These family doctor and emergency-room alternatives are popping up in more storefronts around the country — but they differ in price and quality of care.

The next time you get sick or need a physical, there’s a good chance you’ll be seen not in a hospital or your primary-care physician’s office, but in a clinic based in a drugstore or supermarket. Retail health clinics, popping up everywhere from strip-mall storefronts to Wal-Marts, are one of the newest alternatives to the doctor’s office — no appointment necessary. There are now nearly 1,400 stand-alone clinics across the country, 54 more than last year and over twice as many as five years ago. That’s in addition to about 8,700 urgent-care centers, which treat more serious ailments and injuries. The proliferation of the walk-in clinics is largely an effort by the overburdened health system to divert patients with minor ailments to facilities that are less expensive than the emergency room: On average, retail and urgent-care clinics cost 80% less than the E.R., according to the Rand Corp., a research firm, and a study by BlueCross and Blue Shield of Minnesota found clinic visits cost half as much as a primary-care appointment. And as health reform kicks in and millions of newly insured patients flood the system, experts say, the difficulty of getting an appointment at a regular doctor’s office could make the clinics the only realistic option for some consumers.

Things walk-in clinics won't tell you

But patients choose the clinics not just out of desperation, but because they offer another advantage over traditional doctor offices: convenience. The clinics are open on nights and weekends — after most primary-care physicians have gone home — and since walk-in patients are welcome, people can go when they first feel sick, instead of waiting for their doctor’s schedule to open up. Plus, the clinics offer fast service, so people need not block off half a day to sit in the waiting room: The average patient is in and out in 15 to 20 minutes, according to the Convenient Care Association, the retail clinics’ trade group. “We were considered the soccer mom favorites early on,” says Tine Hansen-Turton, executive director of the association. Indeed, a Rand study found that patients who try retail clinics are 67% less likely to go to a doctor the next time they get sick with a similar problem, a phenomenon health experts view as potentially dangerous: “If every time a patient goes to a retail clinic is one less visit to their doctor, could they be undermining primary care relationships?” questions Ateev Mehrotra, a Rand health policy analyst.

2. “…but it’d be better if we didn’t.”

There’s one fundamental reason that clinics should not replace primary-care doctors, say experts: Most retail clinics don’t have a doctor on staff. Nurse practitioners make up 95% of the clinics’ workforce, with physician assistants and a handful of doctors accounting for the rest, according to the Convenient Care Association. “It’s apples and oranges, comparing retail clinics to primary care providers,” says Ann O’Malley, a senior fellow with the Center for Studying Health System Change. But even though studies show that those providers still deliver adequate treatment, having “another cook around the pot” may disrupt the continuity of a patient’s care, says Mehrotra. While a regular doctor will have access to a patient’s medical records and history — everything from immunizations to allergies to past surgeries — a retail clinic won’t have any of it. And lacking a relationship with the patient, clinic providers may have a harder time picking up on symptoms if something major is awry. “A nurse practitioner in a drugstore, however well-trained, typically has never seen the patient before and knows nothing about them,” says Alan Sager, professor and director of the health reform program at the Boston University School of Public Health. “How will they do at differentiating between a routine problems and something much more dangerous underneath?” Clinics are also not designed for follow-up care, and a patient’s primary-care doctor may never find out about the visit, so medical complications could go unnoticed: “There’s a risk that things will fall through the cracks,” O’Malley says.

The disconnect can be costly, especially if a primary-care physician duplicates a test the patient had in the clinic because it was lost in the shuffle. Add to that the potential for expensive complications: Clinics “are not looking at the long-term costs of missing a diagnosis,” O’Malley says. Still, clinic visits currently account for less than 1% of all outpatient medical care, and the Convenient Care Association says the clinics are meant supplement primary care, not replace it: “We’re a piece of the health-care system, not an end-all be-all,” says Hansen-Turton.

3. “Our agents are everywhere.”

Alternatives to the ER

Even though proponents say they don’t intend clinics to replace conventional doctors, the health-care system has been steering patients toward them with incentives consumers may find it hard to resist. Some insurance companies such have waived copays for clinic visits, making them cheaper still than traditional doctors — Blue Cross and Blue Shield of Minnesota, which already nixed clinic copays, recently made clinic visits completely free to members in certain plans. The insurer “feels so strongly that this type of care makes sense,” says a company spokeswoman, though she qualifies that clinics are appropriate for some simple issues but not for all care. “These models weren’t set up to be like your primary-care physician.” Many hospitals have also started requiring payment up front from individuals who come to the emergency room with non-urgent complaints — often delivering the bill with a nudging reminder that they’d pay less at a clinic. “The key thing health plans are thinking about is, anytime they can get anybody out of the emergency room to an urgent-care or other clinic is savings for them,” Mehrotra says. Still, insurance companies are treading lightly to avoid discouraging patients from seeking the care that they need: “They’re using very careful language — no one wants members to not go to the emergency room when it’s appropriate,” says Allan Khoury, a senior health-management consultant with Towers Watson.

4. “Convenience comes at price.”

Before you stop in for a flu shot next time you’re out shopping for groceries, you might want to ask for a price check. Retail clinics like the one in your local supermarket tout the savings they offer compared with prices at traditional health-care offices: The Convenient Care Association brags that the clinics are the cheapest option for primary care. Indeed, many clinics post a menu listing prices for different services — a transparency common in nail salons and spas, but not doctors’ offices. But although clinics may look alike from the outside, there may be big differences in their prices for treatment. Urgent-care clinics offer a wider range of services than the typical convenient-care clinic in a pharmacy or storefront, but they also charge more — even for the same basic services offered by the other clinics. The reason for the markup is that, unlike other convenient care clinics, urgent-care clinics have a doctor on the premises. And while basic retail clinics are usually the cheapest option in studies of comparative pricing, it is less clear whether urgent-care clinics come out ahead or behind the regular doctors’ office. For example, retail clinic visits average $75 before insurance, compared with $120 for a primary-care appointment and $122 for a stop at an urgent-care facility, according to the Convenient Care Association. But a study by Rand Corp. found physician offices to be more expensive than all types of clinics, when the cost of prescriptions was taken into account.

Insurance coverage can also be trickier at the clinics. Many clinics accept plans from the large insurers like Aetna or Cigna, but Blue Cross and regional plans are accepted to a lesser extent, according to Khoury. And while experts say patients would rarely join a primary-care physician practice that wasn’t in their plan’s network, they might be less careful about choosing in-network clinics. Clinics are happy to provide similar services regardless of the network; patients though may get a surprise bill later, since out-of-network visits are more expensive. Find out if your health insurance fully covers the clinic visit before dropping in, says O’Malley: “It may be a convenient place to get a flu shot, but it might be out-of-network.” Blue Cross and Blue Shield of Minnesota, for one, says it was the first to offer any reimbursement of retail clinic visits, but notes that coverage varies by plan and clinic, and doesn’t depend on whether the clinic is in a chain drugstore or is independently owned. In some ways, the clinics might be too convenient for patients’ own good, as about 5% of patients would have otherwise let the problem go away on its own and not paid a dime: “An innovation like this might inadvertently add to health-care spending,” says Arnold Milstein, a professor of medicine who directs Stanford’s Clinical Excellence Research Center.

5. “Coming soon to a hospital near you.”

Even as convenience clinics have been finding ways to draw patients away from emergency rooms and their family doctors’ offices, hospitals and physicians have been devising a plan to get them back. Some primary-care doctors have been extending their office hours, staying later or even opening their doors on Saturdays. Hospitals are also building fast-track areas into their emergency departments to mimic the convenient-care clinic model. While a convenient-care clinic could refer a patient practically anywhere, a hospital that can get the person to come to its own version of a clinic can send the patient to a doctor within its own system. “From the health-system point of view, it is increasing the amount of business they have,” Khoury says. In part, it’s a response to competitive pressure from the clinics, but the hospitals and physician offices have a twofold stake in keeping their patients’ care under their control. In addition to keeping a patient’s business, they also want to show that they operate as an accountable health organization, closely managing the care that their patients receive — especially amid scrutiny by modern health-care reform advocates. In turn, health insurers will be more likely to partner with systems that demonstrate accountable care, say experts: More control over a patient’s referrals “helps them keep their costs low so they can sell their services to the health plans,” Khoury says.

6. “We practically self-regulate.

Concerned about safety in the clinics, several states, including Massachusetts and Illinois, have tried to impose restrictions on them. Some of the proposed rules have attempted to increase doctors’ oversight of the clinics. Right now, about 20 states allow nurse practitioners to operate clinics without a doctor to provide guidance or supervision. Texas is the only state requiring that clinics have a physician in-house. But the Federal Trade Commission warned the states trying to crack down that their proposed legislation would unnecessarily put the clinics at a competitive disadvantage, since there was no evidence that their current mode of operation posed any danger to patients. The Convenient Care Association says that the clinics generally monitor themselves to ensure safety, often appointing an experienced nurse or physician assistant as medical director. “They self-regulate a lot, making sure quality is the focus,” says Hansen-Turton. “We don’t want to be singled out because the only thing that makes us different from other providers is we just happen to be in a drugstore or a supermarket.”

7. “Coincidentally, we’re having a sale on cough syrup.”

With large drugstore companies now running some of the largest chains of clinics, some medical professionals are concerned that the relationships might pose a conflict of interest, as health-care providers’ in the clinics might overprescribe medication in order to drum up business at their own pharmacy. But the clinics say that they encourage patients to fill prescriptions wherever they prefer, and a Rand study found that antibiotic prescribing at retail clinics was similar to that at doctor’s offices. Experts say that clinics affiliated with large chains might have another handy advantage: They can share patient histories between clinics, and are also more likely to partner with hospitals, allowing them to plug into larger networks of electronic medical records.

8. “The doctor doesn’t have to see you now.”

Wal-Mart limps behind in health-clinic race

As much as urgent and convenient-care clinics portray themselves as cheaper substitutes for the emergency room, there is one important difference: While hospitals receive federal subsidies and are required to see patients who show up in their E.R.s, the clinics, operated by private corporations, can turn people away. Refusing a patient would usually come down to insurance and whether the patient could pay for the treatment, says Hansen-Turton of the Convenient Care Association: “It’s a business model.” Still, she says, 40% of clinic patients don’t have insurance, but can afford the average $75 visit, which is much less than the typical E.R. bill.

9. “There’s only so much we can do.”

Most retail clinics offer the same limited variety of health services, treating sore throats and sinus infections and providing flu shots and basic physical exams. Urgent-care centers have slightly broader capabilities, and can often take X-rays and do stitches. But the clinics aren’t designed to be one-stop shops, so some ailments might be too serious for the clinic to handle: More than 2% of walk-in patients are sent elsewhere, according to Rand. (The Convenient Care Association says its member clinics tell emotional stories about helping the rare person who arrives mid-heart attack get to an emergency room.) As most clinics do not have a doctor on site, nurse practitioners use a sort of flow-chart-style guideline known as evidence-based medicine, which ensures that staff members stick to proven protocols but that also limits flexibility in the care they provide. In addition, many Americans don’t even have access to a clinic: More than 90% of them are located in urban areas, with the highest concentration appearing in higher-income neighborhoods, not in rural places that already lack adequate health-care access, according to Rand. Some clinics are experimenting with new services, however, with some now offering chronic-illness care and weight management, but they have to balance the demand for such care — in a store setting with somewhat limited privacy — with the additional cost of providing it: “It’s our decision in this particular type of model to be more limited in scope,” says Hansen-Turton of the Convenient Care Association.

10. “We might be ‘pill mills’ in disguise.”

As authorities across the country attempt to crack down on illegal use of prescription drugs, some so-called pill mills, operations that excessively dispense prescription painkillers, have been using the retail health clinic craze to sneak under the radar. Doctors in California and Texas have been sanctioned and in some cases even arrested for running pill mills disguised as urgent-care clinics, writing thousands of prescriptions for addictive painkillers. One California physician reportedly prescribed narcotics to an undercover officer who presented the doctor an X-ray of a dog. While experts say it’s difficult to know how many of such facilities — typically independent, freestanding outfits — are operating illegally, the Washington state Department of Health recently developed posters featuring guidelines discouraging the abuse of pain medications at the request of local urgent-care clinics. But as more clinics open, it may be harder to distinguish the legitimate from the corrupt: “The more you get these different types of clinics all over the place, the harder it is to monitor,” O’Malley says.