represent substitution of physician office visits and 6.9% represent substitution of ED visits.

The retail clinics studied treated a limited set of health conditions considered “low acuity,” (typically low severity) such as urinary tract infections, sinusitis, immunizations, and other preventive services from 2010 through 2012. Using a matched design to track healthcare utilization and spending associated with 11 low-acuity conditions among 2 sets of Aetna enrollees, users and nonusers of retail clinics, the researchers determined whether retail clinics represented substitution or new utilization by focusing on the change in use of physicians’ offices and EDs.

The authors used claims and enrollment data for 519,542 Aetna enrollees in 22 cities with retail clinics who visited at least once for treatment of a low-acuity condition during the study period and compared them with 861,557 other enrollees who did not visit clinics. Aetna covered retail clinics during the entire study period, and copayments for those visits were comparable to copayments for visits to physicians’ offices. Enrollees over age 65 were excluded from the study as they likely had Medicare.

The increased spending from new utilization outweighed the savings from substitution, the study found. Instead of decreasing spending overall, use of a retail clinic was associated with 21% higher spending for low-acuity conditions (an increase of $14 per person per year relative to $66 spent by nonusers). The authors note that it is not surprising that retail clinics increase utilization for low-acuity conditions, because they focus on convenience and lower per-visit costs, and may actually be viewed as a “disruptive innovation in healthcare,” similar to other disruptive innovations. For example, the introduction of laparoscopic technology greatly increased the number of gallbladder removals performed.

Although use of retail clinics could prevent costly complications by addressing an illness earlier in its course than would otherwise have occurred, the authors point out that most care at retail clinics is paid for by health plans, which may not see an increase in utilization as increasing value because the conditions treated are typically self-limiting and may not improve long-term health. The authors suggest that future research be undertaken to investigate how retail clinics affect coordination of care, care for chronic illnesses, and overall spending.