One of the hopes about retail clinics is that they would help to reduce the number of emergency department (ED) visits for minor health problems at hospitals in their vicinity. That is not the case, according to a Rand study published in the Annals of Emergency Medicine. Look closer, though, and the findings suggest that retail clinics may steer some privately insured people away from hospital EDs.

ED visits are one of the most expensive silos in health care, and curtailing their overuse has long been on insurers’ wish list. Retail clinics are located in drug stores like CVS or Rite Aid or in large retail stores like Target or Walmart. Often, care is provided by a nurse practitioner rather than a physician.

This study looked at more than 2,000 emergency departments across 23 states from 2007 to 2012. The overall finding was that the opening of retail clinics was not associated with any significant reduction in visits to emergency departments for 11 low-acuity ailments (allergic rhinitis, bronchitis, conjunctivitis, other eye conditions, influenza, otitis externa, otitis media, pharyngitis, upper respiratory infections/sinusitis, urinary tract infections, and viral infections).

When the researchers broke down the ED statistics by payer, the privately insured group was the only one for which both the number (1,235 in 2007 versus 950 in 2012) and rate (119 per 1,000 ED visits in 2007 versus 108 in 2012) of low-acuity ED visits decreased during the study period.

Ateev Mehrotra, MD, an associate professor at Harvard Medical School and a member of the Managed Care editorial advisory board, was one of the co-authors of the study. He says that “contrary to our expectations, we found retail clinics do not appear to be leading to meaningful reductions in low-urgency visits to hospital emergency departments.”

Privately insured Americans may be the exception to the rule, because many retail clinics have opened in higher-income neighborhoods, where a greater proportion of residents have private insurance compared with residents of low-income neighborhoods, according to the study.

Retail clinics first began appearing in 2000, and now there are nearly 2,000 in operation across the United States, according to Rand. The clinics account for about six million patient visits a year. Clinic visits are less expensive than physician office or ED department visits, both because fees are lower and fewer tests tend to be performed.

Locations and hours of retail clinics are designed to satisfy an unmet desire for convenience in health. A report by Pricewaterhouse­Coopers in June projected that 40% of consumers (consumers were not defined) will seek care from a retail clinic this year.

But that convenience is apparently feeding demand for care that might not otherwise exist. Earlier this year, Mehrotra was the senior author on a paper published in Health Affairs that found that 58% of the visits to retail clinics for the same 11 low-acuity conditions represented new utilization, not substitution for care that would have been delivered elsewhere. That research, which used 2010–2012 Aetna claims data, found that retail clinic use was associated with an increase in health care spending of $14 per person per year.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.