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Management in Practice

Can health be a retail business?

MinuteClinic was founded in 2000 to provide retail healthcare — walk-in care for common illnesses. There are more than 500 MinuteClinics across 26 states and they have seen more than two million patients. CVS bought MinuteClinic in 2006 and most clinics are located in CVS pharmacies. Q3 talked with Cris Ross, MinuteClinic’s chief information officer, and Dr. James Hartert, the company’s chief medical officer, about how their business could change healthcare.

Q: From a business perspective, what need is MinuteClinic filling?

MinuteClinic puts healthcare in the pathway of consumers — where they live and work. We’re a no-appointment model and typically treat things like sore throat; eye, ear, and nose infections; bronchitis; and basic skin conditions, like poison ivy or sunburn. We post prices outside the clinic and accept insurance as well as cash payment.

Q: Who is your demographic?

Our visits are about one-third pediatric and two-thirds adults. A typical adult patient is between the ages of 25 and 55. The number of insured and uninsured patients is generally representative of the community that we’re in. If we’re in a community with lots of insurance, typically most of our patients are insured. If we’re in a market with more uninsured patients, we tend to see that.

Q: What does MinuteClinic do to existing models of healthcare delivery?

We are a disruptive innovation. We use price transparency, so people know what they’re going to pay before the service begins. We provide copies of medical records to the patient and to their home physician after every visit. We are very focused on consumerism and how to present healthcare as a product or service that someone would want to buy. And we’re conscious of the attributes people think about when they buy things. And all of those are a little bit unusual in the medical world. We’re clearly not going to help revolutionize cardiology or oncology, at least not directly, but we think we can help push the importance of primary care and reform in the primary care space.

Right now, primary care medicine is really struggling. There’s a decline in the number of primary care physicians. It is less lucrative than being a specialist. There are problems that are beyond what MinuteClinic can affect in terms of the ways Medicare, Medicaid, and private insurance reimburse for primary care, as opposed to advanced services. We think that primary care is probably under-compensated. But aside from that, if primary care is going to get itself in the right place, primary care practices are going to have to think about how to be more efficient and less of a cottage industry. And we think that our presence shows that there are ways you can do that.

In our clinics, we don’t have administrative staff. We don’t have a large waiting room. We don’t have receptionists. We don’t have billing clerks. The nurse practitioner does everything. And it’s all documented in the patient’s electronic medical record.

Q: How does the electronic medical record fit in?
We’re an add-on to someone’s normal medical care. So, it’s important for us to get medical records to the patient’s medical home. Out of the last half-million patient visits we sent out 320,000 records to physicians for patients who identified a medical home. Those 320,000 went to 18,000 different practices in all 50 states, plus the District of Columbia. We’ve got a major problem in dispersion of records. We don’t have one or two trading partners like some metro-based medical practice might have. We’ve got tens of thousands of people we need to get records to.

That’s why we’re looking for strong, intermediary-type organizations that have the scale and scope to be able to exchange these medical records. There are a number of very exciting developments that are coming, and MinuteClinic is involved in pilots in two or three of those.

I think we’re at the cusp of substantially more medical transactions on a national basis. There have been some regional initiatives and most of those have been hard-wired exchanges between known trading partners, like between a hospital and a clinic group. I think what’s about to happen is the broader availability of data between infrequent trading partners. It’s very exciting.

Just over a year ago, we converted to an industry standard called the continuity of care record, or CCR, and we’ve been strong advocates for CCR. What’s happening now is that that standard has really gained traction in particular in the consumer space and the personal-health-records space. Big players, like Google, have announced CCR will be the record that they use for exchange of medical data. Microsoft is using CCR as one of the standards they support.

Q: How does MinuteClinic fit into the broader healthcare reform effort?
There is no single solution that is going to fix everything. I don’t think a payer-only strategy will help. I don’t think a provider-only strategy will help. I don’t think a consumer-only strategy will help. I think disruptive reforms like MinuteClinic are helpful, if for nothing else, we might shake things up in ways that lead to powerful developments someplace else.

We clearly will not have an effect in the near term on the way that hospitals behave, for instance, but who knows? Someone might see the way that we’ve made healthcare more of a consumer service as opposed to traditional medical service and maybe think differently about how they’d present care. Payers may learn something from us, and modify the way that they design benefit plans for employers.

We get a lot of interest from employers who say, “MinuteClinic looks cheaper; it looks like my employees will miss less time at work. Gosh, I want that.” Disruptive innovations usually are something that happens over on the corner and then spread.

Dr. James Hartert
Chief Medical Officer

Q: What are the medical challenges to healthcare at MinuteClinic?
We don’t try to be all things to all people. We think that being really good at a select number of things is preferable. We obsess about quality.

One hundred percent of care is protocol- and guideline-driven. There’s still certainly room for the professional practice of medicine by our nurse practitioners, but the guidelines are a decision-support tool. We have checklists of questions that should be answered, triage modes, and care algorithms. The guidelines are robust enough to deal with the variation of patient experience, but since we deal with relatively minor acute illnesses, the approach lends itself to a very predictable algorithm- and protocol-driven experience and a very consistent care experience.

We published some data around strep throat in the American Journal of Medical Quality in November that analyzed 57,000 patients over a one-year period who came to a MinuteClinic complaining of acute sore throat. Best practice today would say that if you do a rapid strep screen, and it’s positive, you should treat with antibiotics. Any negative test, you should do a confirmatory test, which we do, and if that’s positive, we treat with antibiotics. Everyone else receives symptomatic treatment and antibiotics are withheld. We know from our data that 99.15% of the time that’s exactly what happens in our system. I’m not aware of another care system that could show that degree of compliance and consistency.

We are also 100% e-prescribers except in a few states that statutorily prohibit e-prescribing. Hopefully, they’ll catch up. E-prescribing has safety mechanisms from legibility of the prescription to checks against recorded allergies to averting harmful drug-drug interactions. Essentially, the system won’t allow clinicians to generate a prescription if the patient has a recorded allergy. The electronic environment allows for guideline adherence and creates a number of safety nets that we believe lead us to deliver a higher-quality product than elsewhere.

Q: What is MinuteClinic doing to change the way primary care doctors care for their patients?
I can give you a perfect example. Yesterday, my family was going to a large group practice where we’ve been receiving our care for years, and right outside the waiting room of the internal-medicine department there is now an immediate care clinic. A sign says, if you have a sore throat, cold, or minor illness, stop here and we’ll see you. It wasn’t there two months ago. It’s now integrated in their group practice.

Physicians also increasingly refer their patients to us during nighttime and weekend hours. They get a phone call. Someone says this and this and this. They tell them, “Go to your local MinuteClinic.”

While almost universally we see some initial apprehension from practitioners, I would say as they experience us in the marketplace, they see we’re good corporate citizens. We’re complementary to them; the fact that they refer their patients to us and the patient has a good service experience, it reflects back to them. They know they get copies of the medical records and know the services we provide are evidence-based, highly protocol-driven, so the trust factor grows and grows the longer we’re in a market.

Do you see this potentially opening up opportunities for primary care medicine?
If we’re able to deal with the runny noses, coughs, sore throats, and bladder infections, perhaps it frees up the primary care physicians to deal with more complex illnesses, or diagnostic problems, or continuity of care. Looking forward, it frees them up to focus on what they were truly trained to do. It matches their skill set better with patient needs and that brings efficiency to the healthcare delivery system, so that the outcomes are better, satisfaction is better, costs are lower. This is all from the patient perspective.

Some of the critics have said that we’re the death of primary care. That’s a myth. I think that’s a gross overstatement. We cannot exist in isolation. We need a robust, well-developed healthcare system to refer into. We believe in the medical home. We don’t want to be the medical home.

Our footprint is predominantly in retail environments, most in CVS pharmacies, a few in grocery stores, and a few in worksites such as Best Buy, Medtronic, Carlson Companies, and the University of Minnesota.

The satisfaction of our system is through the roof. We have patients who are absolutely delighted with the service experience they receive. We are right-sized, right-engineered, and very efficient. We have multiple studies that show that we’re somewhere between 30% and 80% less expensive than an alternative provider. As compared to a physician’s office, we’re 30% to 50% cheaper. Compared to urgent care, 50% cheaper; compared to emergency rooms, 80% less expensive. In terms of the public policy agenda of convenient access, quality service, best practice and harnessing best technology, patient outcomes, low cost, we’ve got a very robust system.

Q: How do you think this sort of innovation will play into the healthcare reform debate?
I believe that meaningful reform needs to include a structural reform of how healthcare services are delivered in terms of the right place, the right product, the right time, the right practitioner. The healthcare system is highly fragmented and desperately in need of automation and connectivity with information technology and needs to be right-sized particularly to meet the needs of a population that increasingly is struggling with chronic diseases rather acute episodes of illness. We fit in as a tangible example of the private marketplace delivering structural reform to healthcare delivery.

Out footprint is pretty bare bones. Our major vehicle is our electronic medical record, a competent practitioner, a telephone, and a few diagnostic tests. That’s generally for pin-stick-type technologies — doing a cholesterol check, a blood-sugar test.

Our physical platform is highly standardized, and it ties into the management in that we don’t have a whole bunch of one-offs in terms of physical layout, scope of services, or how they’re equipped. They’re all virtually identical, so it becomes a much more manageable proposition.

Our 515 stores look and feel almost identical. We are accredited by the Joint Commission. I believe we’re the only retail health facility to be so. When the Joint Commission comes to visit us, they often say, “When you’ve seen one hospital, you’ve seen one hospital. When you’ve seen one MinuteClinic, you’ve seen all MinuteClinics.”

Interviews conducted and edited by Ted O’Callahan