Healthcare delivery continues to evolve to meet ever-changing patient demands. Over the years, rural doctors who historically performed house calls have been replaced with regional physician groups and community hospitals that are owned and managed by large health systems with multiple locations. Nearly 70% of physicians now work for a corporate entity instead of private practices. Telehealth visits increased 26x during the COVID-19 pandemic and have since leveled off, but are still a preferred method for many individuals and types of care.
The latest industry evolution is the expansion of retail healthcare delivery. Pharmacies, department stores, convenience stores, and technology companies are all shifting the standard of care toward retail or online centers that provide care at the same place you already shop for household supplies, groceries, or prescriptions. These new entrants are largely focused on offering primary care, urgent care, and a growing list of specialty services to make care more easily accessible, affordable, and cost-transparent. Patient satisfaction, convenience, quality care, and brand loyalty are core to their business models. Retail health centers have the potential to change the landscape of healthcare delivery, but there are challenges to overcome.
Patient expectations about provider availability and care coordination can present a challenge for retail centers. Payers have the added complexity of managing accurate directories that include information about retail health centers, fragmented medical histories, and patient engagement. By working together with authentic data, both payers and retail health centers have a unique opportunity to significantly impact patient care.
Patient Experience
For the patient, the experience at these retail centers can be vastly different from visiting a traditional physician’s office. When seeking care from a retail center, patients are oftentimes not making the decision based on the availability or reputation of a specific physician. Instead, the decision is based on the urgency of the care they need combined with their prior experience with the brand and overall convenience.
Once a patient chooses a brand and makes an appointment, they may have little input into how healthcare professional treats them. Rather than physicians, oftentimes, care is provided by mid-level clinicians who are qualified to provide care for the most common conditions. As a result, if a patient suspects their treatment needs are more complex and will require attention from a specialized care team, they may be referred to a physician outside the retail center, causing delays and potential frustration. Effective communication and accurate care coordination are key to maintaining a positive patient experience.
Follow-up coordination may be handed off to centralized, back-office call centers with no direct relationship with the patient or the practitioner, possibly leading to negative impacts on both efficiency and care quality. Patients may perceive the transition as impersonal, and the potential exists for additional back and forth if further clarification is needed, producing additional burdens for retail centers to maintain repeat customers and consistently generate a desirable patient experience.
Challenges for Payers
For payers, the growth of retail centers poses challenges and opportunities for network administration, care accessibility, and outcome management. Payers have a unique opportunity to add these retail outlets and their staff to their existing networks, resulting in lower member costs and increased convenience. In some cases, payers may design their networks and benefit structures to incentivize the use of these centers through lower out-of-pocket expenses or build tighter networks that require the use of retail centers for primary and urgent care. Building proactive partnerships with familiar retail delivery chains increases consumer trust that payers can fulfill patient needs.
Care availability from retail health centers is an undeniable benefit for patients who need care for a non-emergent condition. However, it can pose a challenge for provider data management, as many retail centers schedule their providers to work at separate locations or via telehealth platforms, with different hours on varying days of the week. This creates a significant hurdle for payers to support their members’ efforts to find care and maintain an accurate provider record for administrative and claim payment purposes.
The increase in retail locations has increased care accessibility, frequently leading to higher utilization and a decentralized medical history. Members may still pursue treatment with a traditional primary care provider (PCP) for regular preventive care or chronic condition management, in addition to specialty care and retail centers. This lack of care coordination from a traditional PCP can lead to problems relating to cost and outcome management. Ensuring seamless member navigation through various points of care will require payers to develop deep relationships with the retail centers in addition to local specialty care providers to which they refer patients. This may take the form of proactive partnerships like co-branding, data-sharing arrangements, or value-based contracting that incentivizes outcomes across parties.
Data is key to harnessing the opportunities
While retail care centers create an opportunity to improve access to care, they can encounter issues with coordinating care, maximizing patient engagement, maintaining accurate provider records, and helping members improve their health outcomes and manage costs.
Obtaining precise provider information is pivotal for payers to help their members find care quickly and for retail centers to have efficient operations for care coordination and referrals. Data on referral patterns and member behaviors across healthcare organizations will be critical for payers and retail centers to effectively manage the current decentralized delivery model. Insights and patterns from this data can help payers identify opportunities for value-based contracting, proactive partnerships, and network design that can ultimately reduce cost and improve health outcomes for their members.
Accurate patient data is key for both retail health centers and payers looking to coordinate care and drive positive outcomes The inability to reach a patient to schedule appointments, follow up on medication adherence, coordinate further care, or engage the patient in available health programs creates an immediate barrier for both retail health and payers. When these processes go awry, the patient may perceive a failure of both their payer and the retail health center, making it difficult for both to retain the patient as a customer.
Patients are increasingly utilizing retail health outlets for their care, and payers are recognizing the value the centers can provide for their members. The key to success lies in thoughtful engagement with the consumer, underpinned by accurate data that enables effective communication, care coordination, and promotes patient-centered care.
About Adam Rarick-Varner
Adam Rarick-Varner is a Senior Director of Healthcare Strategy at LexisNexis Risk Solutions. Throughout his career, Adam has spent over 20 years working at national health plans in a variety of roles, including leading back-office operations, customer-facing operations, call and claim center innovation, business and IT support, product development and process improvement. Adam holds an MS in Industrial/Organizational Psychology from the University of Tennessee Chattanooga, and a BA in Psychology from Bryan College.