Retail Care Clinic Industry

Mark Masselli: Welcome to Conversations on Health Care. I am Mark
Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Welcome back to our regular listeners that means anyone
who heard us last week which was our first show.

Margaret Flinter: Mark, I was happily surprised at how many people sent
us Emails after the show.

Mark Masselli: Through the miracles of the Internet, they were able to
listen at www.wesufm.org .

Margaret Flinter: And the Emails came from all over from Denver,
Washington DC, Norway.

Mark Masselli: You have got family in Norway?

Margaret Flinter: No, but I think you do.

Mark Masselli: Really?

Margaret Flinter: Some people gave us ideas for future shows and some
people suggested that they would like to be on the show as future
guests.

Mark Masselli: One listener who asked us to dive more into the finances
of the public option wrote the economics of the model really needs an
explanation which is convincing about personal cost.

Margaret Flinter: And my personal favorite was the guy who wrote what
is this, Care Talk.

Mark Masselli: So keep listening and send us more Emails at
[email protected] .

Margaret Flinter: Last week, Speaker of the House Nancy Pelosi joined us
for our first show to talk about the public option. That was just days
after finance Chair Senator Max Baucus released his long awaited bill.
Over these days, Senator Pelosi has continued to push for the public
option saying the plan could save the Federal Government money and not

add to the country’s deficit something in line with President Obama’s
objectives in health care reform.

Mark Masselli: Well she is a drum major for public option. We also had
Dr. Mitch Katz from San Francisco here to talk about Healthy San
Francisco, one program that is already proving it’s possible to extend
health care to the uninsured in a cost e ! ective way.

Margaret Flinter: Remember Dr. Katz really stressed the need to have
enough providers who can actually serve new patients and that’s what led
us to the topic of today’s show, the Growth of the Convenient Care Clinic
Industry. Retail clinics have sprouted up inside drugstores and retail
locations like CVS and Wal-Mart; it’s seen as one way to increase access
to basic health care services at a ! ordable prices.

Mark Masselli: Today, we will look at two models of retail clinics first, we
will speak with Sandra Ryan, Chief Nurse Practitioner O " cer of Take Care
Health Systems that owns and operates retail clinics inside Walgreen
drugstores.

Margaret Flinter: Then we are going to speak with Dr. John Agwunobi.
Dr. Agwunobi is President of Wal-Mart’s Health and Wellness Division.
We will talk to him about how Wal-Mart leases space to local independent
healthcare providers to provide those health services to Wal-Mart
customers.

Mark Masselli: But first as always, at least since the last week, we will
start with the health care headlines from Lucy Nalpathanchil, our
producer here at Conversations, Lucy.

Lucy Nalpathanchil: I am Lucy Nalpathanchil with this week’s headline
news. The Federal Government will begin rolling out the H1N1 vaccine to
state and local governments next week. US Health and Human Services
Secretary Kathleen Sebelius says the government has purchased 250
million doses enough for every American who wants the vaccine.

Kathleen Sebelius: This is not a mandatory vaccination campaign, it is
entirely voluntary. We have made it clear that we think it’s a good idea
for people particularly folks in the target populations to be vaccinated but
there is nothing mandatory about it.

Lucy Nalpathanchil: The government recommends the vaccine for young
children, pregnant women, and those with chronic conditions. The FDA

has approved 2 doses for children 9 years and younger, 1 dose for those
10 years and older. Secretary Sebelius also stresses that the vaccine is
safe.

Kathleen Sebelius: W have a high degree of confidence in the vaccine’s
safety that this is being made exactly like seasonal flu, it’s been made,
we have lots of data on 100 million people a year getting the seasonal flu
vaccine and we have every reason to believe this will operate exactly the
same way.

Lucy Nalpathanchil: How the vaccine is distributed is up to state
governments; governors and their public health directors are
coordinating with hospitals, community health centers and clinics to
determine how much vaccine to get and who will distribute the doses.
Turning to the US capital, senators within the Finance Committee are still
o ! ering multiple amendments to US Senator Max Baucus’s Health Care
Reform Bill; one issue that came up was a revision to lower the cost of
health insurance for people who would be required to purchase it. The
question of a ! ordability remains a sticking point between Democrats and
Republicans in both Chambers. Senator Baucus’s plan made news last
week after he left out a public option, this week senators will o ! er
amendments to get the public option in the bill and after the Finance
Committee agrees on a bill, Senate Majority Leader Harry Reid will work
to merge the Finance Bill with the Senate Health Committee Bill before a
plan is brought to the floor for a vote. We will continue to follow what
develops. This week we take a look at the retail care industry, clinics that
o ! er basic health care services in places like drugstores, Minute Clinic is
seen as the pioneer of retail care clinics. The Minnesota Company was
founded in 2000, today Minute Clinics are found in CVS stores across the
country. I visited a Minute Clinic in Avon, Connecticut. The Minute Clinic
is nestled in the corner of the store past the checkout counters.
Connecticut manager of Minute Clinic operations Marilyn McGuire takes
me through the check-in process.

Marilyn McGuire: So here we are in front of the kiosk. As you can see it’s
a touchscreen to start and it is going to ask you why you are here. The
two main option at this point in time are, are you here for a flu or
pneumonia shot, one of the very common visits these days, or are you
here for another service. If you are here for a flu shot, you just hit Yes,
and go to the next screen.

Lucy Nalpathanchil: Above the touchscreen is an electronic menu that
shows customers what services are available and exactly how much they

cost. A flu shot starts at $62 and the clinic takes most insurance plans.
McGuire says the upfront cost add to the quickness of a customer’s visit.

Marilyn McGuire: What we o ! er to people is an alternative to going to the
Urgent Care or the Emergency Room for what we call Acute Episodic
Issues such as sore throat, conjunctivitis, sinusitis, bronchitis. We have
actually started out with perhaps a handful of things we did and we have
now I would say we do a 2 ½ times the services.

Lucy Nalpathanchil: During my visit, most people walked over to the
clinic for flu shots. Ray Dubock came with his 4 year old daughter
Jordan.

Ray Dubock: You can go right down the street, come in and out very
quickly, get your flu shot rather than waiting at the grocery store where
you are in line for an hour to get one, this is much more convenient.

Lucy Nalpathanchil: And convenience is key to this growing industry.
Tine Hansen-Turton, executive director of the Convenient Care
Association says 2 years ago there were 150 retail care clinics in the US
now there are more than 1200. Hansen-Turton says the clinics aren’t
meant to replace primary care providers but they are sta ! ed with
qualified nurse practitioners so they can o ! er a critical access point to
providing care.

Tine Hansen-Turton: We only have to look to Massachusetts 2 years ago
where the Governor made health care insurance available to 340,000
adults and the next day they flooded the Emergency Rooms and the
doctors’ o " ces had to close because they couldn’t take on new patients.
So we believe that in order for health care reform to be successful, you
are going to need an access point like a retail clinic.

Lucy Nalpathanchil: And the quality that care retail clinics o ! er is getting
noticed. Grand Health recently published a study in the Annals of
Medicine that found care at retail clinics is comparable to doctor o " ce
visits without having to wait for an appointment. Minute Clinics may
have been the first retail care clinics but now several retailers have
stepped into the ring. Conversations on Health Care spoke to two leaders
in the convenient care industry. Here’s Mark Masselli and Margaret
Flinter interviewing Sandra Ryan, Chief Nurse Practitioner O " cer of Take
Care Health Systems which owns and operates retail clinics inside
Walgreens.

Mark Masselli: Sandy, we are so pleased that you are able to join us
today to talk about what’s still a relatively newcomer to the health care
market, the retail or convenient care clinic.

Sandra Ryan: Thank you Mark for having me. So retail clinics like you
said it’s fairly new to the health care market. Take Care Health Systems,
who I work for, which is part of Walgreens the wholly owned subsidiary,
we have about 350 clinics in 19 states. And what these clinics are being
recognized for is their incredible convenience for patients and access,
non-traditional health care access point for patients that are a ! ordable
and that have quality of care being delivered and using an innovative
model of nurse practitioners to really be the sole providers of care in this
clinic.

Margaret Flinter: You know as I recall the original target market might
have been called the soccer mom market, busy moms just picked up the
kids from sports or school maybe needed an ear ache, soar throat or pink
eye looked at quickly and either couldn’t get in to the pediatricians or
didn’t have time. Has that changed? Are you seeing a di ! erent kind of
demand for services now and maybe tell us a little bit about who is your
typical customer if there is such a thing?

Sandra Ryan: With the existence of the clinics, we have seen kind of a
shift in some of the demographics. But the soccer mom still is one of the
most, I want to say, educated consumer driven models out there where
they are looking for convenience, they are looking for access, they are
looking for quality of care for their children. We have a big demand
between that 18 and about 50 year old range where people who are
coming in are looking for convenience, they are working individuals,
adults who are coming in right before work, coming in during work, it’s
quicker and easier to get in versus making an appointment or a large
percentage of this population about 30% do not have healthcare coverage
right now so that they are without insurance and we become an option
other than urgent cares and emergency rooms.

Mark Masselli: How do you respond to critics that it disrupts patient
provider relationships?

Sandra Ryan: There has been a lot of mechanisms that have been put in
place so that if people do have healthcare providers that they normally
see that records are being transmitted, that communication is made back
to that provider. There is a huge percentage as well that do not have a
relationship where we have actually as an industry been working to get

those patients back into the health care system linking them up with a
health care home so that they have a routine provider that they see for
routine health care needs. So the beauty of the retail clinic environment,
all people who belong to the Convenient Care Association which is this
retail care environment have electronic health records. So when you talk
of continuity, we have actually stepped beyond a lot of individual
practices out there in trying to build continuity within our own
environment and reached out to other providers to have continuity in that
respect. I can tell you as an industry goal, it is our goal to promote
continuity because that’s in the best interest of the patient.

Margaret Flinter: Now Sandy as a nurse practitioner yourself I know
prevention is always on your mind and the US Preventive Services
Taskforce has that very specific list of what’s highly recommended,
immunization in cancer, cardiovascular screenings, diagnostic tests.
When we look at the list of services that a retail clinic provides, probably
a lot of them can be delivered in this setting. I know prevention is a
priority for you but have you been able to translate this into your
business strategy and clinical services in the retail clinics?

Sandra Ryan: We launched I think it was last year we launched actually an
HRA a Health Risk Assessment o ! ering to patients which does exactly
that. It’s a screening for a health evaluation which looks at obviously
some metabolic levels, the chemistry panels and di ! erent things but also
asks pertinent questions as to those routine things that are
recommended at certain ages so getting a mammogram, having a pap
smear done those di ! erent things in trigger point so that we can
document and facilitate for patients to get those things done. So as you
see the industry evolve, there would be more and more coming in that
direction that’s trying to promote health and wellness within the setting
because we are a unique setting. We have seen our immunization
o ! erings go from starting o ! the industry we only o ! ered a very few to
now we have a pretty complete suite of immunizations that we o ! er out
for both pediatrics and adults.

Mark Masselli: We are talking with Sandy Ryan, Chief Nurse Practitioner
O " cer of Take Care Health Systems. Sandy, quality safety services it’s a
challenge to monitor each of these in just one practice and you are doing
it with more than a 1000 nurse practitioners and 352 clinics and 19
states, how do you do it?

Sandra Ryan: Well that’s the beauty of having electronic health records
and having electronic capability. And again from an industry standpoint

where the retail clinic had a true advantage to the traditional healthcare
system is we started with a blank slate so we were able to design and
implement and put process and procedures in place from the very
beginning. So we have established ways of doing electronic peer-to-peer
review between our NPs, actually reviewing quality of care issues as well
as collaborative position reviews. So they review a percentage of records
per state per regulation of our NP’s practice and so we are able to
actually generate reports so I could tell you any day of the week what
every NP scores are in quality on both of those as well as track National
HEDIS measures on three of the most common things that we see within
our environment and I can tell you that our scores particularly on HEDIS
exceed the national benchmark.

Margaret Flinter: Sandy as you know Mark and I lead a statewide
community health center and as a community health center we are very
focused on vulnerable and special populations particularly the uninsured,
the low income, the publicly insured patients not traditionally the focus
for the retail clinic industry but might this be changing? We hear that in
some states, Medicaid is beginning to cover services at the retail clinics;
tell us your perspective on this and maybe a little bit about how that ties
to a chronic disease management as well as prevention.

Sandy Ryan: From our standpoint, we have always been trying to have
access for everyone. So in states, where we have been able to, we have
negotiated contracts with Medicaid and Medicare because we too believe
in trying to have access for everyone. Not all the retail partners have
taken the same approach but Take Care and Walgreens definitely is
committed to that. As far as chronic care delivery absolutely that is
something that we will be expanding services into as we move forward.
So recently, we have launched a few more new services, we are looking at
launching care for asthma and diabetes and di ! erent things in the future.
So again the more that we can get the states to accept the services and
believe it or not sometimes it’s hard to negotiate with them but we
definitely are committed to doing that.

Lucy Nalpathanchil: That was Sandra Ryan, Chief Nurse Practitioner
O " cer of Take Care Health Systems. Wal-Mart is also involved in
convenient care but it follows a di ! erent model, unlike CVS or Walgreens
Wal-Mart’s clinics are operated by independent healthcare providers. To
find out more, Mark and Margaret spoke with Dr. John Agwunobi,
P resident of Wal-Mart’s Health and Wellness Division.

Mark Masselli: Dr. Agwunobi thank you for speaking with us today.

Dr. John Agwunobi : Hi Mark, hi Margaret.

Margaret Flinter: Hi, and thanks again so much Dr. Agwunobi for joining
us on Conversations. You know I want to start with a pretty basic
question. We are not used to hearing Wal-Mart and health care in the
same sentence; we think of Mal-Mart really as a retail giant. So tell us
why it decided to get into direct health care services.

Dr. John Agwunobi: Well I have to tell you Wal-Mart sees and serves 140
million individuals every single week. A 140 million people walk through
our doors to seek some product or service in our stores, and it’s a natural
fit for us to then ask them how can we help you, what don’t you have in
your community that we might provide. And the overwhelming, many of
the voices said we need you to help us with basic health services, we
need you to help us make it more a ! ordable, make it more accessible
and make it simpler, and the retail health clinics that we o ! er are one of
the responses to that demand.

Mark Masselli: Any one of us who have shopped at Wal-Mart knows that
you attract a huge and diverse customer base; can you tell us more about
the typical customer that uses the retail clinic?

Dr. John Agwunobi: Well the typical customer that comes to a retail clinic
is an individual, typically a family, a mom or a dad with their child,
sometimes it is a teenager or an older person but they all share in
common this notion that they don’t have a lot of time so they can’t a ! ord
to schedule for an appointment 5 weeks ahead or 4 weeks out, they don’t
want to have to stand and wait for 4 hours before they get to see a nurse
practitioner or a doctor and so that’s why it’s a walk-in type setting in
these retail clinics. And many of them are what we would refer to as
being price sensitive, they care how much their healthcare costs and so
these clinics post the prices on the wall so that the patients know what
they are going to spend before they come in. Some have insurance some
don’t.

Margaret Flinter: You know when we looked around at the retail clinic
industry we see that it has a number of players but there is a dominant
model and that dominant model seems to be all the clinics owned and
operated by one entity that employs the sta ! and really controls the care.
But it seems to us that Wal-Mart took a di ! erent path, you lease space
within your stores to local healthcare providers. Can you tell us a little bit
about why you adopted that model?

Dr. John Agwunobi: We believe strongly in the notion of a medical home,
every person ultimately should have a place that they naturally turn to for
their ongoing health care needs overtime. And because these clinics are
structured to deliver just kind of on time basic care for episodic events, it
just felt better to have it connected to their medical homes in someway
and that’s why we have gone the route we have gone of having local
providers come into our store and operate these clinics.

Mark Masselli: This is Conversations on Health care, we are talking with
Dr. John Agwunobi, P resident of Wal-Mart’s Health and Wellness Division.
You know that all retail clinics have one thing in common, they use an
electronic health record. Retail clinic operators like Take Care Health
Systems and Minute Clinic use electronic health records to monitor the
quality of the health care. Since Wal-Mart doesn’t actually own the
clinics, how do you monitor care?

Dr. John Agwonubi: Wal-Mart, as a company, we are not a part of that
clinical relationship between the patient and the provider in a retail clinic
that’s we think a very unique relationship, one that isn’t necessarily
improved Wal-Mart being a part of it. We do require for example that the
hospital provider that the nurse or the doctor in the clinic that is taking
care of the patient that they have all of the standards and the
expectations on quality that they would have in their hospitals or in their
community health center or in their practice. We ask in contract that that
quality, those expectations be extended into the retail clinic in a Wal-
Mart store. We do provide as a service to the providers an electronic
medical record in each of our Wal-Mart retail clinics, the basic
arrangement is that they rent their electronic medical record from us, it’s
used from us and it allows them to connect the patient that they see in
the Wal-Mart retail clinic back to their larger medical record in their
hospital or in their doctor’s o " ce or in their community health center. So
we o ! er that to our operators as a service to them. It also allows
customers who would visit a hospital operated clinic in Wal-Mart on the
east coast to be able to pull up their records if they entered a retail clinic
operated by a di ! erent operator on the west coast but Wal-Mart doesn’t
actually have access to or dive into the medical details of each of the
patients that walk in our doors, our role it so serve the providers.

Margaret Flinter: You have held some very high profile public health
positions, Assistant Secretary for Health in the US Department of Health
and Human Services, an Admiral in the Public Health Service and you have
served as the Director of Health for the State of Florida so we know you

have faced a lot of public health emergencies in your career. From your
perspective, is there a role for retail clinics from that public health point
of view?

Dr. John Agwunobi: Absolutely. For those individuals that walk into a
clinic and perhaps they don’t have insurance and they are not receiving
care, typically they find that these clinics allow them to take care of the
basic healthcare needs; I have my little Johnny has a cold or my wife has
an ear infection. But it also is a place where we then plug these
individuals back into the local infrastructure, we have them find providers
in their communities, we help find medical homes for them in their
communities, these retail clinics have clinics also in the practice of
immunizing and some of them, the hospitals that operate or the clinics
that operate these clinics also o ! er screening for certain illnesses and
diseases.

Mark Masselli: And as you sort of look at that and you sort of look at the
current debate that’s going on, how do you see the role of retail clinics
evolving?

Dr. John Agwunobi: That’s a good question. Number one, we do this as
a partnership with hospitals or community health centers or doctor
practices and so the evolution will be largely driven by where those
entities are going in the future, it won’t all be Wal-Mart pushing it one
way or the other. Our role ultimately is to make sure that overtime the
cost of health care hopefully will become less so more people can access
it and over time these clinics become a larger part, a more important
part, of their local health care networks.

Mark Masselli: We have been speaking with Dr. John Agwunobi, P resident
of Wal-Mart’s Health and Wellness Division. Dr. Agwunobi, thank you so
much for speaking with us today for Conversations on Health Care, I am
Mark Massellie.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Each week, Conversations points out a bright idea about
how to fit wellness and healthy choices into the daily life of your
community.

Margaret Flinter: Here’s Lucy with a bright idea from Oakland, California.

Lucy Nalpathanchil: We ask our children to pay attention but do we teach
them how, and that’s the question that the Park Day School has been
answering in recent years with a program called Mindful Schools. It
started with experienced meditation teachers adapting their lessons to
school children, 15 minute lessons 3 times a week in a 5 week course.
They provide mindfulness exercises in listening, breathing, movement
and developing kind and caring thoughts and the results were so positive
that they immediately began to o ! er the program to other schools. It’s
an impressive track record, the Mindful School teachers have trained
really 5000 students in both public and private schools and many serve
predominantly underserved populations. It’s an idea which has been
embraced in a number of communities. In Los Angeles, a group called
the InnerKids Foundation calls it the new ABCs Attention, Balance and
Compassion. So what does meditation for kids look like? Well it’s not at
all like sitting in a lotus position and saying Om. Some of the techniques
might include walking meditation or exercising all 5 senses and talking
about how di ! erent it is to slow down and focus your awareness. And
there seems to be a special benefit when a whole school takes
mindfulness training together. Kids can remind each other to take a
breath instead of lashing out and teachers also benefit from minutes
spent on thinking calm and positive thoughts. When everyone in the
school trains together, supporters of mindfulness meditations say the
e ! ect multiplies and moves the whole culture of the school in a more
positive and peaceful direction. Now that’s a bright idea.

Margaret Flinter: That’s Conversations on Health Care for this week. I
am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Lucy Nalpathanchil: Conversations on Health Care broadcast from the
campus of Wesleyan University at WESU streaming live at
www.wesufm.org and brought to you by the Community Health Center.