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Retail Health Care Clinics and Nurse Managed Health Centers

Delaware Technical Community College

Amanda Smith



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

reach the future of healthcare accessibility.


Retail Health Care Clinics and Nurse Managed Health Centers

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

seeking an OBGYN waited, on average, 51 days (Merritt Hawkins, 2017). Overall, patients

seeking a dermatologist in the 15 metropolitan areas surveyed waited an average of 32 days

(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

and perform simple diagnoses and procedures (Rosenthal, 2014).


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

schedules (Godman, 2016).


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

promotion, disease prevention, and the management of chronic conditions (Hansen-Turton,

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

commonly affiliated with a university (Hansen-Turton, 2010). By implementing policies that

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

accommodate the increase of insured Americans.

Key Stakeholders

Local and State

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-

managed health centers. The University of Delaware is an influential part of Delaware’s

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

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

to generate some income.

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

would support keeping the practice in place.


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

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

Services (Morse, 2019).

Goals and Strategies for Implementation

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

credentialing, contracting, and reimbursement (Multistate, n.d.).

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

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.

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 more support there may be for change.

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.


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