The Archives of Internal Medicine recently published a study of geographic trends in retail healthcare. It found that only a small percentage of retail clinics are located in low-income areas. This is rather surprising news given that the industry has been touted as a solution for the poor and uninsured. It's also perhaps dismaying for convenient care professionals, nurse practitioners whose training and education are focused on serving the underserved.

"My observation is that the slam-dunk demographic is the dual-income, well-educated parents with kids," says Tom Charland, CEO of Merchant Medicine, a firm that analyzes markets for retail clinics and employer sites. "So it's no accident that these are the locations where retail clinics operators have placed most of their clinics."

Tracy Klein, NP, a member of the Oregon Board of Nursing who has worked in a convenient care setting, says another determinant of clinic location choices is the availability of primary care locations for referral purposes.

Charland believes education also plays a role. Many patients who visit retail clinics have diagnosed themselves and are seeking confirmation, he suggests. "Those who tend to self-diagnose are those who are confident in their observations, and that tends to be a more highly educated person."

Study Findings
The study found that only 123 of 930 retail clinics studied (14%) were located in low-income areas. (The full citation for the study is Pollack CE, Armstrong K. The geographic accessibility of retail clinics for underserved populations. Arch Intern Med. 2009;169[10]:945-949.)

To a certain degree, lower-income patients will travel to the clinics regardless of their location. Craig Pollack, MD, the lead author of the study, says other reports show that many patients who visit convenient care clinics are paying out of pocket or have no health insurance.

"It is unclear whether these individuals live in the vicinity of retail clinics or if they are willing to travel farther in order to be seen in them," Pollack says. "If retail clinics are considered an important component of the delivery system, then rethinking their distribution may allow for greater accessibility for vulnerable populations."

Reshaping the Future
How can NPs help expand retail healthcare into more underserved areas? The study article suggests that federal or municipal incentives could help attract clinic operators to lower-income locations. Klein agrees. "Now that clinics are accepting Medicaid and Medicare and aligning with hospital systems and large employers, they may be better positioned to subsidize locations in more diverse areas," she explains.

Charland points out that income is less a factor than culture and language when determining whether a clinic will be successful in a certain location. And that means the success of clinics in lower-income areas hinges on nurse practitioners.

"Healthcare is a very personal thing, and it requires trust between the patient and practitioners," Charland notes. "So if you get into situations where there are language issues and cultural issues . [you need] a practitioner who speaks a specific language and is culturally sensitive. It's very difficult to do that in a retail clinic."

If NPs in retail clinics can cater to the multiethnic and multicultural populations in lower-income areas, clinics there could have a better shot at success. "It all boils back down to the nurse practitioners and how much exposure they have had to different ethnicities and how comfortable they are, and how comfortable they can communicate to the patient they are," Charland explains.

It's a complicated issue, he says, and critics of the retail healthcare industry may tend to throw stones at operators who open clinics in predominantly upper-income, outer-ring suburbs. "But that's where they've figured it out. It's not that they don't want to be in other parts of a metro area, it's just that they haven't quite figured out how to do it. They've tried, but not with great success."

Big Box Solutions?
Charland predicts that Wal-Mart may have the best shot at resolving this problem. If Wal-Mart were to open federally qualified clinics, cost and reimbursement challenges would be lessened. And potential hospital system partnerships could address cultural sensitivity, he says.

Because a cross-section of the population shops at Wal-Mart, clinics located in these stores could serve everyone.

Jennifer Ford is the associate editor and our retail health columnist. Reach her at jford@advanceweb.com.

14% of retail clinics are in low-income areas

81% of retail clinics are in areas predominantly populated by white people

7% of people in areas with retail health clinics live in poverty

Source: Pollack CE, Armstrong K. The geographic accessibility of retail clinics for underserved populations. Arch Intern Med. 2009;169(10):945-949.