The Health Care Industry

By: Susan Ladika

Pub. Date: March 27, 2020 Access Date: November 10, 2022

Source URL: https://library.cqpress.com/cqresearcher/cqresrre2020032700

©2022 CQ Press, An Imprint of SAGE Publishing. All Rights Reserved. CQ Press is a registered trademark of Congressional Quarterly Inc.

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Table of Contents

Introduction

Overview

Background

Current Situation

Outlook

Pro/Con

Chronology

Short Features

Bibliography

The Next Step

Contacts

Footnotes

About the Author

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Page 2 of 19 The Health Care Industry CQ Researcher

A CVS in San Ramon, Calif., offers free sanitizing wipes for shoppers during the coronavirus pandemic. In some stores, CVS operates HealthHUBS that provide services such as treatment for coughs or help managing chronic conditions, part of an effort to expand health care options. (Getty Images/Smith Collection/Gado/Contributor)

Introduction Amid the tumult and disruption caused by the global coronavirus pandemic, a physician shortage and rising health care costs, providers and insurers have been focusing on new ways to make care more accessible to consumers. Changes include placing health clinics in retail stores where consumers can get primary care services, find help managing chronic conditions or even take a yoga class. Providers also are turning to telehealth — offering care via computer, phone or mobile device. Mergers and partnerships among retailers, insurers and providers are driving some of the changes as the health care industry struggles to bring down the high costs of care in the United States. The coronavirus pandemic is also boosting telehealth. But some experts worry about the quality of care offered by these new services. They warn that retail clinics and telehealth can undercut patients' relationships with primary care doctors. Yet given the physician shortage, other experts say retail clinics and telehealth have a vital role to play.

Overview When Rosita Rodriguez came to a CVS drugstore in Spring, Texas, last year looking for pain medication, she met with the “care concierge,” Jesse Gonzalez. He helped the 68-year-old select medication, then told Rodriguez she could get her glucose level checked at the store and join free yoga classes.

“I did yoga, and it was such a joy,” said Rodriguez, who now regularly visits the store. “Whenever I need something, I see Jesse. He's there for me.”

The store in the Houston suburb is one of CVs' new HealthHUBs, where customers can receive primary care services including flu shots and treatment of coughs, get help managing chronic conditions such as diabetes and participate in health and wellness classes. The new clinics were spurred by CVs' $69 billion acquisition of health insurer Aetna in 2018.

National Guard soldiers set up a triage tent on March 19 in the parking lot of the Adventist HealthCare White Oak Medical Center in Silver Spring, Md., in preparation for an expected onslaught of coronavirus patients. The pandemic has brought a renewed focus on the U.S. health care system and how to improve it. (Getty Images/Drew Angerer)

The HealthHUBs are part of a growing trend to put health care more directly in the hands of consumers. That might mean visiting a drugstore or big-box store for health care, or consulting with a physician by phone, mobile device or computer. The landscape also is shifting as health insurers and care providers put a greater emphasis on “well care,” aimed at keeping consumers healthy, rather than just providing treatment when someone is ill. Besides seeking to keep people healthy longer, insurers and providers say they want to make health care more accessible and to lower sky-high medical costs.

“Consumer-centric health care coordination could be a way to essentially transform care delivery,” says Sonal Kathuria, managing director in the health practice of the consultancy Accenture.

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But some experts say these changes could reduce the quality of care without necessarily lowering costs. The reason, they say, is that visits to clinics can result in less continuity of care, as one health care provider may not be aware of the care a patient has already received.

The information patients share with health care providers, and the treatment they receive, “needs to get integrated somewhere into an individual's health record,” says Dr. Ken Abrams, managing director and life sciences and health care national physician leader at the global consulting firm Deloitte. “If you ignore it, there are more opportunities for error.”

Health care is a huge business in the United States. Spending on all health care climbed to $3.6 trillion, or more than $11,000 per person, in 2018 — a 4.6 percent increase from 2017, according to the Centers for Medicare & Medicaid Services (CMS), the federal agency that supervises those two programs. (Medicare primarily provides health insurance to those age 65 and older; Medicaid offers coverage to lower-income adults.)

Health care spending made up 17.7 percent of U.S. gross domestic product (GDP) in 2018, far higher than that of 10 other high-income countries, such as Germany and the United Kingdom. A study by the Commonwealth Fund, a foundation that promotes a high-performing health care system, found that in 2016, the world's other wealthy countries spent an average of 11.5 percent of GDP on health care.

One reason for the disparity is that the cost of medical care is far greater in the United States than elsewhere. In 2017, the average price for heart bypass surgery in the United States was $78,000, more than twice the price in the United Kingdom and Switzerland, according to a study by the International Federation of Health Plans, which represents health insurance CEOs from around the world. Basic health care visits and medications are also much more expensive in the United States than in other countries.

“It is staggering how much [more expensive] the United States is,” said John Hargraves, director of data strategy for the Health Care Cost Institute, which collects claims data from several health insurance companies.

Costs are expected to keep rising as Baby Boomers — the generation born between 1946 and 1964 — age. Total health care spending in the United States is projected to reach almost $6 trillion by 2027, and will account for 19.4 percent of GDP, according to the Centers for Medicare & Medicaid Services.

The aging population and growing demand for health care services come at a time when the U.S. physician shortage is projected to reach as many as 122,000 by 2032, including between 21,000 and 55,000 primary care physicians, according to the Association of American Medical Colleges.

These trends were already well established before the coronavirus pandemic, which is almost certain to increase the constraints and pressures on the U.S. health care system. As that system struggles to cope with the pandemic, it may be forced to rely even more on the new forms of health care delivery to relieve some of the strain.

What the pandemic's ultimate impact will be is “the million-dollar question,” says Dr. Ateev Mehrotra, an associate professor of health care policy at Harvard Medical School. “My sense is that it will drive a big bump longer term,” especially with telehealth.

Alternative Types of Care

Many experts across the health care spectrum hope that the increasing use of alternative care such as telehealth — consulting with providers by telephone or online — and retail clinics will improve access to care and help control health care costs.

“Consumers are demanding more and more access to care,” Abrams says, adding that retail clinics and telehealth are “very much consistent with our 24/7 culture.”

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At the same time, insurers who are involved in retail clinics hope to “sell not just diabetes medication, but diabetes management” and “change the behavior of those [patients] you're financially responsible for,” says Jeff Gourdji, a partner with the consultancy Prophet.

But not everyone is convinced these new models will become widely used.

“This is going to take a lot of cultural change for patients to feel that this is a reasonable option for them,” Mehrotra said. Patients may be willing to get a flu shot at a drugstore, but not to go there for help managing their diabetes, he said.

Nevertheless, studies show that “in general, people are pretty happy with the clinics” because of the quality of the care they receive, Mehrotra says.

Retail health clinics are not new, but their numbers have been growing and the scope of their services is expanding. In 2016, the United States had more than 2,000 retail clinics.

CVS acquired MinuteClinics, which provided basic services such as treatment for an ear infection or sore throat, in 2006, and the Walgreens and Walmart chains have similar retail clinics.

After a pilot program at three stores in the Houston area, CVS announced in 2019 it would roll out its HealthHUBs to 1,500 locations by the end of 2021.

“We have a sense of urgency about the need to bring real change to health care,” said Kevin Hourican, then-president of CVS Pharmacy, who cited the importance of creating “an entirely new consumer experience and [helping] people on their path to better health.”

Meanwhile, Walgreens and Humana began partnering on two senior-focused primary care clinics in the Kansas City, Mo., area in 2018 and last year announced plans to add two more in the Kansas City region and one in Anderson, S.C.

In September, Walmart added a health center to its superstore in Dallas, Ga., a suburb of Atlanta. Walmart Health offers primary care, X-rays, lab work, counseling, dental care, community health programs and health insurance education and enrollment. Services are available to anyone, regardless of whether they have health insurance. A primary care visit costs $40; an adult dental checkup and cleaning is $50. Counseling costs $1 per minute. Walmart has opened its first drive-thru coronavirus testing centers in the Chicago area, and other retailers are expected to follow suit.

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Another growing alternative is telehealth. (See Short Feature.) These services are typically offered by a direct-to-consumer telemedicine provider, such as Teladoc Health or MDLIVE, or through a major health system, such as the Cleveland Clinic, a medical center in Ohio.

Because of the coronavirus pandemic, experts are promoting telehealth as a way to help diagnose COVID-19, and to keep patients with other ailments out of doctors' waiting rooms. Several health insurers, including Humana and Aetna, are temporarily charging no co-payments for all consultations done via telemedicine, and the Trump administration is expanding access to telemedicine in Medicare.

“The use of telemedicine is going to be critical for management of this pandemic,” said Dr. Stephen Parodi, executive vice president of external affairs, communications and brand for the Permanente Foundation, the national leadership and consulting organization for Kaiser Permanente, a major West Coast health system.

A 2019 survey by data company J.D. Power found about 10 percent of consumers had used telehealth to consult with a health care provider in the previous 12 months. Hospitals also are increasingly using telehealth.

Critics worry about the quality of care offered by telehealth providers and retail clinics. Mehrotra, who has conducted more than a dozen studies on telehealth services, says that quality of care “varies from company to company.”

While retail clinics and telehealth can provide immediate care, “primary care tends to perform better” over the long term because of the continuity of care to patients, says Shawn Martin, senior vice president of advocacy, practice advancement and policy for the American Academy of Family Physicians, based in Leawood, Kan. The question with these alternate-delivery models is “how to incorporate them into the primary care system,” he says.

Dr. Mark J. Werner, director of clinical consulting for the Chartis Group, a Chicago-based health care consulting firm, said retail clinics do not necessarily provide quality care or reduce costs. “None of the research has shown… these approaches to delivering care has meaningfully addressed cost,” Werner said.

The pandemic also is complicating things for retail clinics. Many of the clinics, according to public health experts, lack essential safety protocols and protective equipment. Experts fear they are becoming prime locations for the coronavirus to spread among patients and the doctors and nurses treating them.

While CVS says its new HealthHUBs are outperforming a control group of its traditional stores in terms of sales and new customers, Walgreens is shuttering its company-run clinics because of challenges in becoming profitable.

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A doctor (foreground) consults with a patient through videoconferencing. Experts hope telehealth will improve access to health care while helping to control costs. (Getty Images/BSIP/Universal Images Group/Contributor)

Many of the changes in the industry are tied to mergers and partnerships between health insurers and health care providers, both of which want to lower costs and increase profitability. Insurers Cigna and Health Care Service Corp., the parent company of five Blue Cross and Blue Shield plans, have invested millions in telehealth provider MDLIVE.

Another change is the rising number of insured following passage of the Patient Protection and Affordable Care Act (ACA) in 2010: About 90 percent of Americans now have health insurance, up from 82 percent in 2010.

The two remaining Democratic presidential candidates differ on what should happen to the U.S. health insurance system. Sen. Bernie Sanders of Vermont calls for a government-run single-payer system that he calls Medicare for All. Former Vice President Joe Biden calls for strengthening the ACA by adding a so-called public option, government-sponsored coverage that would provide an alternative to private insurers. How health insurance might be transformed if a Democrat wins the White House in November is anyone's guess.

Background Rise of Urgent Care Centers

From the turn of the 20th century until recently, Americans received medical care from two main providers: doctors and hospitals.

“Before, you went to a doctor's office or the ER. Neither of those is sufficient,” Deloitte's Abrams says.

The first urgent care centers were created in the 1970s, offering patients the opportunity to receive medical care without having to make an appointment, and providing care when most doctor's offices were closed or when treatment was needed promptly but did not merit a trip to the emergency room.

Since then, the number of urgent care centers has risen from 6,400 in 2014 to more than 9,200 in June 2019. Those figures do not include clinics located inside retail stores.

A family physician and a businessman started the first retail health clinics, known as QuickMedx, in the Minneapolis area in 2000. They accepted only cash payment and treated a handful of medical conditions, such as strep throat and flu. The clinics were designed to be a more affordable alternative to urgent care centers.

The name was changed to MinuteClinic in 2003. In 2006, MinuteClinic outlets began to be located at CVS stores, and CVS then acquired MinuteClinic. As of 2017, the company had more than 1,100 retail clinics in CVS and Target stores.

Walmart, Walgreens and other retailers also began to open clinics inside their stores in the 2000s.

Nurses, nurse practitioners and physician's assistants primarily staff these clinics. To compete with the clinics, some major hospital systems have placed health clinics inside retailers, such as a partnership between Walgreens and the not-for-profit health system TriHealth, which operates seven clinics at Walgreens stores in the Cincinnati area.

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Patients wait in a hallway at Grady Memorial Hospital's emergency department in Atlanta in July 2006. Urgent care centers were created in the 1970s to help reduce the workload at overcrowded hospitals. (Getty Images/Jonathan Torgovnik)

Telehealth also grew as the use of the internet and cellphones spread in the early 21st century. Teladoc, which says it is the country's oldest and largest telehealth provider, was founded in 2002 and began serving patients in 2005. Consumers can reach a physician through their mobile device, computer or phone.

For the first nine months of 2019, Teladoc reported it had almost 3 million virtual visits, a 64 percent increase from the first nine months of 2018, and virtual visits for mental health care were rapidly expanding.

Generally, patients go online or call in to consult with a telehealth provider. They discuss the patient's symptoms and, if needed, a prescription is placed at the patient's pharmacy. A patient may be told to go to the emergency room, or to consult with a local physician for follow-up care.

Along with easy access to care, virtual visits tend to be much cheaper than in-person ones. A study by the RAND Corp., a California-based think tank, in 2017 found telehealth visits cost about $79, compared with $146 for in-person visits. But the study also said that access to telemedicine generated new demand for health care, so it did not necessarily produce cost savings.

Demand for medical care has increased in the past decade for a variety of reasons. One is that the ACA, which Congress passed in 2010, has increased insurance coverage by providing subsidies in the form of tax credits for households whose incomes are between 100 percent and 400 percent of the federal poverty level. Subsidies in 2020 are available for individuals who earn up to $49,960 and for families of four who earn up to $103,000. The ACA also expanded Medicaid to include all those whose incomes are below 138 percent of the federal poverty level, although not all states have widened their Medicaid coverage.

Arthur Barrett (left) of New York City signs up for health insurance coverage in March 2014, made available through the Affordable Care Act. The law has helped cut the uninsured rate in the United States. (Getty Images/Andrew Burton)

In addition, the ACA supported health care delivery methods aimed at reducing the cost of care.

The law has faced numerous legal challenges over the years. In 2012, the U.S. Supreme Court upheld the law's constitutionality, ruling that the individual mandate, which required all Americans to obtain health insurance or pay a financial penalty, was authorized under Congress' power to levy taxes. The following year Americans started signing up for coverage on the federal and state health exchanges created under the law, and ACA coverage began in 2014.

In 2015, the U.S. Supreme Court ruled the federal government could provide subsidies to residents in states that did not establish their own exchanges. Two years later, congressional Republicans with the support of President Trump tried to repeal the ACA, but the measure did not pass in the Senate.

Current Situation Legal Challenges

Despite the fact that millions of Americans have gained health insurance coverage since 2010, the ACA's future remains uncertain.

With Congress' passage of the 2017 Tax Cuts and Jobs Act, the tax penalty for failing to purchase health insurance was eliminated. A group of states, led by Texas, filed suit in 2018, arguing the ACA is unconstitutional without the tax penalty. A federal District judge in Texas agreed.

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In December, the Fifth Circuit Court of Appeals in New Orleans ruled the individual mandate was unconstitutional, but it sent the case back to the District judge in Texas to determine whether other parts of the law also are unconstitutional, as the judge had ruled.

“It's really hard for me to believe that courts and the Supreme Court won't find a way to create severability of various provisions of the law,” in which other parts of the law can stand even if one part, such as the individual mandate, is void, says Martin of the American Academy of Family Physicians.

Seventeen Democratic-led states, the District of Columbia and the Democratic-controlled U.S. House of Representatives are fighting to preserve the law, and the Supreme Court in early March agreed to review the appellate court's decision. The case likely will be heard in the fall.

“As Texas and the Trump administration fight to disrupt our health care system and the coverage that millions of people rely upon, we look forward to making our case in defense of the ACA. American lives depend upon it,” said California Attorney General Xavier Becerra, who is leading the Democrats' defense of the ACA.

Texas Attorney General Ken Paxton, a Republican, expressed confidence the Republican challenge will prevail. “The federal government cannot order private citizens to purchase subpar insurance that they don't want, and I look forward to finally settling the matter before the U.S. Supreme Court,” he said.

The Wellness Campaign

Some health care providers and health insurers are putting an increasing focus on wellness.

“So much of what influences your health outcomes is outside the clinic,” says Dr. Dora Hughes, associate research professor of health policy and management at George Washington University. During the Obama administration, she worked as a counselor for Health and Human Services Secretary Kathleen Sebelius.

These factors include income level and whether individuals have safe housing and access to healthy food and transportation.

At Northwest Permanente, a medical group based in Portland, Ore., patient navigators have been added to the staff to help determine whether patients need extra assistance, such as locating secure housing or financial aid. “They are there to help address the social and nonmedical needs of our members by building trusting relationships with patients, helping them to connect with resources in their communities, and to activate individual patients' care plans,” said Dr. Imelda Dacones, the health system's president and CEO.

A teleconsultation takes place in February between medical staff at Wuhan Union Hospital, located in the city where the coronavirus first appeared late last year, and Guangzhou Medical University in Guangzhou, China. The pandemic is spurring questions about next steps for the health care industry. (Getty Images/Xinhua/Xiao Yijiu)

The ACA, meanwhile, seeks to improve care and lower costs by rewarding doctors and hospitals for producing good health outcomes rather than focusing on a large volume of patients.

The Centers for Medicare & Medicaid Services, for example, is now allowing Medicare Advantage plans to provide extra services to members with chronic conditions to improve their health and quality of life. (Medicare Advantage provides Medicare benefits through a private insurer.) As a result, some insurers are working with ride-sharing companies such as Uber or Lyft to offer free rides to medical appointments, or with Papa, which provides companionship from “grandkids on demand.”

“The ACA has helped to drive these partnerships,” Hughes says. And even if the ACA is overturned, “the private sector has embraced the newer models of care. The old days of practicing medicine are over.”

Mergers and Partnerships

CVs' acquisition of Aetna is fueling its retail clinic effort. In November, CVS Chief Executive Officer Larry Merlo said the

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