Bobbi Radford showed up at the CVS MinuteClinic in Batavia, Ohio, last Thanksgiving because she had pain in her arm.
“I waited an hour and then was told to go to the [emergency room].,” Radford said. Filling the staffer in on her history of congestive heart failure, she was directed to go to the ER. But Radford says after she did that, it was determined at the ER that she had a case of tennis elbow.
“It was a waste of my time, and I still had to go to my family doctor,” Radford said.
Despite their early promise of convenience and accessibility, in-store clinics haven’t been the golden egg-laying goose many retailers originally envisioned. That’s why Walmart recently announced it would shutter its 51 in-store full-service healthcare centers. Another symptom of the ailing market is Walgreens, which announced the closing of 160 VillageMD locations (Walgreens owns a 63% stake in VillageMD, which also operates free-standing clinics). CVS’s MinuteClinic, the largest in-store clinic with over 1,100 locations, has announced dozens of clinic closings this year in Southern California and New England.
Not all patient experiences are negative. Karla Lemon of Conway, South Carolina, says she uses CVS’s MinuteClinic for vaccines or sinus infections. “I’ve had a pretty good experience with them,” said Lemon.
But the business experience in the retail health clinic space has largely disappointed. That’s not a huge surprise to Timothy Hoff, professor of management healthcare systems at Northeastern University. Hoff has researched retail health clinics and how they deliver primary care and says that the margins can be thin to non-existent, and that the many other challenges have hindered their success. What was not too long ago viewed as the “2.0” version of primary health care is now being left behind in the wake of closed in-store clinics.
“1.0 was the rise of urgent care centers. Those were places 20 or 30 years ago that gave people alternatives to primary care doctors,” Hoff said. But about 15 years ago, Hoff says, the space began moving into heavily trafficked stores like groceries and department stores with health care attempting to meet people where they were. But this presented challenges that many retailers, and even some providers, weren’t familiar with.
“Some of these organizations grew this part of their business too quickly and didn’t realize the cost model in sustaining these,” Hoff said. Insurance reimbursements at these clinics are low, but the expenses have gone way up. “I just don’t think the math works for many places now to have many of these. Some of these large organizations are retrenching and pulling back,” Hoff added.
The retail clinics depend on volume selling. “If you can’t pump through a lot of patients, it doesn’t work,” Hoff said. Staffing was also a struggle. “They ended up being more expensive to run than they thought, combined with a workforce shortage, they just didn’t work.”
There is also the issue of cross-selling. A lot of retail chains use clinics as loss leaders to steer customers to other products and services they sell: lure customers in, in the hope they buy other stuff. But the model didn’t materialize. If someone is sick enough to seek care, they probably won’t be in the mood to purchase a pint of ice cream or socks while they are out. Likewise, “people coming in for groceries won’t necessarily hop over to the clinic,” Hoff said.
A retail reality check for MinuteClinic
Colleen Sanders, a family nurse practitioner in Washington, D.C., who now works in healthcare education, worked a two-year stint at MinuteClinic. She pointed to margin and staffing issues she witnessed.
“Health care is a business in the USA; while we look at the giant numbers of how many billions are generated, it doesn’t mean there will be big margins. I think retailers have realized that they will not be making millions and millions of dollars,” said Sanders. “Margins are small.”
Staffing costs, meanwhile, slicing into already thin margins, meant that when Sanders worked at MinuteClinic, she did everything from checking people in, to billing and cleaning the clinic at the end of the day, and any support staff was undertrained, at best, she said. “That was the model to ensure they could do it so they didn’t have to add staff. But with volume, you need ancillary staff so the professional can dedicate time to patient care, because that is where you can bill insurance and revenue comes in.”
The 15 minutes that she was allotted to see a patient often just wasn’t enough for the complex ailments people sometimes have. For some patients, service simply wasn’t fast enough: Sanders recalled a 7-year-old she was treating remark that treatment was taking more than a minute. Ultimately, Americans’ “want-it-now” culture doesn’t mesh with medicine, and that is what the retail clinic closures are signaling. “The pace at which we want health care to work isn’t congruent with actually providing the level of service we should be providing, coupled with the cost of having support staff,” Sanders said. “If we wanted to make a dent in retail health care, then we would staff with registered nurses instead of medical assistants, but that would cost too much.”
CVS wouldn’t comment directly on the closings, but a spokesperson described the latest strategy as a combination of care delivery capabilities — a blend of virtual, in-store, and in-home services — that delivers a “more convenient experience.”
Walmart and the problem of volume vs. price
In 2019, Walmart announced a bold initiative to open 4,000 in-store health clinics by 2029. But those plans ended with the recent closing of the 51 clinics it had opened.
“Primary health care is a low margin business,” said Arielle Trzcinski, a principal analyst covering health care at research firm. Forrester. ”Compared to what they see in traditional retail, health care is a fundamentally different business,” Trzcinski said, citing the challenges of navigating insurance companies and administrative burdens that health care brings.
Retailers can’t recoup money from offering primary care as a loss leader in the same way other health care organizations can.
“Primary care is a feeder for patients that need higher acuity services, such as surgery or specialists. Hospitals make money on the back end and Walmart or Walgreens didn’t have that,” Trzcinski said. CVS fares better because of its merger with health insurer Aetna that now allows for upselling of other services, including mental health.
“Walmart ultimately thought they were solving an important issue,” Trzcinski said, but she added that Walmart never really put its full marketing muscle behind the effort or created relationships with other employers to make a pathway into the clinic. “They set out to make health care more affordable and convenient for their customers. But to do that you need volume. … It takes volume or a different pricing structure, to make it work, and Walmart, in the end, had neither calibrated correctly.”
A missed opportunity for rural America
Sanders says the business model’s constraints have even undermined one of the retail clinic concept’s great promises: health-care delivery to rural areas.
“Walmart tried to go into rural areas where providers were scarce and to meet a community need; I think it is a great idea because everyone knows where the local Walmart is. But getting providers to go to rural areas and work is really challenging. The quality of life and the things people can do in a small town are not as appealing as urban centers, so they pay providers a premium to work there,” Sanders said, and that is one more thing that eats into revenue.
Retailers will continue to experiment with the model.
Dollar General, for example, has attempted a “workaround” by offering mobile clinics that visit some of its rural locations, and offer a variety of minor medical services.
Amazon’s recent launch of One Medical, which features a $9-a-month subscription charge for existing Prime members, offers another way to make money.
“They get your cash whether you end up using the service or not, and it is a good price if you need the care,” said Virgil Brantz, CEO of Washington-based fintech health platform MacroHealth. The care is virtual, but you can walk in if you are near a One Medical facility. Unlike most models that make money when patients come, “Amazon makes more money if you don’t show up. So there is something a little different about this retail model,” Brantz said.
In-store health clinics can be profitable and viable, and retailers are experimenting with piecemeal approaches tailored to the local market. Walgreens recently announced the opening of a handful of in-store health clinics in Connecticut, which will be run by Hartford HealthCare, with the clinics being called “Hartford HealthCare at Walgreens.” Patients will be able to go beyond typical small-scale clinic services and tap into Hartford’s larger network of specialists and care options.
And in Phoenix, a Be Well Health Clinic operates in a Walgreens near the campus of Arizona State University, catering just to sexual health issues.
“The common thread is it is a locally-based partnership with a local provider with the shared goal of offering convenience and access,” said a Walgreens spokesperson.
Meanwhile, in Atlanta, Little Clinics, which operate inside Kroger, is shifting services to focus on senior care.
Walmart and Kroger did not respond to requests for comment.
This is all part of what Hoff calls “health care 3.0,” a continuing disruption and evolution of primary care delivery based on market and customer needs, and including retail clinics. New models will emerge, and not every model will work.
“Every several years, there is a run of outsiders trying to make changes to health care, good and bad,” Brantz said. Inevitably, they “hit the brick wall of the reality of just how complex healthcare can be.”