1. Nelson, Roxanne BSN, RN


NPs are finding new job opportunities, but with some old turf issues.


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While they are not the solution to our health care problems, clinics based in a retail setting may give patients more options. Also known as convenient care clinics, they are appearing all over the country at retail stores such as Wal-Mart, Walgreens, Kroger, Target, and CVS.


"Right now we have 320 clinics, and by the end of this year we'll have between 600 and 700 members," says Tine Hansen-Turton, executive director of the Convenient Care Association (CCA), a trade organization established in 2006 that represents 80% of the retail clinic population.


Although there is some variation, the retail clinics generally abide by the following standard business model:


* Care is provided by NPs or physician assistants.


* Services are limited to treatment of common illnesses (such as colds, allergies, sinus infections), mild skin problems (such as poison ivy, impetigo, cold sores), and preventive care (such as vaccines).


* Cost is low, ranging from about $30 to $60, depending on the service.


* Service is provided on a first-come, first-served basis, and the wait is generally less than 15 minutes.



Retail clinics may be a viable option for care for the nearly 47 million uninsured Americans, as well as for those who are frustrated by long waiting times to see their regular providers, who probably do not offer weekend or evening hours. Retail clinics are generally open seven days a week, have extended evening hours, and require no appointments. According to an April AARP Bulletin article, "Care in the Express Lane," the cost can be as much as 50% lower for the same service performed at a physician's office and a fraction of the price of an ED visit.


"Approximately 30% of patients say they do not have a primary health care provider," says Hansen-Turton. "And about 40% report that their only other option would have been to go to the ED or an urgent-care facility."


A number of health insurance and managed care corporations have been receptive to reimbursing costs for these services. CIGNA HealthCare was one of the first health insurance companies to endorse the idea of retail health care centers when it became affiliated with the MinuteClinic retail medical clinics. According to a CIGNA newsletter published in April, as of May 1, it will also offer member coverage at another chain, RediClinic, LLC.

Figure. NP Sheryl Ba... - Click to enlarge in new windowFigure. NP Sheryl Barthalow (left) checks Ann Theisen's daughter Hannah (center), age six, into the MinuteClinic at Cub Foods in Maple Grove, Minnesota. Retail care clinics provide services for patients with common illnesses, mild skin problems, and preventive care needs.

"This is cost-effective, high-quality care, and the trend is growing and it is here to stay," says Wendy Sherry, vice president of product development at CIGNA.


Monitoring the quality of the care. Retail clinics have been both lauded and criticized, the latter primarily by physician groups, who say they are concerned about the quality and continuity of care. Many of them, including the American Academy of Family Physicians (AAFP) and the American Medical Association (AMA), have issued guidelines that they believe will promote patient safety and an adequate level of care quality in this setting. The Illinois State Medical Society has introduced legislation that would require operating permits and set standards. The CCA has also developed standards for care quality in the retail clinic setting. (See for a list of the standards.)


The clinics maintain strict protocols and follow guidelines from the AMA and AAFP, explains Sherry. "The quality of care is very consistent and we have not seen any issues with patient satisfaction. Members are also averaging more than one visit per person, an indication of satisfaction."


A Wall Street Journal Online-Harris Interactive poll conducted between March 20 and 22 showed that 83% of respondents were satisfied with the convenience of the clinics and 90% were "very or somewhat satisfied with the quality of care." In addition, 80% expressed satisfaction with the cost.


Retail clinics are staffed primarily by NPs and follow state regulations regarding scope of practice and prescribing authority. All clinics have a collaborating physician, but the regulatory framework varies by state, says Hansen-Turton. Only six states, for example, have on-site physician support requirements for NPs, with Texas having the most restrictive rules, she explains. The majority of states also do not have laws limiting the number of NPs that one physician may support.


The safety of NPs has been well established. "The first studies from the 1970s showed that there is no difference in the quality of care between NPs and physicians, and those data have held," says Ken Miller, PhD, RN, CFNP, FAAN, associate dean of the College of Nursing at the University of New Mexico Health Sciences Center and immediate past president of the American College of Nurse Practitioners. "Studies show that NPs are able to perform 70% to 90% of what a primary care physician does."


As for retail clinics breaking continuity of care, Miller explains that the retail clinics either send an electronic copy of the medical record to the physician's office or give the patient a printed copy to give to their provider.


Opportunities for nurses. The retail clinic represents a new professional opportunity for NPs. Tracy Klein, MS, WHCNP, FNP, says that the retail clinic appealed to her because it was a "start-up model" at the time she started working in this setting. "It was important to me to feel that I had a part in the process of educating the public and in the corporation running the clinic," she says. Klein is currently an advanced practice consultant at the Oregon State Board of Nursing.


The part-time schedule also appealed to her, since she had a full-time administrative job and was in the first year of a PhD program. "The flexibility and limited scope of the retail clinic are well suited to part-time work," Klein explains. "Full-time employees were less satisfied. They found the work less of a challenge, isolating, and somewhat monotonous." Klein suggests that NPs may find more satisfaction in working in retail clinics in states where theirs is a more autonomous position.


The vast majority of NPs are employed by the companies that own the clinics, but a few have embraced the retail clinic model as a business opportunity. NP Juliet Santos, MSN, APRN-BC, owns Early Solutions Clinic, LLP, in Michigan. Her business consists of five clinics in full operation, two more that are almost ready to open, and three others under construction.


"I want other NPs to know that this is something that they can do too," Santos says. In addition to her corporation, Santos still maintains her family practice and hospital privileges.


It is an enormous leap to become an entrepreneur, and Santos notes that she had initially offered several NP colleagues the opportunity to go into business with her. "They all turned me down," she said. "Maybe it was financial, or they just didn't want to make the commitment. It does change your entire lifestyle."


Santos is hopeful that at some point, the NPs whom she employs will be interested in investing in the business. She says, "This model is still very new; it's a new field, and not something they teach you about in school."


Roxanne Nelson, BSN, RN