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June 16 2017

Response to Retail Health Clinics Convenience Should Not Fragment Care

As the trade association for the retail-based convenient care clinic industry, we always welcome interest in the
clinics and the value they provide to our nations healthcare delivery system. Retail-based convenient care clinics
are known for providing high-quality, accessible, and affordable healthcare. We have reviewed the new set of
principles adopted by the American Medical Associations (AMA) House of Delegates at the 2017 AMA Annual
Meeting.

The Convenient Care Association and its members recognize the importance of undertaking a collaborative
approach to health care to ensure the best patient care. Convenient Care is a patient-centric model of health
care committed to high- quality, easy access and affordable health care and acts as a connecting point for
patients to the health care system. The scopes of services by the clinicians in each clinic are subject to state law.
These clinicians scope of services may change to reflect advances in technology and the evolution of best
practices in the provision of high-quality patient care.

Convenient care clinics (CCCs), sometimes referred to as retail clinics, are healthcare facilities located inside
retail locations, such as pharmacies and grocery stores. The industry is currently made up of more than 2,300
clinics across more than 43 states and Washington D.C. Our members have collectively provided more than 40
1
million patients, and over 90 percent of patients are satisfied with clinic services. CCCs offer high-quality, low-
cost, and accessible healthcare. The care is provided by fully licensed and board certified nurse practitioners and
physician assistants who undergo a rigorous credentialing process, and encompasses basic primary care,
preventive and wellness services, and some chronic disease monitoring and treatment. All members of the CCA
are either certified or accredited by national organizations, such as The Joint Commission and the Accreditation
Association for Ambulatory Health Care. Research on the industry has documented time and again that retail
clinics deliver high-quality, cost-effective care and adhere to evidence-based practice guidelines. The CCA
represents more than 97 percent of all retail clinics currently in operation.

CCC services, which are convenient and affordable, help increase access to care and prevent complications that
often result in costly emergency room admissions. A major study sponsored by the RAND Corporation and
published in the Annals of Internal Medicine found that care at convenient care clinics was equivalent in quality to
2
other settings and 40 to 80 percent less costly.

The Convenient Care Association offers the following comments in response to the American Medical
Associations principles related to retail health clinics.

1. Retail health clinics must help patients who do not have a primary care physician or usual
source of care to identify one in the community.

CCA Comment - As many as 60% of patients who use CCCs do not have an established primary care
physician relationship and retail clinics fill a gap that would otherwise be filled by costly and unnecessary
emergency room visits. Patients who do not have a primary care provider are educated about the
importance of such a relationship, provided with a list of primary care providers in the area, and
encouraged to establish a relationship with a primary care provider. The clinical affiliations and
collaborative partnerships between private operators and health systems/physician groups facilitate,
foster and strengthen these relationships as the clinics work closely with primary care physicians (when
that is the patients choice) for comprehensive patient care.

1
Convenient Care Association, http://ccaclinics.org/about-us/about-cca.
2
Comparing Costs and Quality of Care at Retail Clinics with that of Other Medical Settings for Three Common Illnesses,
Annals of Internal Medicine, August 2009.
 All CCC operator members of the Convenient Care Association abide by the Convenient Care
Association Quality and Safety Standards. Paragraph 6 of the Standards provides: All CCA Members are
committed to encouraging patients to establish an ongoing relationship with a primary care provider, and
to making appropriate and careful referrals for follow-on care and/or for conditions that are outside of
the scope of the clinics services.

2. Retail health clinics must use electronic health records to transfer a patients medical records to
his or her primary care physician and to other health care providers, with the patients consent.

CCA Comment CCCs already use electronic health records to ensure high-quality healthcare and
monitor evidence-based practice performance. Indeed, there was widespread use of EHRs in CCCs well
before it became even moderately accepted by most primary care physician offices.

All CCC operator members of the Convenient Care Association abide by the Convenient Care
Association Quality and Safety Standards. More than 95% of all retail clinics are members of
CCA. Paragraph 5 of the Standards provides: All CCA Members use Electronic Health
Records to ensure high-quality, efficient care.

3. Retail health clinics must produce patient visit summaries that are transferred to the appropriate
physicians and other health care providers in a meaningful format that prominently highlight
salient patient information.

CCA Comment All CCC operator members of the Convenient Care Association
abide by the Convenient Care Association Quality and Safety Standards. Paragraph 8
of the Standards provides: All CCA Members provide access to the visit record,
written discharge instructions and educational materials to patients upon leaving the
clinic to ensure that patients understand any diagnosis made, recommended
treatment and care plans. The sharing of visit records, written discharge instructions
and educational materials is completed in a HIPAA-compliant manner.

4. Retail health clinics make provisions for appropriate follow-up patient care.

CCA Comment - As many as 60% of patients who use CCCs do not have an established primary care
provider relationship and CCCs fill a gap that would otherwise be filled by costly and unnecessary
emergency room visits. Patients who do not have a primary care provider are educated about the
potential importance of such a relationship, provided with a list of primary care provider in the area, and
encouraged to establish a relationship with a primary care provider. It is, however, the patients choice as
to where and with whom to seek their health care, which is an essential part of the definition of patient
centered care. The clinical affiliations and collaborative partnerships between private operators and
health systems/physician groups facilitate, foster and strengthen these relationships as the clinics work
closely with primary care physicians for comprehensive patient care.

All CCC operator members of the Convenient Care Association abide by the Convenient Care
Association Quality and Safety Standards. Paragraph 6 of the Standards provides: All CCA Members
are committed to encouraging patients to establish an ongoing relationship with a primary care
provider, and to making appropriate and careful referrals for follow-on care and/or for conditions that
are outside of the scope of the clinics services.

5. Retail health clinics should work with primary care physicians and medical homes to support
continuity of care.

CCA Comment - Convenient care clinics are increasingly a valuable part of this nation's healthcare
ecosystem (not apart from it), providing easy access to high-quality, affordable care, connecting patients
with other providers as necessary, and, increasingly, facilitating care that is being managed by other
providers. Private operators of CCCs have clinical affiliations with major health systems across the
country which enables sharing of patient information to ensure continuity of care, involving thousands of
primary care and specialty physicians. By working in collaboration with physicians and health systems,
CCCs help to lower costs for acute illnesses and chronic disease care by providing coordinated and
complementary care and reducing emergency department visits. The industry is committed to
 collaboration and partnerships across different healthcare delivery sites, recognizing the value each
setting delivers.

All CCC operator members of the Convenient Care Association abide by the Convenient Care
Association Quality and Safety Standards. Paragraph 4 of the Standards provides: All CCA Members
build collegial relationships with the traditional health care system and its providers, to share patient
information as appropriate and ensure continuity of care. All patients are given the option of sharing
their health care record with other providers.

6. Retail health clinics should use local physicians as medical directors or supervisors of retail
clinics.

CCA Comment Convenient care clinics are increasingly a valuable part of this nation's healthcare
ecosystem (not apart from it), providing easy access to high-quality, affordable care, connecting patients
with other providers as necessary, and, increasingly, facilitating care that is being managed by other
providers. Private operators of retail health clinics have clinical affiliations with major health systems
across the country which enables sharing of patient information to ensure continuity of care, involving
thousands of primary care and specialty physicians. By working in collaboration with physicians and
health systems, CCCs help to lower costs for acute illnesses and chronic disease care by providing
coordinated and complementary care and reducing emergency department visits. The industry is
committed to collaboration and partnerships across different healthcare delivery sites, recognizing the
value each setting delivers.

Further, CCC providers adhere to evidence-based protocols that adhere to established clinical practice
3
guidelines and regulations. CCCs are not operating off of standing orders, but rather employ educated
professionals who make decisions based on evidence based practices as well as individual patient
needs. Moreover, studies have demonstrated that retail clinics have excellent clinical quality outcomes,
4
adhere to evidence-based guidelines, and provide cost-effective care. Retail health clinics also use
electronic health records to ensure high-quality healthcare and monitor evidence-based practice
performance.

All CCC operator members of the Convenient Care Association abide by the Convenient Care
Association Quality and Safety Standards. More than 97% of all CCCs are members of CCA. Paragraphs
3, 4 and 5, respectively, of the Standards provide: (3) All CCA Members use evidence-based guidelines
and protocols to provide quality healthcare, (4) All CCA Members build collegial relationships with the
traditional health care system and its providers, to share patient information as appropriate and
ensure continuity of care. All patients are given the option of sharing their health care record with other
providers, and (5) All CCA Members use Electronic Health Records to ensure high-quality, efficient care.

7. Retail health clinics should not expand their scope of services beyond minor acute illnesses
including, but not limited to, sore throat, common cold, flu symptoms, cough and sinus infection.

CCA Comment Convenient care clinics are increasingly a valuable part of this nation's healthcare
ecosystem (not apart from it), providing easy access to high-quality, affordable care, connecting patients
with other providers as necessary, and, increasingly, facilitating care that is being managed by other
providers. Private operators of CCCs have clinical affiliations with major health systems across the
country which enables sharing of patient information to ensure continuity of care, involving thousands of
primary care providers (PCP) and specialty physicians. By working in collaboration with providers and
health systems with the patients approval, CCCs help to lower costs for acute illnesses and chronic
disease care by providing coordinated and complementary care and reducing emergency department
visits. The industry is committed to collaboration and partnerships across different healthcare delivery
sites, recognizing the value each setting delivers.

3
Jacoby, Richard, Albert G. Crawford, et al. Quality of Care for 2 Common Pediatric Conditions Treated by Convenient Care
Providers. American Journal of Medical Quality. 2010.
4
Shrank, William H., Krumme, Alexis A., et al. Quality of Care at Retail Clinics for 3 Common Conditions. American Journal
of Managed Care. 20, No. 10 (2014):794-801.
 Additionally, convenient care is a patient-centric model of health care committed to high-quality, easy
access and affordable health care and acts as a connecting point for patients to the health care system.
The scopes of services in each retail health clinic are subject to each states mandated professional scopes
of practice, and are supported by evidence-based guidelines. Clinics scope of services may change to
reflect advances in technology and the evolution of best practices in the provision of high-quality patient
care. All services provided at convenient care clinics are within the clinicians licensed scope of practice.

Convenient care clinics can play a complementary and access-enhancing role with respect to the delivery
of chronic care. For patients with chronic conditions, compliance with treatment and medication regimes
is critical to long-term health, and CCA members believe that it can serve as a valuable partner to the
PCP and Patient Centered Medical Home (PCMH) community in the treatment of these patients with retail
clinics: (1) guideline-based care, (2) commitment to collaboration and data-exchange with PCPs, and (3)
convenient, community-based locations and extended hours. Many CCCs already work collaboratively
with multiple large health systems and physician groups, providing ongoing monitoring and care for
patients with chronic disease.

CCA and our members are interested in participating in appropriate peer-reviewed research looking at
clinical outcomes for chronic disease care. The industry remains committed to providing accessible,
affordable high-quality care.

All CCC operator members of the Convenient Care Association abide by the Convenient Care
Association Quality and Safety Standards. Paragraph 2 and 4 of the Standards provides: (2) CCA
Members are committed to monitoring quality on an ongoing basis, and applying the data derived from
quality review to implement operational and clinical improvements. Mechanisms of review may include
but are not limited to: Peer review; Collaborative physician review; Collecting aggregate data on selected
quality and safety outcomes; Collecting data on patients perceptions of care and engagement with the
model. (4) All CCA Members build collegial relationships with the traditional health care system and its
providers, to share patient information as appropriate and ensure continuity of care. All patients are
given the option of sharing their health care record with other providers.

For the healthcare reform to be successful given the growing shortage of primary care physicians, retail-based
convenient care clinics often represent the only healthcare access point for millions of people. We are proud to
have been able to provide more than 40 million high-quality, accessible and affordable patient visits, and to serve
as a portal into the healthcare system for many, working in collaboration with health systems and physician
groups nationwide. For more information about retail clinics and their value proposition of proving affordable, high-
quality, accessible care, I encourage you to visit www.ccaclinics.org.

Very truly yours,

Tine Hansen-Turton
Executive Director
Convenient Care Association