Amanda Smith
2/21/2019
RETAIL HEALTH CARE CLINICS AND… 2
Abstract
This paper is a plan for action regarding the status of retail health care clinics and nurse managed
health centers. The paper discusses the problems faced by Americans with greater healthcare
needs, the ever-increasing amount of insured Americans, and the lack of primary care physicians.
The paper determines the problem, solutions, key stakeholders in changing policy, and a plan to
The Problem
Since the implementation of the 2010 Patient Protection and Affordable Care Act the
percentage of uninsured Americans has fallen drastically. About 48 million people in 2010
lacked health insurance, and in 2016 that number had fallen to about 28.6 million uninsured
people, which is about a 60% growth (Bakalar, 2017). In comparison, in 2010 there were
209,000 primary care physicians and in 2016 there were 246,000 primary care physicians
(National, 2018). Other statistics centers determine that there has only been a 12% increase of
primary care physicians from 2010 to 2016 (Young et al, 2016). The numbers of insured people
are a good improvement and are proof that the Affordable Care Act has promoted greater access
to healthcare with more available coverage. However, the amount of primary care physicians did
not grow nearly as much from 2010 to 2016. So this begs the question: where are all those newly
insured individuals receiving healthcare? How can physicians compensate and perform adequate
care for increasing numbers of patients? Are there enough medical centers for those patients to
be physically seen?
The answer is no. Increasing patient numbers has been detrimental to some practices, and
causes wait times for appointments to be excessive. Data collected from 15 U.S. metropolitan
cities by a survey conducted by Merritt Hawkins, a national physicians search firm, has indicated
excessive appointment wait times (2017). The mean wait time of the metropolitan areas in the
U.S. to see a physician for a first time appointment was 24 days in 2016 (Merritt Hawkins,
2017). The average wait time to see a cardiologist in those 15 major cities across the U.S. was 21
days (Merritt Hawkins, 2017). The Merritt Hawkins (2017) survey showed that in 2016 in
Boston the average wait time to initially see a physician was 52 days. Patients in Philadelphia
RETAIL HEALTH CARE CLINICS AND… 4
seeking an OBGYN waited, on average, 51 days (Merritt Hawkins, 2017). Overall, patients
(Merritt Hawkins, 2017). Delays in being seen by a primary care physician or specialist can
decrease quality of life, lead to greater healthcare spending, and, in some instances, increase the
risk of death. For example, patients who are referred for chronic pain may need to wait weeks to
be seen and in the meantime they are managing pain with medication, which increases the
overall cost of their care. Hospital and practice policy needs change to reduce the delay for
patients to see physicians. There is a lot of potential for telehealth technologies and nursing
practice growth to compensate for quicker appointment times. Dr. Steven Pizer from
Northeastern University stated to the New York Times that he suggests that wait times could be
decreased by allowing nurses and physicians assistants more leeway to open their own practices
Solutions
On that note, some potential solutions to remedy this lack of healthcare access is to opt
for more nursing-managed health centers and retail health care clinics. Retail health clinics are
an option for immediate care that doesn’t warrant a trip to the emergency department. They are
typically found in drugstores, supermarkets, ‘big-box’ stores, and other retail settings and can
offer treatment for minor illnesses, physicals, and vaccinations (Godman, 2016). These clinics
are typically staffed with nurse practitioners or physicians assistants and don’t require an
appointment (Godman, 2016). They are a good option for people seeking health services on a
budget because the cost for treatments, physicals, and screenings tend to be lower than going to a
physician’s office, and they have a wider range of business hours to accommodate varying
Nurse-managed health centers (NMHC) are also an option for healthcare. They are
staffed by advanced practice registered nurses (APRN) that, depending on state laws, don’t
require oversight by a physician. The model of care for these centers is typically wellness
2010). These centers are also more cost effective than a physician’s office visit and often serve
vulnerable, underserved, and uninsured individuals (Hansen-Turton et al, 2010). NMHC’s are
would allow NMHC’s and retail health clinics to flourish there will be greater access to
healthcare for vulnerable populations and areas, and an increasing number of providers to
Key Stakeholders
Local and state-wide stakeholders that can potentially influence policy formation are key
to building a successful campaign that focuses on promoting retail health clinics and nurse-
economy, and therefore, has influence when determining new laws and policies. UD generates
about $2.8 billion in economic activity for the state of Delaware (UDaily, 2019). The public
university currently has a nurse-managed health center (NMHC) within their new state-of-the-art
Star Campus. The health center has seven registered nurses with a variety of degrees and
specialties that are available for primary care, exercise and nutrition counseling, health coaching,
and women’s health, and there is also an on-site Parkinson’s clinic (UD Health Clinics, 2019).
The center is open to the public and also serves as an educational opportunity for UD nursing
students at the graduate level (UD Health Clinics, 2019). The university and the state are most
RETAIL HEALTH CARE CLINICS AND… 6
interested in promoting and protecting their interests, especially if there are good results, and
backing policies that would allow the NMHC to grow are important. Having a NMHC within the
college is a good way to increase interest in the nursing program, promote public relations, and
The plan is to include the nurses who are employed at UD’s NMHC as stakeholders when
formulating policy for the advancement of these centers. The plan is to also bring policies to the
attention of the Associate Dean of Nursing and Healthcare Innovation at UD, Emily Hauenstein,
who is researching new ways to deliver health services to vulnerable populations (Experts,
2019). The University of Delaware has a vested interest in continuing policy formation that is in
favor of NMHC and retail health clinics, and the state of Delaware has a vested interest in the
work of UD’s programs. By including a large organization that is able to provide backing for
policy formation a policy has a greater chance of being heard and supported. Not to mention the
many students and community members who receive care from the Star Campus’ NMHC that
National
Stakeholders who have the ability to propose a plan for national consideration and policy
are the state senators and representatives of Delaware. There are currently two state senators,
Senior Senator Thomas Carper (D) and Junior Senator Chris Coons (D) (Senators, 2019).
Delaware has one state representative, “at-large” representative Lisa Blunt Rochester (D)
(Representatives, 2019). Senator Thomas Carper, since the 2015-2016 Congress, has proposed
three bills related to health services, one of which related to federal reimbursement for state
telehealth services that focus on mental health treatment (Sponsored Legislation, n.d.). This
could indicate that Carper is interested in federal funding and formulating a policy for
RETAIL HEALTH CARE CLINICS AND… 7
reimbursement for state programs that promote access to health services and he may be
interested in backing bills that would promote NMHC’s and retail health clinics. Senator Chris
Coons is currently working towards improving the Patient Protection and Affordable Care Act to
assist small businesses and insurance agencies with providing necessary coverage (Health Care,
n.d.). Mr. Coons appears to have an open mind and would be interested in the possibilities of
new legislation that would promote greater healthcare access with NMHC’s and retail clinics.
Lisa Blunt Rochester, Delaware’s at-large Congresswoman, just recently worked together with
representatives from Florida, Michigan, and Georgia to introduce the MORE Health Education
Act. The act is set to increase funding to educate potential enrollees about policy options,
enrollment dates, and available financial support through the Centers of Medicare and Medicaid
One goal I would hope to achieve is to secure direct insurance reimbursement for
advanced practice primary care nurses within the next five years to secure payment for many
facilities that utilize advanced practice nurses. The regulations for insurance reimbursement for
advanced practice nurses is a barrier to the growth of nurse-managed health centers (Mason et al,
2016, pg. 296). Since 2009, the Advanced Practice Nurse Multistate Reimbursement Alliance
has partnered with the American Association of Nurse Practitioners to enhance NP support for
Another goal I would like to achieve is to allow advanced practice registered nurses
(APRN) to practice outside of the supervision of a physician. There are currently 23 states that
allow APRN’s full practice autonomy (FPA), meaning they can practice outside of physician
supervision, and Delaware is currently not one of the states (States, 2019). The states differ in
RETAIL HEALTH CARE CLINICS AND… 8
their regulations of APRN’s, some require they work for a certain amount of time under a
physician before reaching FPA and some don’t, and some states require continuing education so
they can prescribe medications and some don’t’. This movement will allow greater access to
health services and allow medical professionals more patient care time and less consultation
requirements (Mason et al, 2016, pg. 297). Many states who do not currently allow FPA for
APRN’s have a bill in place that would expand their scope and allow them to work
independently. Florida Senator Jeff Brandes recently filed bill SB 972, which would allow
APRN’s to practice to the full extent of their education and training without a protocol
agreement (Cassarino, 2019). Several days later, Florida Representative Pigman filed HB 821
that would enable full practice authority for APRN’s (Cassarino, 2019). Perhaps the greatest
resistance to allowing full practice authority for APRN’s are physicians groups.
Talking Points
The purpose of the talking points is to create a clear and concise discussion when faced
with policymakers about proposed solutions for the problem. The first talking point I would
discuss is the actual problem with the accessibility to health services as it relates to appointment
wait times and the lack of operating health centers. This would be the first point because it opens
up the topic and describes the issue. The second talking point I would discuss are potential
solutions and the barriers to achieving them. This would include legislation, pending bills, or
groups that would further hinder the benefits of nurse-managed health centers and retail health
clinics. The third talking point I would discuss is my goals for legislation and policy that would
allow for greater healthcare access. This includes greater autonomy for nurse practitioners and
physicians assistants and an increase in federal funding and/or reimbursement for health clinics
and centers.
RETAIL HEALTH CARE CLINICS AND… 9
90 Day Plan
In the next 90 days I plan to contact my state and national stakeholders and outline the
problem and potential solutions. I would feel most fortunate to have a discussion with them on
why some solutions may be viable and others may not be viable. The next step would be
outlining a bill for the solutions and contacting my Delaware Senators and Representative to
have them edit and present the bill to their parties. Once more ideas are exchanged I would plan
to create a website for the issue and viable solutions and use social media to further the public
outreach. It would be a good idea to visit retail health clinics and nurse-managed care centers and
determine what the coordinators or employees deem to be their most pressing problems. This
issue may not be a problem for some Americans so they do not even know health services may
be a challenge to access for some. The greater the understanding of the problem the public has
The Future
In conclusion, the goal of implementing policies that increase the amount of retail health
clinics and nurse-managed health centers is a stepping stone for greater healthcare access.
Vulnerable populations and underserved areas will especially benefit from an increase in
qualified primary health providers and health center locations that remain open for business with
federal funding and insurance reimbursement. The Affordable Care Act of 2010 paved the way
for a greater population of insured individuals, and the aftermath of that act will lead to more
providers and healthcare sites through even more policy implementation and reform.
RETAIL HEALTH CARE CLINICS AND… 10
References
Bakalar, N. (2017, May 22nd). Nearly 20 million have gained health insurance since 2010.
insurance-numbers-nchs.html
Cassarino, D. (2019, February 14th). Florida Nurse Practitioner Network. Breaking news!! fpa
bills filed and house committee hears aprn panel testimony. Retrieved from
https://fnpn.enpnetwork.com/nurse-practitioner-news/198741-breaking-news-fpa-bills-
filed-and-house-committee-hears-aprn-panel-testimony
staff/experts/emily-hauenstein/.
Godman, H. (2016, January 15th). Retail health clinics: the pros and cons. Retrieved from
https://www.health.harvard.edu/blog/retail-health-clinics-the-pros-and-cons-
201601158979.
Hansen-Turton, T., Bailey, D. N., Torres, N., & Ritter, A. (2010, September). American Journal
https://journals.lww.com/ajnonline/Fulltext/2010/09000/Nurse_Managed_Health_Centers
.17.aspx.
Health Care. (n.d.). Ensuring quality, affordable health care for all Americans. Retrieved from
https://www.coons.senate.gov/issues/health-care.
Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E. T. (2016). Policy and politics in
Merritt Hawkins Team. (2017, September 22nd). Physician appointment wait times and medicaid
and-insights/thought-leadership/survey/survey-of-physician-appointment-wait-times/.
Morse, K. (2019, February 6). Blunt, Rochester, Castor, Kildee, and Macbath introduce the more
https://bluntrochester.house.gov/news/documentsingle.aspx?DocumentID=192.
for-nurse-practitioners/multistate-reimbursement-alliance-msra.
National Center for Health Statistics. (2018, July). The number of practicing primary care
https://www.ahrq.gov/research/findings/factsheets/primary/pcwork1/index.html.
https://www.govtrack.us/congress/members/DE#representatives.
Rosenthal, E. (2014, July 5th). The New York Times. The health care waiting game. Retrieved
from https://www.nytimes.com/2014/07/06/sunday-review/long-waits-for-doctors-
appointments-have-become-the-norm.html
https://www.govtrack.us/congress/members/DE#senators.
RETAIL HEALTH CARE CLINICS AND… 12
https://www.carper.senate.gov/public/index.cfm/sponsoredbills.
States Granting NP Full Practice Authority. (2019). 23 states with np practice autonomy.
practice-authority/.
UDaily. (2019). Investing in the first state’s future. Retrieved from https://www.udel.edu/.
UD Health Clinics. (2019). Nurse managed primary care center. Retrieved from
https://sites.udel.edu/nmhc/.
Young, A., Chaudhry, H. J., Pei, X., Arnhart, K., Dugan, M., & Snyder, G. B. (2016). A census
https://www.fsmb.org/siteassets/advocacy/publications/2016census.pdf.