Repeat Retail Clinic Visits: Impact of Insurance Coverage and Age of Patient

Abstract

As retail clinics provide a less costly alternative for health care, it would be reasonable to expect an increase in multiple (repeat) retail visits by those patients who may have expenses for receiving primary care. If costs were not a significant factor, then repeat visits should not be significantly different between these patients and those with coverage for primary care visits. The hypothesis for this study was that patients with the potential for out-of-pocket expenses would have a higher frequency of repeat retail clinic visits within 180 days compared to those with primary care coverage. A retrospective chart review was conducted of 5703 patients utilizing a retail clinic in Rochester, Minnesota from January 1, 2009 through June 30, 2009. The first visit to the retail clinic was considered the index visit and the chart was reviewed for repeat retail clinic visits within the next 180 days. Using a multiple logistic regression model, the odds of a pediatric patient (N=2344) having a repeat retail visit within 180 days of the index visit were not significantly impacted by insurance coverage (P=0.4209). Of the 3359 adult patients, those with unknown coverage had a 25.6% higher odds ratio of repeat retail clinic visits than those with insurance coverage (odds ratio 1.2557, confidence interval 1.0421–1.5131). This study suggested that when cost is an issue, the adult patient may favor retail clinics for episodic, low-acuity health care. In contrast, the pediatric population did not, suggesting that other factors, such as convenience, may play more of a role in the choice of episodic health care for this age group. (Population Health Management 2012;15:358–361)

Introduction

I n the spectrum of health care reform, with significant legislative policy changes either enacted or proposed, the marketplace expansion of retail clinics may be looked at as a “disruptive technology.” The impact of this new model of care on health care systems has potential concerns (quality, lack of continuity) and yet others see areas of opportunity with the increased capacity and efficiency of care that this model may provide.¹

Cost savings has been shown to be one of the factors associated with patients choosing retail clinics.² An initial study in 2008 did demonstrate significant diagnosis-specific cost savings per episode of care.³ A recent study found that for 3 common illnesses, retail clinics were less costly and had no apparent change in quality metrics when compared to other primary care sites.⁴ If the benefits of retail clinics to the health care system are efficiency and cost-effectiveness, is the patient able to determine the level of services they need appropriately? One recent study demonstrated that patients seen in retail clinic settings tended to be less complex and that there was no difference in follow-up for their chronic disease management,⁵ suggesting that patients are able to appropriately self-select the level of care needed for their low-acuity medical conditions.

If overall cost to the patient were the major consideration, it would be reasonable to expect an increase in multiple (repeat) retail visits by those patients without insurance coverage, as retail clinics provide a less costly alternative for the patient. If cost were not a significant factor, then repeat visits should not be significantly different between those patients with insurance coverage and those without. Retail clinics do have a limited “menu” of services provided. Patients who have utilized the services previously have experienced the potential benefits and limitations to this type of episodic care. Thus, those patients are making a distinct choice if they choose to make a repeat visit to a retail clinic versus a primary care provider.

Because access to primary care availability also may have an impact on the utilization of retail clinic services, patients of 1 large primary care practice were compared. The patients were divided into 2 groups: those with institutional insurance coverage (IIC) and those with other or no insurance coverage (ONIC). These 2 groups had the same access to the same primary care providers and retail clinics. The IIC patients had no out-of-pocket expense for a primary care visit, whether with their primary care provider or at the retail clinic. The patients in the ONIC group potentially had out-of-pocket costs for which they were responsible. All “other” insurance carriers would have at least a co-payment, and those without insurance would have had to pay the entire cost of the retail clinic visit (which was less than 50% of the cost of a primary care office visit within the same institution). Because there was a potential cost barrier for access to primary care for the ONIC patients, the hypothesis for this study was that these patients would have a higher frequency of repeat retail clinic visits within 180 days compared to the IIC patients. The study examined the adult and pediatric populations separately.

Methods

This study was a retrospective chart review of 5703 patients paneled to the primary care practices in Rochester, Minnesota from January 1, 2009 through June 30, 2009, who also were seen in an affiliated retail clinic. Baseline data were obtained for the calendar year 2009. To allow the maximum amount of time for potential repeat visits and a consistent time frame for each patient, the first visit to the retail clinic practice was considered to be the index visit and the patient's chart was reviewed for repeat retail clinic visits in the subsequent 180 days. The retail clinics were staffed by nurse practitioners from the Department of Family Medicine, Mayo Clinic Rochester and were located in 2 separate retail settings. The retail clinics provided a menu of services for specific diagnoses, with set fees. There were 3359 (59.0%) unique individual adult patients (age 18 and older) and 2344 unique pediatric patients (41.0%).

The primary care providers were members of the Department of Family Medicine and the Divisions of Primary Care Internal Medicine and Community Pediatrics and Adolescent Medicine from Mayo Clinic Rochester, Minnesota. The patients were from a community-based practice, and approximately 50% were employees or dependents of Mayo Clinic and covered by the clinic's insurance plan (IIC group). The retail clinics and primary care practices shared an electronic medical record. Only patients who previously had given permission for inclusion in research studies were included in the analysis.

The dependent variable was whether the patient had a repeat retail clinic visit within 180 days of the index visit. The independent variables were age, sex, marital status (adult patients only), insurance coverage, and outpatient utilization patterns as determined by number of outpatient visits by the patient in the preceding 6 months.

Categorical data were analyzed with chi-squared analysis and numerical variables with Mann-Whitney testing by MedCalc software, version 11.5.1.0 (MedCalc Software bvba, Mariakerke, Belgium; www.medcalc.org). Logistic regression analysis retained all independent variables for either age group. This study was approved by the Mayo Clinic Institutional Review Board.

Results

A total of 1218 (21.4%) of the 5703 patients seen at the retail clinics during this time frame had a repeat visit during the 180 days following the index visit.

Pediatric retail clinic patients

In the univariate analysis of the population of pediatric patients who utilized the retail clinic during the first 6 months of 2009, those 625 (26.7%) patients who had repeat retail clinic visits within 180 days of the index visit were slightly younger and had increased outpatient clinical visits for the 6 months prior to the index visit. There was no difference in the sex of the patient or the percentage with IIC (Table 1).

Table 1.

Patient Demographic and Clinical Variables of the Pediatric Population Utilizing Retail Clinics in Rochester, Minnesota During January to June 2009, with Single or Multiple Retail Clinic Visits

Patients <18 Years of Age	Repeat Retail Clinic Visits N=625	Single Retail Clinic Visit N =1719	P Values
Age (years)	7.1 (1–17)	8.1 (1–17)	<0.0001
Sex (% female)	55.2%	50.7%	0.0615
Institutional insurance coverage (% covered)	70.9%	69.9%	0.6920
Outpatient visits 6 months prior to index	1.8 (0–19)	1.5 (0–15)	0.0010

Using multiple logistic regression, the odds of a pediatric patient having a repeat retail visit within 180 days of the index visit were not significantly impacted by IIC. Age was inversely associated with the odds of repeat clinic visits, as was the sex of the patient, with girls more likely to have had a repeat visit. In multivariate analysis, the presence of prior utilization as gauged by the number of outpatient clinical visits in the prior 6 months remained an independently significant variable also (Table 2).

Table 2.

Multiple Regression Model for Odds of a Repeat Retail Clinic Visit Within 180 days of the Index Visit for Pediatric Patients in Rochester, Minnesota During 2009

Pediatric Patients <18 Years of Age N=2344	Odds Ratio for Repeat Retail Clinic Visit within 180 Days of Index Visit	Confidence Interval	P Values
Age	0.9559	0.9369–0.9753	<0.0001
Sex (female)	1.2288	1.0206–1.4795	0.0296
Insurance coverage	1.0870	0.8872–1.3318	0.4209
Outpatient visits 6 months prior to index	1.0666	1.0229–1.1122	0.0025

Adult retail clinic patients

A total of 593 (17.7%) of the 3359 unique adult patients seen in the first 6 months of 2009 had at least 1 repeat retail clinic visit within 180 days of their index visit. The patients who made repeat retail clinic visits had greater prior 6-month utilization of outpatient visits, were more likely to be women, and were less likely to have IIC (Table 3).

Table 3.

Patient Demographic and Clinical Variables of the Adult Population Utilizing Retail Clinics in Rochester, Minnesota During January to June 2009, with Single or Multiple Retail Clinic Visits

Patients ≥18 Years of Age	Repeat Retail Clinic Visits N=593	Single Retail Clinic Visit N=2766	P Values
Age (years)	39.2 (18–91)	40.3 (18–92)	0.1282
Sex (% female)	73.0%	66.1%	0.0012
Married (% married)	62.1%	65.8%	0.0948
Institutional insurance coverage (% covered)	59.5%	64.0%	0.0475
Outpatient visits 6 months prior to index	2.3 (0–18)	1.9 (0–26)	0.0021

Multiple logistic regression revealed that those adult patients who were covered by IIC were less likely to be repeat utilizers of retail clinics. Thus, the ONIC patients had a 25.6% higher odds ratio (OR) of repeat retail clinic visits than those who had IIC (OR 1.2557, CI 1.0421–1.5131). Prior outpatient utilization was again an important factor in driving repeat visits, with a 5% odds of repeat visits increasing with each additional outpatient visit in the prior 6 months. Age and sex also were independently significant variables, while marital status was not (Table 4).

Table 4.

Multiple Regression Model for Odds of a Repeat Retail Clinic Visit Within 180 days of the Index Visit for Adult Patients in Rochester, Minnesota during 2009

Adult Patients ≥18 Years of Age N=3359	Odds Ratio for Repeat Retail Clinic Visit within 180 days of Index Visit	Confidence Interval	P Values
Age	0.9945	0.9883–1.0008	0.0085
Sex (female)	1.3312	1.0887–1.6278	0.0053
Marital status (married)	0.9637	0.7901–1.1756	0.7157
Insurance coverage	0.7964	0.6609–0.9596	0.0167
Outpatient visits 6 months prior to index	1.0511	1.0197–1.0834	0.0013

Discussion

Our hypothesis for the adult patients was correct in that the ONIC patients were more likely to have repeat retail clinic visits. Although no specific data on this were revealed in our retrospective chart review, perhaps the perceived value of the care received in the context of lower cost was an important consideration for this group, as has been demonstrated in other settings.² As well, patients who made repeat visits had prior exposure to retail practices and understood the differences between retail and primary care medicine. These patients were making the choice of provider for their low-acuity health concern as informed consumers.

From an insurance or health plan point of view, the development of a retail clinic could be concerning as a cost center and another avenue for patients to utilize resources. Our data demonstrated that adult IIC patients were less likely to make repeat retail clinic visits, thus lessening the concern about possible overutilization with the development of the new health care resource.

Our hypothesis was not correct for the pediatric population in this study. The presence of IIC was not a significant factor in the frequency of repeat retail clinic visits. In this situation, with the parents/guardians directing a majority of the health care decisions, other factors, such as convenience, may be the determining decision point. These findings are consistent with previous studies that showed that families with children were one of the groups that had increased utilization of retail clinics, and that convenience was cited as the most common reason patients choose retail clinics.^6,7

This study and others that we have done have demonstrated consistently that prior individual patient health care utilization patterns appear to predict future medical visits, including visits to retail clinics. For example, when we tested the impact of age, severity of illness, and obesity on primary care visits, the previous pattern of visits was significant.^8,9 When we tested the impact of electronic consults, online visits, and retail clinics on visits or standard costs in comparison to usual care, the number of previous visits was significant.^10

–13 Any studies of the impact of practice innovations on visit rates or costs that fail to adjust for previous visit patterns have omitted an important confounding variable.

This study was performed in 1 large multidisciplinary primary care group in Minnesota, the majority of whose patients are covered by a large single insurance carrier (IIC). The results may not be consistent with those seen in other locations or in those practices with a different market of insurance products. Another potential limitation was that we did not distinguish between patients with other insurance versus no insurance within the ONIC group. There was minimal racial and socioeconomic heterogeneity in the primary care practice studied. A majority of the visits to the retail clinic in 2009 were made by patients covered by the institutional insurance plan and other retail clinics with a different market of insurance products may have different results. Further study into the patients' reasons for choosing the option of a retail clinic would be interesting, based on the findings of the current study. In addition, many of the IIC patients had medical training, whereas ONIC patients were less likely to have medical training. Patients with a medical background may use retail clinics differently and this potential effect could not be separated out and controlled for by the independent variables available for analysis.

Conclusions

In the primary care practice studied, those adult patients whose health care coverage was of an insurance product that covered both primary care and retail clinic medical costs equally (and with no out-of-pocket expense) did not experience increased utilization in the form of repeat retail clinic visits. The adult patients who had other or no insurance coverage did experience increased odds of repeat retail clinic visits during the 180 days after their index visit. This suggests that for those patients who may have a financial cost, retail clinics were perceived as a value for episodic, low-acuity health care. In contrast, the pediatric population did not have any differences in the utilization odds for repeat retail clinic visits. A suggestion was that other factors, such as convenience, may play more of a role in the choice of episodic health care for this age group.

Footnotes

Acknowledgment

Jerry Sobolik, B.S. and Julie Maxson, B.A. abstracted the data analyzed in this study.

Author Disclosure Statement

Drs. Angstman, Bernard, Rohrer, Garrison, and Mac-Laughlin disclosed no conflicts of interest with regard to this manuscript.

The Department of Family Medicine, Mayo Clinic, funded this study.

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