Americans expect convenience and affordability even when it comes to health care.

According to an August 2008 Kaiser Health Tracking Poll from the Kaiser Family Foundation, one in four Americans struggles to pay for health care and rank it as a "serious problem," even above paying for food, debt, rent and gas.

Retail-based clinics (RBCs) that provide quick and easy medical services have set the pace for accessible health care. The Convenient Care Association, a trade group for convenient-care clinics, estimates that there are about 1,000 clinics operating nationwide as of September 2008.

Most retail-based clinics are small operations that consist of a private exam room and waiting area. Staffed by nurse practitioners or physician assistants, they offer services ranging from physicals, flu shots, vaccines, earwax removal and cholesterol screenings to treatment of bronchitis, ear infections, bladder infections, strep throat, poison ivy and more.

RBCs do not treat chronic conditions; instead, they leave those conditions to the proper domain of the primary care physician.

Patient costs

The cost for an uninsured patient paying out-of-pocket is $50 to $80 to see a nurse practitioner at an RBC, significantly less than a visit to a doctor or emergency room. Generally, prices at an RBC will beat those at a traditional doctor's office or urgent-care clinic. Since convenient-care clinics treat only a finite list of ailments, they don't have to invest as much in equipment and supplies, and paying salaries for nurses rather than physicians keeps payroll costs down.

A visionary model

Insurance companies see the benefit of retail-based clinics because of their accessibility, the quality of care they provide and their lower costs.

"Retail health clinics are a convenient solution to address the growing numbers of the population who might otherwise use a higher-cost setting, like an emergency room or urgent-care center, for their primary care needs, or go without seeking care," says Cheryl Leamon, spokesperson for Anthem.

The first RBC opened in 2000 at a Cub Foods store in Minneapolis-St. Paul.

"The conventional wisdom at the beginning was that retail-based clinics would appeal to lower income individuals who didn’t have insurance or established physician relationships," recalls Web Golinkin, president of the Convenient Care Association and CEO of RediClinic. "That was the case to some degree, but a significant number of patients are middle- to upper-income individuals who are insured and have an established physician relationship who don’t feel they have easy access to routine health care."

The retail clinic concept not only cut out waiting room visits altogether, but it also opened up better access to health care access for the 45.7 million Americans who do not have health insurance, as estimated by the Census Bureau.

As one of the industry leaders, CVS Corp. now operates 146 MinuteClinics in eight states.

In the beginning, RBCs accepted only cash. They were an outlet for uninsured people who sought affordable medical treatment for routine maladies. RBCs are now covered by most major insurance providers and accept cash, credit and debit cards.

"Patients are demanding our services and our expansions are based upon market need," says Lauren Tierney, spokesperson for Walgreens' Take Care Health Systems. "We’ve seen more than 600,000 patients since we opened our first clinic in November 2005, with an average 95 percent patient-satisfaction rating. We look at a variety of factors when opening up a clinic — including access to care in the area, the ability to locate where the majority of patients work or live and their ability to secure basic health coverage."

Insurance coverage at retail clinics

Aetna, CIGNA, Humana, Blue Cross/Blue Shield, Medicare and others all cover services provided at retail-based clinics.

"RBCs provide more consistent health care that complements other sources of medical treatment," says Tammy Arnold, a spokesperson for Aetna. "Retail clinics were never intended to take the place of a primary care physician." Most health insurers believe that retail-based clinics lower barriers to health care, promote preventative medicine, ease the burden on emergency departments and are undeniably cost effective.

WellPoint/Anthem, for instance, covers a variety of services at retail clinics including many located within Wal-Mart, Walgreens and CVS locations across the country.

The American Academy of Pediatrics’ five principles to guide retail-based health clinics

Refer patients back to their pediatricians or primary care physicians for future care. Ensure prompt communication with the patient's physician within 24 hours. Use evidence-based medicine. Take necessary precautions to prevent contagious diseases. Don't waive or lower copays for RBC visits so as not to give financial incentive not to visit a physician.

According to Tierney, Take Care Health Systems has partnered with numerous national health insurers and is one of a few operators, including RediClinic, that accepts both traditional Medicare and Medicaid.

Although RediClinic has agreements with large health insurers, Golinkin says that the insurance industry is still in the process of embracing the services that retail-based clinics provide.

"The convenient-care industry is undergoing an evolution and insurers are still determining what services they intend to cover. Insurers understand that increasing health care access through retail-based clinics is not a silver bullet to the health care crisis or the insurance disparity by any means, but it is a significant contribution that is available to everyone," Golinkin says.

A comparative study by Harris Interactive in April 2008 found that the percentage of adults whose health plan covered some or all of the costs of services at an RBC went from 42 percent in 2007 to 62 percent in 2008. The study found that for the insured, the increase of adults visiting retail-based clinics was due to convenience rather than a lack of insurance coverage.

Fine-tuning required

RBCs haven’t been without opposition. The American Academy of Pediatrics (AAP), in particular, opposes RBCs as a source for medical care for infants, children and adolescents, and many retail clinics will not see children 18 months and younger. MinuteClinic, the largest retail-based clinic chain to date, reports that about 29 percent of its clients are children.

When it comes to non-emergency medical treatment, RBCs are alleviating ER overcrowding. And still, most convenient care operators find themselves on the defensive — not from those they treat, but from other health care providers.

In June 2008, the Federal Trade Commission (FTC) declined the request of the American Medical Association (AMA) to increase regulation of clinic facilities by requiring permits, curbing their advertising campaigns and requiring "more physician involvement." The FTC found the strict limitations proposed by the AMA to be anti-competitive.

The AMA also called for an investigation into waivers of state health regulations for clinics, insurance copay waivers and the possibility of conflicts of interest. That alleged conflict includes the partnerships between retail clinics and pharmacy chains, and the fact that store-based clinics provide a higher rate of traffic to pharmacy counters, thus increasing sales of prescriptions and other non-health products. Since doctors are heavily scrutinized over their relationship with pharmaceutical companies, a health clinic owned by a pharmacy should also be scrutinized, asserts the AMA.

According to Golinkin, retail-based clinics do not require patients to purchase prescriptions on-site and they have strict guidelines about directing patients to a doctor when needed.

Arnold says Aetna charges the same copay for retail clinics as they do for primary care physician. However, some insurers such as Blue Cross/Blue Shield of Minnesota are waiving insurance copayments altogether for RBCs in order to drive demand. The FTC stated, "Limiting an insurer’s ability to utilize differential cost-sharing could also be considered anti-competitive."

Generally, if you have health insurance, your out-of-pocket expenses at a retail-based clinic are the same as seeing your doctor.

"The reality of the business so far is that once consumers try us, they are pleased with our services," says Golinkin. "There are some elements of the medical establishment that are nervous about the impact of retail-based clinics, but we are addressing a crisis involving a shortage of primary care physicians. I think once the public and physicians understand what we do and become more comfortable with it, that perception will change."