Freestanding emergency departments, which provide emergency medical care but are physically separate from hospitals, charge many times more than other providers for the same care, according to a new analysis by UnitedHealth Group.
(Standard disclaimers apply: Yes, the nation’s biggest insurer has some skin in the game here on ER costs. But there’s also plenty of other evidence that ER costs are indeed very high.)
How it works: Freestanding ERs often don’t provide treatment for common emergencies like trauma, strokes and heart attacks, per my colleague Caitlin Owens.
Only 2.3% of visits to freestanding emergency departments are for actual emergency care.
The number of these facilities increased from 222 in 2008 to 566 in 2016.
In Texas, the average cost of treating common conditions at a freestanding emergency department is 22 times greater than treatment at a doctor’s office, and 19 times more than at an urgent care center.
If the location of care was changed to one of these cheaper alternatives, it’d save more than $3,000 per visit.
Freestanding emergency departments are disproportionately located in affluent areas that have access to other providers, and in Texas, less than one in four receive ambulances.
The bottom line: It is much, much cheaper to go see your family doctor if you have a fever — the most common diagnosis at Texas freestanding emergency departments.
Mayor Bill de Blasio announced Tuesday a plan to “guarantee health care to all New Yorkers.” Responding to what he described as Washington’s failure to achieve single-payer health insurance, the mayor laid out a “transformative” plan to provide free, comprehensive primary and specialized care to 600,000 New Yorkers, including 300,000 illegal immigrants. “We are saying the word ‘guarantee’ because we can make it happen,” he announced, pledging to put $100 million toward the new initiative.
If spending an additional $100 million is all it takes to pay the health costs of a half-million people, you may wonder why New York City Health + Hospitals (HHC) is going broke spending $8 billion annually to treat 1.1 million people. The answer: Mayor de Blasio is not really proposing anything new; nor is he planning to expand services or care to anyone currently ineligible. All of New York City’s uninsured—including illegal aliens—can go to city hospitals and receive treatment on demand. The mayor is trying to do what some of his predecessors attempted—shift patients away from the emergency room and into primary care, or clinics. In 1995, for instance, then-mayor Rudy Giuliani empaneled a group of experts to address the future of the city’s public hospitals. The panel concluded, in the words of a Newsday editorial, that “for patients, emphasis would be on primary care instead of hurried emergency-room sessions and days of hospitalization.”
The tendency of a segment of the population to avoid the health-care system until a critical moment, relying in effect on emergency rooms for primary care, has been the knottiest problem in public health for decades. Letting simple problems fester makes them more expensive to treat. Using ERs designed to handle resource-intensive trauma situations for basic medical problems is inefficient and wasteful. The city has spent lots of money trying to convince poor, often dysfunctional people to develop regular medical habits by signing up for Medicaid and getting a primary-care doctor.
De Blasio makes it sound as though illegal immigrants have not been able to get health care until now. But in 2009, Alan Aviles, then the city’s hospitals chief, spoke of “hundreds of millions of dollars in federal funds that cover the costs of serving uninsured patients including undocumented immigrants.” Aviles said that the city was renowned for its “significant innovations in expanding access to care for immigrants, including our financial assistance policies that provide deeply discounted fees for the uninsured, our comprehensive communications assistance for limited English proficiency patients, and our strictly enforced confidentiality policies that afford new immigrants a sense of security in accessing needed care.”
In 2013, Lincoln Hospital in the Bronx announced a new “Integrated Wellness Program” targeting seriously mentally ill people with chronic health problems—the same population that tends to be uninsured, to neglect their own care, and to wind up in the emergency room when their diabetes or cardiovascular disease catches up with them. “At Lincoln, we aim to establish best practices that combine physical and mental health—two services which have historically been treated separately,” said Milton Nuñez, then as now Lincoln’s director—words not much different from what Chirlane McCray said at Tuesday’s “revolutionary” press conference.
HHC director Mitchell Katz practically admitted that the mayor’s announcement of guaranteed health care for all is just fanfare, amounting to more “enabling services” for already-existing programs. Asked if uninsured people—largely illegal immigrants—can get primary care now, Katz explained, “you can definitely walk into any emergency room, you can go to a clinic, but what is missing is the good customer service to ensure that you get an available appointment. . . . that’s what we’re missing and the mayor is providing.”
Dividing $100 million by 600,000 people comes to about $170 per person—perhaps enough money to cover one annual wellness visit to a nurse-practitioner, assuming no lab work, prescriptions, or illnesses. Clearly, the money that the mayor is assigning to this new initiative is intended for outreach—to convince people to go to the city’s already-burdened public clinics instead of waiting until they get sick enough to need an emergency room. That’s fine, as far as it goes, but as a transformative, revolutionary program, it resembles telling people to call the Housing Authority if they need an apartment and then pretending that the housing crisis has been solved. Mayor de Blasio is an expert at unveiling cloud-castles and proclaiming himself a master builder. His “health care for all” effort seems little different.
Vertical integration is all the rage in healthcare these days, with Aetna, Cigna and Humana making notable plays.
If the proposed CVS-Aetna, Cigna-Express Scripts and Humana-Kindred deals are cleared by regulators, the tie-ups will have to immediately face UnitedHealth Group’s Optum, which has been ahead of the curve for years and built out a robust pharmacy benefit manager (PBM) business already along with a care services unit, employing about 30,000 physicians and counting.
UnitedHealth formed Optum by combining existing pharmacy and care delivery services within the company in 2011. Michael Weissel, Group EVP at Optum, told Healthcare Dive the company began by focusing on three core trends in the industry: data analytics, value-based care and consumerism.
Since then, the company has been on an acquisition spree to position itself as a leader in integrated services.
“For the longest time, the market assumed that they were building the Optum business [to spin it out] and what is interesting in the evolution of the industry is that that combination has now set a trend,” Dave Windley, managing director at Jefferies, told Healthcare Dive.
“United has now set the industry standard or trend … to be more vertically integrated and it seems less likely now that United would spin this out … because many of their competitors are now mimicking their strategy by trying to buy into some of the same capabilities,” he said.
Weissel said Optum will continue to push on the three identified trends in the next three to five years, with plans to invest heavily in machine learning, AI and natural language processing.
The question will be whether and how the company can keep its edge.
What Optum is
Optum is a company within UnitedHealth Group, a parent of UnitedHealthcare. Optum’s sister company UnitedHealthcare is perhaps more well known within the industry and with consumers.
However, Optum, a venture that encompasses data analytics, a PBM and doctors,has been gradually building its clout at UnitedHealth Group.
In 2017, the unit accounted for 44% of UnitedHealth Group’s profits.
In 2011, UnitedHealth Group brought together three existing service lines under one master brand. Services are delivered through three main businesses within a business within a business:
OptumHealth – the care delivery and ambulatory care capabilities of OptumCare, as well as the care management, behavioral health, and consumer offerings of Optum;
OptumInsight – the data and analytics, technology services and health care operations business; and
OptumRx – its pharmacy benefit service.
The company focuses on five core capabilities, including data and analytics, pharmacy care services, population health, healthcare delivery and healthcare operations. Services include but are certainly not limited to OptumLabs (research), OptumIQ (data analytics), Optum360 (revenue cycle management), OptumBank (health savings account) and OptumCare (care delivery services).
The Eden Prairie, MN-headquartered company has recently expanded its care delivery services, with much of the growth coming from acquisitions. The past two years have seen Optum expand its footprint into surgical care (Surgical Care Affiliates), urgent care (MedExpress) and primary care (DaVita Medical Group).
It’s a wide pool, but the strategy affords UnitedHealth the opportunity to grab more revenue by expanding its market presence. For example, the DaVita acquisition, which is still pending, allows OptumCare to operate in 35 of 75 local care delivery markets the company has targeted for development, Andrew Hayek, OptumHealth CEO, said on an earnings call in January.
Optum’s strategy of meeting patients where they are and deploying more ambulatory, preventative care services works in concert with its sister company UnitedHealthcare’s goal of reducing high-cost, unnecessary care services, when applicable. If Optum succeeds in creating healthier populations that use lower levels of care more often, that benefits the parent company UnitedHealth Group as UnitedHealthcare spends less money and time on claims processing/payout.
The strategy has been paying off so far.
Three charts that show UnitedHealth’s financial health as it relates to Optum
Optum’s presence has grown as it has steadily increased its percentage of profits for UnitedHealth Group.
In 2011, the first year Optum was configured as it looks today, the company contributed 14.8% of total earnings through operations to UnitedHealth Group with $1.26 billion. That’s about 29 percentage points lower than in 2017, when Optum brought in $6.7 billion in profits on $83.6 billion in revenue.
Broken down, it’s clear that pharmacy services make up the lion’s share of the company’s revenue. In 2017, OptumRx earned $63.8 billion in revenue, fulfilling 1.3 billion prescriptions. OptumRx’s contributions to the company took off in 2015 when Optum acquired pharmacy benefit manager Catamaran.
In recent years, OptumHealth has grown due to expansion in care delivery services, including consumer engagement and behavioral and population health management. The care delivery arm served 91 million people last year, up from 60 million in 2011.
OptumInsight has grown largely due to an increase in revenue cycle management and operations services in recent years.
On Wall Street, UnitedHealth Group is performing well and has seen healthy growth since 2008. The stock peaked in January and took a dive when Amazon, J.P. Morgan and Berkshire Hathaway — industry outsiders yet financial giants — announced they would create a healthcare company.
While these charts suggest a dominant force, the stock activity shows that investors believe there’s still more room for competition, if the new entrants play their cards right.
Where Optum could lock out and rivals could cut in on competition
UnitedHealth started down this strategic path many years ago and the rest of the industry just now seems to be catching up.
“Optum’s been the leader in showing how a managed care organization with an ambulatory care delivery platform and a pharmacy benefit manager all in house can lower or maintain and bend cost trend and then drive better market share gains in their health insurance business,” Ana Gupte, managing director of healthcare services at Leerink, told Healthcare Dive. “I think they have been the impetus in the large space for the Aetna-CVS deal.”
Because the company is multi-dimensional, Optum’s competition will be varied. If all the mergers making news — including the Walmart’s rumored buyout of Humana — close, here’s what competition could look like:
Perhaps oddly, its largest revenue contributor, OptumRx, seems to have the largest vulnerability for competition in the coming years.
Optum’s competitive advantage in the PBM space is driven largely by already realized integration. Merging data across IT systems is no easy task, and Optum has spent years harmonizing pharmacy data across platforms to assist care managers in OptumCare to see medical records for United members.
Anyone with experience implementing EHR systems can tell you such integration doesn’t happen over night.
If the Cigna-Express Scripts deal closes, the equity can compete with OptumRx, but the technology investment needed to harmonize data and embed Cigna’s service and pharmacy information into Express Scripts servers will take time, Windley said. Optum, on the other hand, has invested in the effort and integration for years.
Gupte says the encroaching organizations in the PBM space have the ability to realize the efficiencies and savings and the integrated medical that Optum has been realizing across OptumRx and the managed care organization.
Optum’s leg up in PBM space could last two to three years over the competition, she said.
On the care delivery side, OptumHealth has been purchasing large physician groups for a variety of services. There are only so many large physician groups putting themselves on the market, and Optum has been making bids for them.
There’s still a bit of white space to fill in its 75 target markets, but analysts note Optum may have the competition on lock in this space
Even if CVS-Aetna closes, OptumCare is a $12 billion business with many urgent and surgery care access points. If CVS-Aetna is finalized, the company will have about 1,100 MinuteClinics capable of realizing efficiencies with Aetna, but, as Windley notes, they likely won’t have primary care or surgery care elements.
There’s also a lot of time and capital needed for building out and retrofitting retail space to medical areas.
On the surgical care services, “I don’t see either Cigna, Aetna or Humana getting into that business,” Gupte said. “That will be one element of their footprint on care delivery that will be unique and differentiated for them.”
Urgent care has the potential for outsider competition, she added. However, Optum is using its MedExpress business to treat higher acuity conditions and have an ER doctor on staff in each center. Compared to the typical types of conditions treated in retail clinics or those that would be feasible over time, Gupte believes services that could be seen in CVS or Walmart would be lower acuity, chronic care management services.
“[Optum has] been so proactive and so strategic I don’t think there’s going to be a lot of reactive catchup they have to do,” Gupte said. “I think it’s going to be hard for the other entities to play catch up, outside of the PBM.”
One potential issue will be harmonizing the disparate businesses so patients can be effectively managed across the various organizations, Trevor Price, founder and CEO of Oxean Partners, told Healthcare Dive.
“I think the biggest challenge for Optum is operationalizing the combined platform,” Price said. “The biggest question is do they continue to operate as individual businesses or do they merge into one.”
Optum will continue to explore ground in the three core trends it has identified.
Out of the three, consumerism has the longest path to maturity in healthcare, Weissel said, adding he believes consumerism is going to change healthcare more than any other trend over the next decade.
“There is a wave coming, and this expectation that we will move there,” he said. “Increasingly, this aging of people who become very comfortable in a different modality is going to tip the balance with how people will want to interact with healthcare. I know there’s pent up demand already.”
That means the company is putting bets into the marketplace around consumer building and segmentation models as well as thinking about how to connect data to allow patients to schedule appointments, view health records, sign up for insurance, search for providers or renew prescriptions online.
Consumer-centric projects currently underway include digital weight loss programs — including streaming fitness classes — and maternity programs to track pregnancy. The company is also experimenting with remote patient monitoring to understand the impacts on those with heart disease or asthma and to search for service opportunities.
Optum will pursue investments as well as acquisitions to push into the consumer space.
“When it comes to acquisitions to Optum overall, we’re always in the marketplace looking to extend our capabilities, to extend our reach in the care management space to fill in holes or gaps that we have,” Weissel said. “That’s a constant process in our enterprise.”
Phoenix-based FastMed Urgent Care has signed a definitive agreement to acquire NextCare Holdings of America, a Mesa, Arizona-based provider of urgent care and occupational medical services.
The combined company will have 251 clinics in 10 states — merging FastMed’s 110 clinics in Arizona, Texas and North Carolina with NextCare’s 141 in Arizona, Colorado, Kansas, Missouri, New Mexico, North Carolina, Oklahoma, Texas, Virginia and Wyoming.
The deal, which is subject to regulatory approvals, is expected to close within 60 days.
The shift to value-based care and greater use of alternative care sites is one factor fueling growth in urgent care centers. Meanwhile, the million of Americans newly insured under the Affordable Care Act and a growing aging population has driven up emergency room volumes.
In a 2015 survey, 75% of emergency department physicians said visits had increased over the past year. The result is an overtaxed emergency staff and long wait times for patients. By contrast, urgent care offers medical care when and where patients need it and at a lower price point.
According to MarketsandMarkets, the global urgent care market will reach $26 billion by 2023, growing at a compound annual growth rate of 5.3%. Driving growth are lower costs and shorter wait times, growing investment in the sector, aging of populations and strategic partnerships between urgent care providers and hospitals.
In July, Morristown, New Jersey-based Atlantic Health System and MedExpress partnered to improve urgent care access and care coordination between the companies. The collaboration will allow MedExpress’ urgent care patients to get care at an Atlantic Health facility if more advanced care is needed.
And in October, Walgreens announced a strategic collaboration with Michigan-based McLaren Health Care aimed at improving health and pharmacy services. The vertical pact came as CVS Health and Aetna were wrapping up their megamerger.
In this new medical age of urgent care centers and retail clinics, that’s not a simple question. Nor does it have a simple answer, as primary care doctors become increasingly scarce.
“You call the doctor’s office to book an appointment,” said Matt Feit, a 45-year-old screenwriter in Los Angeles who visited an urgent care center eight times last year. “They’re only open Monday through Friday from these hours to those hours, and, generally, they’re not the hours I’m free or I have to take time off from my job.
“I can go just about anytime to urgent care,” he continued, “and my co-pay is exactly the same as if I went to my primary doctor.”
People are flocking to retail clinics and urgent care centers in strip malls or shopping centers, where simple health needs can usually be tended to by health professionals like nurse practitioners or physician assistants much more cheaply than in a doctor’s office. Some 12,000 are already scattered across the country, according to Merchant Medicine, a consulting firm.
There’s little doubt that the front line of medicine — the traditional family or primary care doctor — has been under siege for years. Long hours and low pay have transformed pediatric or family practices into unattractive options for many aspiring physicians.
And the relationship between patients and doctors has radically changed. Apart from true emergency situations, patients’ expectations now reflect the larger 24/7 insta-culture of wanting everything now. When Dr. Carl Olden began watching patients turn to urgent care centers opening around him in Yakima, Wash., he and his partners decided to fight back.
They set up similar clinics three years ago, including one right across the street from their main office in a shopping center.
The practice not only was able to retain its patients, but then could access electronic health records for those off-site visits, avoiding a bad drug interaction or other problems, said Dr. Olden, who has been a doctor for 34 years.
“And we’ve had some folks come into the clinics who don’t have their own primary care physicians,” he said. “So we’ve been able to move them into our practice.”
By opening clinics to compete with urgent care centers, Dr. Carl Olden’s practice in Yakima, Wash., was able to retain its patients and move some walk-ins into the fold.
The new deals involving major corporations loom over doctors’ livelihoods, intensifying pressure on small practices and pushing them closer to extinction.
The latest involves Walmart and Humana, a large insurer with a sizable business offering private Medicare plans. While their talks are in the early stages, one potential partnership being discussed would center on using the retailer’s stores and expanding its existing 19 clinics for one-stop medical care. Walmart stores already offer pharmacy services and attract older people.
In addition, the proposed $69 billion merger between CVS Health, which operates 1,100 MinuteClinics, and Aetna, the giant insurer, would expand the customer bases of both. The deal is viewed as a direct response to moves by a rival insurer, UnitedHealth Group, which employs more than 30,000 physicians and operates one of the country’s largest urgent-care groups, MedExpress, as well as a big chain of free-standing surgery centers.
While both CVS and UnitedHealth have large pharmacy benefits businesses that would reap considerable rewards from the stream of prescriptions generated by the doctors at these facilities, the companies are also intent on managing what type of care patients get and where they go for it. And the wealth of data mined from consolidation would provide the companies with a map for steering people one way or another.
On top of these corporate partnerships, Amazon, JP Morgan and Berkshire Hathaway decided to join forces to develop some sort of health care strategy for their employees, expressing frustration with the current state of medical care. Their announcement, and Amazon’s recent forays into these fields, are rattling everyone from major hospital networks to pharmacists.
Doctors, too, are watching the evolution warily.
“With all of these deals, there is so much we don’t know,” said Dr. Michael Munger, president of the American Academy of Family Physicians. “Are Aetna patients going to be mandated to go to a CVS MinuteClinic?”
Constant Changes in Care
Dr. Susan Kressly, a pediatrician in Warrington, Pa., has watched patients leave. Parents who once brought their children to her to treat an ear infection or check for strep, services whose profits helped offset some of the treatments she offered, are now visiting the retail clinics or urgent care centers.
What is worse, some patients haven’t been getting the right care. “Some of the patients with coughs were being treated with codeine-based medicines, which is not appropriate at all for this age group,” Dr. Kressly said.
Even doctors unfazed by patients going elsewhere at night or on weekends are nervous about the entry of the corporate behemoths.
“I can’t advertise on NBC,” said Dr. Shawn Purifoy, who practices family medicine in Malvern, Ark. “CVS can.”
Nurse practitioners allow Dr. Purifoy to offer more same-day appointments; he and two other practices in town take turns covering emergency phone calls at night.
And doctors keep facing new waves of competition. In California, Apple recently decided to open up its own clinics to treat employees. Other companies are offering their workers the option of seeking medical care via their cellphones. Investors are also pouring money into businesses aiming to create new ways of providing primary care by relying more heavily on technology.
Dr. Olden’s office door. In the age of urgent care centers and consolidations, the traditional doctor is being pushed closer to extinction.CreditDavid Ryder for The New York Times
An Absence of Proof
Dr. Mark J. Werner, a consultant for the Chartis Group, which advises medical practices, emphasized that convenience of care didn’t equal quality or, for that matter, less expensive care.
“None of the research has shown any of these approaches to delivering care has meaningfully addressed cost,” Dr. Werner said.
Critics of retail clinics argue that patients are given short shrift by health professionals unfamiliar with their history, and may be given unnecessary prescriptions. But researchers say neither has been proved in studies.
“The quality of care that you see at a retail clinic is equal or superior to what we see in a doctor’s office or emergency department,” said Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School, who has researched the retail clinics. “And while there is a worry that they will prescribe antibiotics to everybody, we see equal rates occurring between the clinics and doctor’s offices.”
Still, while the retail clinics over all charge less, particularly compared with emergency rooms, they may increase overall health care spending. Consumers who not long ago would have taken a cough drop or gargled with saltwater to soothe a sore throat now pop into their nearby retail clinic for a strep test.
Frustration with the nation’s health care system has fueled a lot of the recent partnerships. Giant companies are already signaling a desire to tackle complex care for people with a chronic health condition like diabetes or asthma.
“We’re evolving the retail clinic concept,” said Dr. Troyen A. Brennan, the chief medical officer for CVS. The company hopes its proposed merger with Aetna will allow it to transform its current clinics, where a nurse practitioner might offer a flu shot, into a place where patients can have their conditions monitored. “It requires new and different work by the nurse practitioners,” he said.
Dr. Brennan said CVS was not looking to replace patients’ primary care doctors. “We’re not trying to buy up an entire layer of primary care,” he said.
But people will have the option of using the retail clinic to make sure their hypertension or diabetes is well controlled, with tests and counseling provided as well as medications. The goal is to reduce the cost of care for what would otherwise be very expensive conditions, Dr. Brennan said.
If the company’s merger with Aetna goes through, CVS will initially expand in locations where Aetna has a significant number of customers who could readily go to CVS, Dr. Brennan said.
UnitedHealth has also been aggressively making inroads, adding a large medical practice in December and roughly doubling the number of areas where its OptumCare doctors will be to 75 markets in the United States. It is also experimenting with putting its MedExpress urgent care clinics into Walgreens stores.
Big hospital groups are also eroding primary care practices: They employed 43 percent of the nation’s primary care doctors in 2016, up from 23 percent in 2010. They are also aggressively opening up their own urgent care centers, in part to try to ensure a steady flow of patients to their facilities.
One Medical has centers in eight cities with 400 providers, making it one of the nation’s largest independent groups.
HCA Healthcare, the for-profit hospital chain, doubled its number of urgent care centers last year to about 100, according to Merchant Medicine. GoHealth Urgent Care has teamed up with major health systems like Northwell Health in New York and Dignity Health in San Francisco, to open up about 80 centers.
“There is huge consolidation in the market right now,” said Dr. Jeffrey Le Benger, the chief executive of Summit Medical Group, a large independent physician group in New Jersey. “Everyone is fighting for the primary care patient.” He, too, has opened up urgent care centers, which he describes as a “loss leader,” unprofitable but critical to managing patients.
Eva Palmer, 22, of Washington, D.C., sought out One Medical, a venture-backed practice that is one of the nation’s largest independent groups, when she couldn’t get in to see a primary care doctor, even when she became ill. After paying the annual fee of about $200, she was able to make an appointment to get treatment for strep throat and pneumonia.
“In 15 minutes, I was able to get the prescriptions I needed — it was awesome,” Ms. Palmer said.
Patients also have the option of getting a virtual consultation at any time.
By using sophisticated computer systems, One Medical, which employs 400 doctors and health staff members in eight major cities, allows its physicians to spend a half-hour with every patient.
Dr. Navya Mysore joined One Medical after working for a large New York health system, where “there was a lot of bureaucracy,” she said. She now has more freedom to practice medicine the way she wants and focus more on preventive health, she said.
By being so readily available, One Medical can reduce visits to an emergency room or an urgent care center, said Dr. Jeff Dobro, the company’s chief medical officer.
As primary care doctors become an “increasingly endangered species, it is very hard to practice like this,” he said.
But more traditional doctors like Dr. Purifoy stress the importance of continuity of care. “It takes a long time to gain the trust of the patient,” he said. He is working with Aledade, another company focused on reinventing primary care, to make his practice more competitive.
One longtime patient, Billy Ray Smith, 70, learned that he needed cardiac bypass surgery even though he had no symptoms. He credits Dr. Purifoy with urging him to get a stress test.
“If he hadn’t insisted,” Mr. Smith said, “it would have been all over for me.” Dr. Purifoy’s nurse routinely checks on him, and if he needs an appointment, he can usually see the doctor that day or the next.
“I trust him 100 percent on what he says and what he does,” Mr. Smith said.
Those relationships take time and follow-up. “It’s not something I can do in a minute,” Dr. Purifoy said. “You’re never going to get that at a MedExpress.”
There’s a building threat from the nation’s two retail drugstore giants to hospitals and health systems as providers move toward value-based care and lower-cost outpatient services.
Even with Amazon threatening to compete with retail drugstore chains CVS Health and Walgreens with its own online pharmacy, these retailers aren’t giving up on brick-and-mortar as a way to attract more patients into their stores.
And that’s bad news for the nation’s hospitals and health systems.
There’s a building threat from the nation’s two retail drugstore giants to hospitals and health systems as medical care providers move away from fee-for-service medicine to value-based care and lower-cost outpatient services.
Walgreens and CVS are looking to healthcare as a way to keep customers coming into their stores, particularly in an era where consumers are fleeing brick-and-mortar to shop online via Amazon.
As front-end retail sales have fallen in recent years, CVS and Walgreens are moving more rapidly into healthcare from simply their historic role of filling prescriptions beyond the pharmacy counter and treating routine maladies with nurse practitioners in their retail centers to more services.
They are partnering more closely with health insurance companies that will work harder to funnel more patients to outpatient healthcare services inside the stores that will make them direct competitors of U.S. hospitals and health systems.
CVS has more than 1,100 retail MinuteClinics compared to 800 five years ago and 400 a decade ago.
CVS was opening 100 clinics per year 10 years ago, and that has slowed because they are now focusing on expanding healthcare services in the clinics as well as their stores generally. The same goes for Walgreens.
Walgreens has increased the services in its retail clinics, advertising the ability of nurse practitioners to conduct routine exams and student physicals and has been aggressively lobbying states across the country to change scope-of-practice laws to allow pharmacists to administer an array of vaccines.
“Why not use those locations as a strategy for healthcare?” Walgreens Chief Medical Officer Dr. Patrick Carroll says of the drugstore chain’s nearly 10,000 locations across the country. “We have the space. We should use it.”
To be sure, Walgreens is looking to provide more physician services like x-rays and procedures by partnering with UnitedHealth Group’s Optum to connect its MedExpress brand urgent care centers to an adjacent Walgreens. Like most retailers, Walgreens’ sales of general merchandise in the front end of the store is falling just as pharmacy sales, personal healthcare, and wellness revenues rise.
In the first such ventures, the Walgreens store and the MedExpress center each have their own entrance with a door inside connecting the urgent care center with the drugstore. It’s designed for a medical provider to guide a patient to either facility depending on their prescription or other needs.
For now, there are 15 locations in six states that have MedExpress urgent care centers connected to Walgreens stores as part of the pilot. The markets include Las Vegas; Dallas; Minneapolis; Omaha, Nebraska; two cities in West Virginia; and Martinsville, Virginia.
“We’re working closely with a number of partners in the healthcare community to bring services closer to our customers,” Carroll said. “With our stores serving as more of a neighborhood health destination, we can best meet the changing needs of our customers, while also complementing our expanded pharmacy services.”
Meanwhile, CVS plans to offer more healthcare services inside its stores after its merger with Aetna closes. CVS executives say they aren’t ruling out developing urgent care centers as well.
CVS’ network of nearly 10,000 pharmacies and over 1,000 retail clinics, and Optum’s growing network of ambulatory facilities like the MedExpress urgent care centers are emerging as a model health insurers want to do business with as fee-for-service medicine gives way to value-based care that keeps patients out of the hospital.
And in CVS’ case, the pharmacy will soon own Aetna, a health plan with more than 20 million members. That combination, which is currently wending its way through the regulatory process, is expected to lead to more narrow network health plans that encourage patients to use providers in the Aetna-CVS network over other health systems’ facilities.
Health systems should be concerned, healthcare analysts say.
“CVS and Aetna, in their own words, are promising to reinvent the front door of American healthcare,” says Kenneth Kaufman, managing director and chair of the consulting firm Kaufman Hall. “That promise should be of serious concern for legacy hospital providers since those providers have occupied that front door for the past 75 years.”
CVS Health President and CEO Larry Merlo is beginning to offer some details to their strategies.
While cautioning that it’s “very early” in the development of new programs the combined company will develop, Merlo has said the larger company plans to first focus on three primary patient populations: those patients with any of five chronic diseases: diabetes, hypertension, hyperlipidemia, asthma, and depression.
CVS and Aetna will also focus on “patients undergoing transitions in care,” and a third “broader focus on managing high-risk patients,” Merlo told analysts on the company’s second quarter earnings call in May.
“By extending our new health care model more broadly in the marketplace, patients will benefit from earlier interventions and better connected care leading to improved health outcomes,” Merlo said on September 20 at a CVS Health town hall meeting in Los Angeles.
“Think again about that senior leaving the hospital, knowing that the care plan prescribed by her doctor is being seamlessly coordinated by CVS and her caregiver. By fully integrating Aetna’s medical information and analytics with CVS Health’s pharmacy data and our 10,000 community locations, we can enable more effective treatment of the whole patient,” he says.
St. Louis-based Ascension rolled out a national ad campaign June 4 across television, radio, billboards and direct mail to promote its online scheduling capabilities, which are available in all 22 Ascension markets.
The campaign is aimed at raising brand awareness and communicating patient scheduling options, even for last-minute or same-day appointments.
“Most of us use technology daily to simplify our lives, and the process of getting the care we need, when and where we need it, should be no different. Online scheduling allows consumers to view available appointments at their preferred location and select a time that fits their busy schedules,” Joseph Cacchione, MD, president of Ascension Medical Group, said in a press release. “As we work to improve access to compassionate, personalized care, we must also ensure we are letting consumers know about the new and innovative ways in which we are making the healthcare delivery process easier for them.”
Ascension currently offers online scheduling across 1,200 providers in primary care, urgent care and emergency department care. It has plans to add online scheduling capabilities for specialists and diagnostic and imaging services in the future.
CVS’ recent announcement that the company is expanding its reach in chronic care management is the latest sign that the market has never been more competitive or complicated. (Are you asking yourself, “which market?”) CVS isn’t just protecting its PBM business and driving sales for its retail business. The company has plans to provide one-on-one support and coaching — in a store, via phone, or video — to people who have diabetes, asthma, hypertension, hypercholesterolemia, or high cholesterol, and depression.
This, of course, follows in the footsteps of other companies encroaching on traditional provider-territory, like Optum. OptumCare, the care delivery arm of the company, has 22,000 physicians in 30 markets and 200 surgery centers in 33 states. The combination of the two presents a formidable continuum that could provide consumers with most of the outpatient services they’ll ever need. In other words, the health system brand defined by superior service lines will continue to be less and less relevant as the “top of the funnel” becomes more competitive and more important.
Despite the fierce competition, many health systems continue to focus a large majority of marketing dollars on down-funnel service line care, such as chronic disease treatments and surgeries. There’s logic to that strategy: market and differentiate the services that are most profitable and keep you in business. The problem is that logic doesn’t work in a digital age when consumers have more choices and less patience. Their healthcare mindshare is occupied by a host of companies — like CVS Health and OptumCare — that are more relevant to their daily life than heart surgery or cancer care.
HEALTH SYSTEMS MUST ESTABLISH (AND MAINTAIN) CONTROL OVER THE TOP OF THE FUNNEL
Therein lies the problem for health systems. When Joe Public interacts with your brand, relevance is king. And as we all know, specialty care isn’t relevant to the vast majority of people most of the time. When the competitive field wasn’t as crowded and consumers weren’t showered with more than 5,000 ads every day, it was easier to make an impression that might not be relevant in the moment but could be recalled later when it mattered. That day has passed. The emphasis must shift from awareness and impressions to real engagement.
Health systems — just like any other brands — must be relevant and provide value as often as possible to stay engaged with consumers. Think about your continuum of services as a funnel (Figure 1). Primary care, urgent care, ER, and health & wellness programs sit at the top as these are the services most often used, and represent the most common entry point into your system.
They are also more subject to cost and convenience scrutiny. To maximize the path to specialty and surgical care in the middle of the funnel, health systems can’t just rely on people who go through the side of the funnel – those who did their research to determine which hospital had the best cardiovascular outcomes in the region. For most health systems, the vast majority of their down-funnel, inpatient service line volume — more than 75% — comes from prior top of the funnel activity, not from out of the blue. Health systems need to get as many people in the top of the funnel to build brand, build engagement, and feed all service lines.
Why? Because this is the best way to engage consumers and build brand loyalty. Brand loyalty develops as consumers repeatedly engage with a service over time, and they become repeat customers if they are satisfied. A good experience at the top of the funnel can lead to more profitable business in the middle of the funnel. In fact, our research and work with hundreds of health systems across the country reveals that most people who receive specialty care at a health system had at least one prior experience. And where does most engagement with the healthcare system occur? At the top of the funnel.
Back to CVS. Health systems run the risk of being expensive specialty factories if they cede control of the top of the funnel to competitors — especially competitors who are not other hospitals. The strongest relevance is at the top of the funnel, which is where prescriptions and chronic care management live along with a host of other more frequently used services. CVS Health, Optum, Walgreens, Amazon, and even Google present formidable, well-resourced companies vying for the top of the funnel in some capacity.
What happens outside the hospital is increasingly important to success, so healthcare leaders need to influence or control care across the continuum.
If you’re running a hospital, one irony in the transformation toward value in healthcare is that your future success will be determined by care decisions that take place largely outside your four walls. If you’re running a health system with a variety of care sites and business entities other than acute care, the hospital’s importance is critical, but its place at the top of the healthcare economic chain is in jeopardy.
Certainly, the hospital is the most expensive site of care, so hospital care is still critically important in a business sense, no matter the payment model. But if it’s true that demonstrating value in healthcare will ensure long-term success—a notion that is frustratingly still debatable—nonacute care is where the action is.
For the purposes of developing and executing strategy, one has to assume that healthcare eventually will conform to the laws of economics—that is, that higher costs will discourage consumption at some level. That means delivering value is a worthy goal in itself despite the short-term financial pain it will cause—never mind the moral imperative to efficiently spend limited healthcare dollars.
So no longer can hospitals exist in an ivory tower of fee-for-service. Unquestionably, outcomes are becoming a bigger part of the reimbursement calculus, which means hospitals and health systems need a strategy to ensure their long-term relevance. They can do that as the main cog in the value chain, shepherding the healthcare experience, a preferable position; but physicians, health plans, and others are also vying for that role. Even if hospitals or health systems can engineer such a leadership role, acute care is high cost and to be discouraged when possible.
Since the Affordable Care Act was signed into law in 2010, the environment for healthcare has changed dramatically. Now, it could change even more with the possibility of an ACA repeal. But over the past six years, I have learned a few tips on how to navigate difficult times and transitions through experience, education, and collaboration with colleagues and governmental leaders. Here’s a review of some major industry trends and how healthcare organizations can adapt: