Letters to the Editor  |   February 2008
Time to Respond to In-Store Clinics
Author Affiliations
  • J. Scott Nystrom, MD
    Tufts University School of Medicine, Boston, Mass, Medical Director, Physicians Total Care Inc, Tulsa, Okla
Article Information
Practice Management / Professional Issues
Letters to the Editor   |   February 2008
Time to Respond to In-Store Clinics
The Journal of the American Osteopathic Association, February 2008, Vol. 108, 52-53. doi:
The Journal of the American Osteopathic Association, February 2008, Vol. 108, 52-53. doi:
To the Editor: In-store kiosks staffed by nonphysicians who provide primary healthcare services to ambulatory patients are experiencing explosive growth.1 CVS/pharmacy, Jewel-Osco, Target, Walgreens, and Wal-Mart are just some of the many companies racing to add these “docs in a box” to their customer services.1 Retail store walk-in clinics certainly provide convenience to their customers, but the underlying motives to this trend beg comment. 
In-store clinics essentially take the prescription pad from the physician and move it to the pharmacy to create point-of-care dispensing. The store receives the benefit of having the patient in a retail environment in which the entire process is focused primarily on generating retail sales—not on healthcare. It is time for physicians to respond competitively to this market challenge by moving the dispensing of prescription medications back into physicians' offices, where it originated. 
The current retail pharmacy system of dispensing prescription medications to patients is inefficient. In 2006, pharmacists in the United States dispensed more than 3 billion prescriptions to patients and placed more than 900 million prescription-related telephone calls to physician offices, costing the healthcare industry $280 billion (much of this being unreimbursed costs borne by physicians for office staff, time, and telephone and fax charges).2,3 Each pharmacy call-back costs physicians' practices approximately $5 to $7.3 With the average primary care physician writing about 30 prescriptions per day and handling another 30 requests per day for prescription refills, these costs escalate rapidly.3 The estimated 20 pharmacy-related phone calls made by a typical physician's office every day costs that office $20,000 to $28,000 annually—while unreimbursed physician time doubles these costs.3 By returning medication dispensing to the physician's office, this overhead can be cost-shifted to serve patients better and create an additional source of income for the physician. 
Office dispensing of prescription medications respects patients' time and is likely to increase patient compliance with medication regimens. Only physicians possess the expertise and authority to substitute therapeutically equivalent generic medications for brand-name medications of a differing drug class. Furthermore, the dispensing of prescription medications by physicians could result in huge cost-savings for insurers and consumers.4 
In 2006, the average cost of a generic prescription medication was about $32, while the average cost of a brand-name prescription medication was about $111.4 Thus, the overall national average cost of a prescription medication was more than $88.4 As a result of insurance company policies favoring generic substitutions over brand-name medications, the national rate of generic substitution has increased to approximately 60% of all prescriptions dispensed.4 However, because these policies involve higher copayments on brand-name drugs and limits on the available formularies, they may have had the unintended consequence of decreasing patient compliance with prescribed brand-name medication regimens.5 
By contrast, physicians who dispense their own prescription medications can achieve a generic substitution rate as high as 85%, with an average cost for both generic and brand-name medications of approximately $37 (W.G. Moseley, JD, oral and written communications, December 2007). Without the more widespread application of this kind of direct physician involvement in prescription dispensing, increasing generic prescription rates beyond the current level of roughly 60%4 remains problematic. When the average cost of physician-dispensed prescription medications is less than half the current national average,4 the potential cost savings for both insurers and consumers with a physician-dispensing system are staggering. 
In-store clinics have their place, but so does physician dispensing. Both serve the patient well in terms of convenience and compliance. However, as in-store clinics thrive, will this trend further accelerate the death spiral of primary care?5 Physicians need to concentrate on how to compete with marketplace challenges. To only debate the legality, ethics, quality, and fragmentation of healthcare as provided by retail pharmacy walk-in clinics does not address the reality of consumer demand. 
In the end, the patient (ie, consumer) will decide where, when, and with whom to seek healthcare. Will physicians respond to consumer demand by offering patients a better choice? Whether patients choose to receive their healthcare at the same stores in which they buy toothpaste, toilet paper, and cigarettes may depend on how physicians respond to the challenges posed by in-store clinics. 
Bohmer R. The rise of in-store clinics—threat or opportunity [published erratum appears in N Eng J Med. 2007;356:2437]? N Eng J Med. 2007;356:765-768. Available at: Accessed December 16, 2007.
Hartley CP. E-prescribing: the write move. For The Record. 2006;18:9. Available at: http://www.fortherecord Accessed December 16, 2007.
Turner MJ. Tipping the balance of power with digital patient information. Pharmaceutical Executive. March 1, 2002. Available at: Accessed December 16, 2007.
Generic Pharmaceutical Association. Statistics for 2006. Available at: Accessed December 16, 2007.
Heisler M, Langa KM, Eby EL, Fendrick AM, Kabeto MU, Piette JD. The health effects of restricting prescription medication use because of cost. Med Care. 2004;42:626-634.