Impact of Retail Clinics on Quality & Costs Ateev Mehrotra Harvard Medical School Beth Israel Deaconess Medical Center
Continuing Debate Issue Positives Concerns Quality Costs Access & PCP Relationships Follow guidelines, thus ensuring quality Decrease ED visits Decrease overall costs Improve access for all patients New safety-net provider Deliver poor quality services Overprescribe antibiotics Increase costs due to unnecessary follow-up Undermine patientdoctor relationships Decrease use of preventive care
Continuing Debate Issue Positives Concerns Quality Costs Access & PCP Relationships Follow guidelines, thus ensuring quality Decrease ED visits Decrease overall costs Improve access for all patients New safety-net provider Deliver poor quality services Overprescribe antibiotics Increase costs due to unnecessary follow-up Undermine patientdoctor relationships Decrease use of preventive care
Ongoing Debate Quality Costs
Antibiotic Prescribing Rates Are Similar 80% 60% 40% 20% Retail Clinic MD Office Urgent Care ED 0% Antibiotic Prescribed for Ear Infection Antibiotic Prescribed for Sore Throat Mehrotra et al., Annals of Internal Medicine, 2009
Fraction of Patients with One or More Follow-up Appointments Is Similar 50% 40% 30% 20% Retail Clinic MD Office Urgent Care ED 10% 0% Ear Infection Sore Throat Urinary Tract Infection
Quality of Care in Retail Clinics is the Same or Better as Found in Other Settings 100% 80% 60% 40% Retail Clinic MD Office Urgent Care ED 20% 0% Ear Infection Sore Throat Urinary Tract Infection
More recent data on Acute Respiratory Illnesses Mehrotra et al., Amer Jo of Managed Care, 2015
Patterns Depend on Diagnoses Otitis media, acute sinusitis, strep sore throat URI, nasopharyngitis, nonstep pharyngitis, acute bronchitis, bronchiolitis
Change in ARI Mix
Quality Findings Consistent With Other Research Patient satisfaction very high 1 Quality Follow-up visit rates lower 2 Care concordant with guidelines 3 1 Harris Interactive 2 Rohrer, Qual Manag Health Care, 2008 3 Woodburn, AJMQ, 2007
Ongoing Debate Quality Costs
Significant Per Episode Cost Savings at Retail Clinics $800 $600 $400 Retail Clinic MD Office Urgent Care ED $200 $0 Ear Infection Sore Throat Urinary Tract Infection Mehrotra et al., Annals of Internal Medicine, 2009
No Notable Difference in Prescription Costs $50 $40 $30 $20 Retail Clinic MD Office Urgent Care ED $10 $0 Ear Infection Sore Throat Urinary Tract Infection
More than 100 Million Retail Clinic Type Visits to Physicians and Emergency Rooms each year 120 Millions of Visits per Year 100 80 60 40 20 ED MD Office If these 100 million visits were switched to retail clinics, $4.4 billion in savings to system 0 Top 10 Conditions/Services at Retail Clinic Visits Mehrotra et al., Health Affairs, 2008 Weinick et al., Health Affairs, 2010
Do Retail Clinics Save Money? Depends on Impact on Overall Utilization Substitution Visiting retail clinic instead of physician or ED No change in overall utilization Savings New Utilization Visiting retail clinic instead of staying home Increase in overall utilization Increase spendng Ashwood, et al. Health Affairs, 2016
Study Design Compare outcomes before and after retail clinic entry Two populations Retail clinic visitors Non-visitors who are propensity score matched Outcome Overall utilization & spending for acute care Overall = retail clinic, ED, MD office
Overall Utilization Increases 200 All Care Sites (Office, ED, Retail Clinic) Utilization Rate 150 Retail Clinic Users Rate per 1,000 100 Non Retail Clinic Users 50 Pre Retail Clinics Enter Markets Post 0 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D 2005 2006 2007 2008 2009 Year/Month
Rise in Retail Clinic Utilization
200 Physician Utilization Decreases Slightly Physician Office Utilization Rate p-value < 0.001 150 Rate per 1,000 100 Non Retail Clinic Users 50 Retail Clinic Users Pre Retail Clinics Enter Markets Post 0 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D 2005 2006 2007 2008 2009 Year/Month
Breakdown of Retail Clinic Visits Replace MD visits, 39% New Visits 58% Replace ED Visits 3% Estimate 19.7% Increase in Spending ($30 per member per year)
What about ED visits? RC ED #1 ED #2 Martsolf, et al. Annals of Emergency Medicine, Nov 2016
Mean rate of ED visits for low-acuity conditions (per 1,000 total ED visits) Little Figure 2. Difference Trends in the rate of ED visits in for low-acuity Trends conditions, of by growth ED in retail Visits clinic penetration, 2007 2012 200 175 No growth in retail clinic penetration (N=1,274) 150 135 131 125 100 129 Any growth in retail clinic penetration (N=769) 124 75 50 25 0 2007 2008 2009 2010 2011 2012 Year
Difference by Insurance Type? Translation: Average ED had 1237 ED visits for low-acuity conditions among privately insured patients. If a retail clinic opened up close to an ED, 17 fewer ED visits for privately insured over the year.
Impact on Costs Retail clinics are cheaper than similar care at physician offices and EDs However, retail clinic visits primarily represent new utilization. Small fraction represent replacement of physician visits Little impact on ED visits Overall costs simple acute care 20% higher
Larger Implications Telemedicine evisits Urgent Care Centers
DTC Telemedicine Antibiotic Prescribing 100 90 80 70 60 50 40 30 20 10 0 Teladoc Any Antibiotic MD office *Significant <.05 (comparing Teladoc to physician office) **Adjusted analysis in progress (similar results) JAMA Internal Medicine, 2015
Testing Appropriate & Inappropriate 60 50 MD office 40 30 MD office 20 10 0 Teladoc Testing for pharyngitis Teladoc Testing for back pain *Significant <.05 (comparing Teladoc to physician office) **Conditional on an antibotic being prescribed ***Adjusted analysis in progress (similar results) Telemedicine & E-health, 2015
Breakdown of Retail Clinic Visits Replace MD visits, 39% New Visits 58% Replace ED Visits 3%
NEJM, 2001
Larger Implications New delivery options have the potential to provide equal or superior quality care Cheaper on a per visit basis Convenience drives new utilization Is this new use good or bad? High or low-value care Relative impact on spending
Moving Forward Demand side interventions Focus on higher out-of-pocket costs and high deductibles Consumerism Supply side interventions Shift to global payments Consolidation
mehrotra@hcp.med.harvard.edu