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ABSTRACT Consumer-driven health care has spawned an industry of convenientcare clinics that offer accessible, quality care at a reasonable price.Theprimary health care providers at these clinics are family nurse practi-tioners. Since their debut, these clinics have provided a niche forpeople who do not want to spend hours in emergency departmentsfor minor illnesses and uninsured people who cannot afford the highcosts of health care.This article reviews the history behind conven-ient care clinics and offers some prognostication for the future.

Keywords: accessibility, convenient care clinics, nurse practitioners,quality care, retail clinics

Consumer-Driven Health Care:

Nurse Practitioners Making HistoryKenneth Miller

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January 200932 The Journal for Nurse Practitioners - JNP

Consumers in search of accessible, quality healthcare at a reasonable price have turned theirattention and their health care dollars to the

convenient care industry.This relatively new approach totreatment of minor ailments has provided a new venuefor provision of care by nurse practitioners (NPs). Drugstores, discount shopping centers, grocery stores, andother retail outlets are the geographic locales for thesenew convenient care clinics (CCCs), which are staffedprimarily by NPs, although some are also staffed byphysician assistants (PAs) andphysicians.The “convenience”label for these clinics evolves notonly from the geographic close-ness to the patients’ homes butalso to the fact that the clinics areopen 7 days a week, with easyconvenient parking.The waitingtimes are such that patients canbe in and out in less time than ina primary care office.Addition-ally, the time they might have towait to have their prescriptions filled can easily be spentshopping for needed household goods.The purpose ofthis paper is to detail the rapidly expanding history of this“consumer dream.”

EARLY HISTORYConvenient care clinics made their debut in 2000, whenthe first in-store clinics appeared in Minneapolis-St. Paul,operated by QuickMedx.1 The meteoric rise from lessthan 50 clinics in 2005 to over 1095 in 2008 bears mutetestimony to this new health care venue.2,3 The key to thesuccess of these clinics is not only their accessibility inretail outlets, along with the provision of quality care at areasonable price, but also the economics associated withsuch a venture.

Investment dollars are plentiful, as both public andprivate investors seek a piece of this ever-burgeoning pie.However, both small and large companies have faltereddue to economic decline. Some sought too rapid anexpansion, while others neglected to consider the over-head costs of employing a more costly workforce. Forexample, a large privately owned Las Vegas companyrecently removed itself from the industry.The speculationis that the overhead associated with physician staffing wasmore than had been anticipated.2

ROLE OF NURSE PRACTITIONERSSince their debut, the primary providers of care in theCCCs have been family NPs (FNPs). Based on both theirscope of practice, coupled with the scope of services thatCCCs offer, this group of health care providers seems tobe the best fit for this new model of care. Studies haverepeatedly shown that NPs provide care that is equivalentto, or better than, that provided by family practice physi-cians.4-7 NPs are cost-effective health care providers who,within the CCCs, can help relieve the burden of “non-

urgent” visits to overly bur-dened emergency departments.It is entirely possible that theseCCCs serve a surrogate role as“safety net providers” forpatients who would otherwisehave gone untreated, or inap-propriately used an emergencydepartment for a minor illness.8

Additionally, some of thesenon-urgent conditions, if nottreated in a timely fashion,

could progress to become more serious in nature, thusinvolving a more costly treatment modality.

Ninety percent of all CCC visits involve just 10 com-plaints, specifically: upper respiratory infections, sinusitis,bronchitis, pharyngitis, immunizations, otitis media, otitisexterna, conjunctivitis, urinary tract infections, andscreening labs or blood pressure checks.8 All of these con-ditions or procedures are well within the scope of prac-tice of NPs. It is the role of the NPs in these clinics toassess, diagnose, and treat the illnesses that are within thescope of services that the particular CCC provides.Typi-cally, patients are seen within 15 to 20 minutes after hav-ing signed in to the clinic on computers provided in thepatient waiting area. Each chief complaint has a com-puter-generated protocol that the practitioner uses todiagnose and treat the patient. If the diagnosis falls out-side the protocol and enters a more complex realm ofsigns and symptoms that require additional treatment,these cases are referred to a list of local health careproviders who have agreed to take referrals from theCCC, or the patient is referred to the nearest emergencydepartment, depending on the urgency of presentingsigns and symptoms.An additional safety net is that eachclinic has a collaborating physician with whom the NPcan discuss a particular case. In general, by treating these

By treating these lesscomplex cases, NPs are

freeing up both emergencydepartments and family

practice physicians to treatmore complex cases.

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less complex cases, NPs are freeing up both emergencydepartments and family practice physicians to treat morecomplex cases.

A question that is frequently entertained by both theNPs who work in these clinics and those who supportthis consumer-driven movement is: why would an NPwant to work in a setting in which the scope of servicesis far less than what the practitioner could otherwise doin another setting? The answer to that question is as var-ied as the practitioners who work in the CCCs. Conver-sations with NPs in these clinics indicate that there aremultiple reasons for wanting to work in CCCs. Some likethe “independence” of the role, others like the hours, thebenefits, the collegiality, the ability to enhance theirexpertise by working with a limited number of medicalconditions, and having time to provide preventive educa-tion. More experienced practitioners have indicated thatthey enjoy the less hectic pace of the CCC as comparedto a busy family practice clinic, as it provides them timeto provide some education to the patient.

Given that the NPs are dealing with a limited numberof conditions to treat, there are very few obstacles in theirpractice.A consulting physician is only a phone call away,and the regional NP who oversees the clinic is also avail-able for consultation.

The evolution and rapid rise of CCCs has not beenwithout its detractors. Both the American Medical Asso-ciation (AMA) and the American Academy of Pediatrics(APA) have opposed CCCs primarily on the issues ofcontinuity of care, coordination of care, and economicissues.9-11 However, recent research by the Rand Corpora-tion has provided some data to respond to these con-cerns.8 The disruption of primary care relationships hasproven to be a non-issue. The study found that 60% ofthose visiting a CCC did not have a primary careprovider (PCP); hence, there was no relationship to dis-rupt.The majority of patients using a CCC are in the 18-to 44-year-old range (Table 1), who otherwise might nothave sought care until a more serious set of symptomsdeveloped, thus adding to the increased costs of treat-ment.The second concern revolved around the potentialexacerbation of communication problems between thepatient and the PCP.Yet all clinics provide the patientwith either a written summary of the visit, or if thepatient requests, the clinic will fax a copy of the record tothe PCP’s office. Either way, the communication problemis resolved.

Finally, the potential financial impact to the PCPsby loss of simple acute visits was also addressed.Thestudy noted that, while it is possible that the PCPmight have fewer visits per hour of the simple acutecases, this is potentially offset by the filling of that timewith more complex cases, whose reimbursement ratesare higher than that of the simple acute cases.Anotherperspective that the study did not note was the poten-tial of referrals from the CCCs for more complex casesthat fall outside the scope of services that the clinicsoffer.

The issues raised by the AMA and AAP have beenaddressed by the standards of care developed by theConvenient Care Industry (CCI). CCCs do not seechildren under the age of 18 months. Electronic medicalrecords (EMRs) provide ready access to visit summariesfor PCPs.And all complex cases are referred to appro-priate local health care providers from lists that theCCCs maintain.

The CCCs and the quality health care that they pro-vide are not going away.They have become an integralpart of our health care landscape, and the NPs and theother health care providers who work in these clinics arehelping to meet the crisis of too few primary careproviders that currently exists.The Rand study hasmerely scraped the surface of the types of studies thatneed to be done to show the positive outcomes of theseCCCs.Additionally, studies need to be done to clearlyshow that the clinics offer accessible and quality care at areasonable price.

Table 1. Age and Percentage of Patients Who Visited Convenient Care Clinics Between 2002 and 2005 (N =1.35 million)

Age (years) Percent< 2 0.2

2-5 6.3

6-17 20.3

18-44 43.0

45-64 22.6

> 65 7.5

Total 100

Adapted from Mehrota A, Wange MA, Lave JR, Adams J, McGlynn EA.Retail clinics, primary care physicians, and emergency departments: acomparison of patient visits. Health Affairs 2008;5:1277.

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From an historical perspective, NPs are negotiatingnew modes of care delivery while being groomed intothe eventual role of assuming responsibility for becom-ing the gateway to primary care in this country.This isa result of 2 historical events. First, data over the past10 years reveal a steady decline in the number of fam-ily practice physicians who elect primary care as theirspecialty.The most recent data from the 2008 NationalResident Matching Program show that 2,636 familypractice residencies were offered, yet only 2,387 werefilled.12 Of the number that were filled, less than halfwere filled by U.S. seniors; the other 52% were graduatesof medical schools outside the country. However, thesedeclining physician numbers are offset by an increasingnumber of FNP graduates. In 2007-2008, some 4041FNPs graduated from schools around the country.Thisrepresents 3.5 times the number of U.S. medical schoolgraduates who elected family practice as their specialty.13

Given these data, it is certainly feasible that in the next 5years, FNPs will indeed be the gateway for primary carein the United States.An integral part of this evolutionwill be the services provided by CCCs.

The greatest contribution of the CCI has beentheir clear articulation of the role of the NP. No otherorganization has done so much for NPs in terms ofclarifying and enhancing their visibility to the public.Just as Johnson and Johnson have become the mar-keters for the general nursing community, so too, hasthe CCI become the marketer for NPs.What was oncethe best-kept secret in the health care industry hasnow become the most visible and viable safety net inthe health care industry.

FUTURE ROLE OF THE CCCsThe CCCs are now a monument on the health carelandscape.They offer a viable alternative to once morecostly services that were rendered in primary careprovider offices and emergency departments.They haveestablished themselves as an industry complete withstandards of care, evaluation tools, and satisfaction sur-veys. In 2008, they launched their own newspaper, andheld an inaugural Retail Clinician Education Congress,which proved to be the first of what will become anannual conference. It is possible that the future will alsohold an enhancement to their scope of services, espe-cially in the arena of prevention.What better venue toprovide education than within a CCC, where NPs and

pharmacists can work collaboratively to provide the lat-est information not only on drugs, but also on ways toprevent some of the more common diseases such asheart disease, diabetes, hypertension, obesity, and depres-sion.The opportunities will be endless.And NPs whowere there at the inauguration of this industry will bethere making history through the provision of accessi-ble, quality care at a reasonable price.

References

1. Hansen-Turton T, Ryan S, Miller K, Counts M, Nash D. Convenient careclinics: the future of accessible healthcare. Dis Manage. 2007;10:61-73.

2. Kolar R. A consumer revolution in retail medicine: where is it heading?Healthcare Financial Manage. 2008;62:46-48.

3. Convenience care in the United States. Available at: www.merchantmedicine.com. Accessed October 26, 2008.

4. Sox HC. Quality of patient care by nurse practitioners and physicianassistants: a ten-year perspective. Ann Intern Med. 1979;91:459-468.

5. Spitzer WO, Sackett DL, Sibley JC, et al. The Burlington randomized trial ofthe nurse practitioners. New Engl J. Med. 1974;290:251-256.

6. Lenz ER, Mundinger M, Kane RL, Hopkins SC, Lin SX. Primary careoutcomes in patients treated by nurse practitioners or physicians: two-yearfollow-up. Med Care Res Rev. 2004;61:332-351.

7. Lenz ER, Mundinger MO, Hopkins SC, Lin SX, Smolowitz JL. Diabetes careprocesses and outcomes in patients treated by nurse practitioners orphysicians. Diabetes Educ. 2002;28:590-598.

8. Mehrota A, Wange MA, Lave JR, Adams JL, McGlynn EA. Retail clinics,primary care physicians, and emergency departments: a comparison ofpatient visits. Health Affairs. 2008;5:1272-1278.

9. Corwin RM, Francis AB, McInerny TK, Ponzi JW, Reuben MS, et al. AAPprinciples concerning retail based clinics. Pediatrics. 2006;118:2561-2562.

10. Berman S. Continuity, the medical home and retail-based clinics. Pediatrics.2007;120:1123-1125.

11. AMA takes on retail-based clinics. Available at: http://archives.chicagotribune.com/2007/jun/25/business/chi-clinics_bizjun25. Accessed November4, 2008.

12. Results and data: 2008 main residency match. Available at: www.nrmp.org.Accessed October 26, 2008.

13. Fang D, Htut A, Bednash GD. 2007-2008 enrollment in baccalaureate andgraduate programs in nursing. Washington, D.C.: American Association ofColleges of Nursing; 2008.

Kenneth P. Miller, PhD, RN, CFNP, FAAN, is director of theSchool of Nursing at the University of Delaware in Newark.He can be reached at kpmiller@udel.edu. In compliance withnational ethical guidelines, the author reports no relationshipswith business or industry that would pose a conflict of interest.

1555-4155/$ see front matter© 2009 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2008.11.002

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