Retail Clinics: C A L I FOR N I A Six State Approaches to Regulation and Licensing H EALTH C ARE F OU NDATION Introduction oversight at retail clinics may lead to The recent growth of retail clinics across the inappropriate care delivery. United States presents opportunities and challenges 2. Access for the underserved. Despite their for states working to address access, cost, and generally lower charges, the payment structures quality issues within their health delivery systems. of retail clinics may exclude underserved Issue Brief With more than 1,000 sites in 37 states,1 the populations who are eligible for sliding scale emergence of retail clinics as alternative providers fees in other settings. There is also concern can no longer be viewed as a passing trend and has among some that retail clinics may negatively shaken up traditional health care models for the affect the viability of safety-net clinics. following reasons: 3. Care fragmentation. Care at retail clinics may  Retail clinics are accessible. They are usually interfere with the continuity of care a patient located within suburban drug, grocery, or mass receives through a medical home. merchandise stores, and are open evenings and weekends without an appointment or wait. 4. Conflict of interest. Because retail clinics are often located in a facility with a pharmacy, there  Retail clinic services often cost less. Because is concern that the clinics will influence patients they are staffed mostly by nurse practitioners to buy medications and other items at that rather than physicians and have lower total facility. overhead, their prices are often below those of other types of providers such as emergency 5. Corporate ownership and organizational rooms or urgent care centers.2 issues. Because corporate practice of medicine laws vary from state to state, legal ownership of  Retail clinics offer evidence-based care. retail clinics influences whether and how states Their limited range of services normally regulate those clinics. adheres to established clinical practice guidelines.3 This issue brief explores how six states —  California, Florida, Illinois, Massachusetts, Despite these apparent benefits, retail clinics pose New Jersey, and Texas — are using regulation a number of challenges for state policymakers and and licensure to promote, structure, or limit regulatory agencies working to improve access, the operation of retail clinics. These six states cost, and quality within their health delivery were selected because their recent experiences systems. The challenges identified by stakeholders may provide instructive lessons for other states. during the course of research for this report The states’ approaches to the clinics vary, as do coalesce within five issues: interpretations of how existing regulations fit the 1. Patient safety and quality of care. There retail clinic model. Only one state, Massachusetts, is concern from some stakeholders that has written new regulations expressly for retail F ebruary insufficient state regulation or physician 2009 clinics. Among the steps being taken or considered by Patient Safety and Quality of Care these states are: States have a responsibility to protect public health by ensuring the safe delivery of health care. States can use  Creating a separate regulatory category for retail their regulatory powers to protect and enhance the quality clinics; of patient care at health care facilities.  Licensing retail clinics as they do other health care facilities; Regulation of Clinics Through Facility Licensing The licensing of health care facilities is a regulatory tool  Altering oversight requirements regarding nurse that states can use to help ensure that basic structural practitioners and physician assistants; requirements are in place to provide safe, quality care. Of  Imposing or loosening marketing and advertising the six states discussed in this report, only Massachusetts restrictions; directly licenses retail clinics as a separate type of health care facility. State regulation of other health care facilities  Developing Medicaid policies to facilitate clinic varies: For example, states require hospitals and nursing participation; and homes to meet the most stringent facility standards; some  Requiring clinics to make referrals to primary care states provide separate regulations for ambulatory and providers. urgent care clinics. The project’s researchers conducted interviews with Applying regulations intended for other types of facilities stakeholders in each of the six states concerning the to retail clinics may adversely affect clinic operations. state’s regulation of health services in retail settings. The Massachusetts found that, without multiple waivers of researchers interviewed representatives of state Medicaid minimum standards, retail clinics could not operate and licensing and certification agencies; retail clinics; under the state’s existing regulations for licensed clinics, organizations that represent health care providers, including physical space requirements (retail clinics are including physicians, nurse practitioners, and two state located in settings that average between 200 and 500 primary care associations; and state legislators and/or square feet).4 This prompted the state to promulgate their staff. Interview protocols were tailored for each regulations specifically to address physical space standards stakeholder group. This report addresses some common for retail clinics (as well as issues such as continuity of themes that emerged, as well as each state’s unique care; see below).5 response to the emergence of retail clinics. Conversely, physician offices, the rubric under which Issues for State Policymakers retail clinics operate in most states, usually are not Retail clinics present a series of interrelated considerations regulated with regard to their physical space. In most for state policymakers and regulators. States may want states, retail clinics formally organize themselves as to consider how regulation of retail clinics might affect physician offices, and thus are not subject to state facility patient safety, quality of care, access to medical care for regulation. the underserved, continuity of care and medical homes, and potential conflicts of interest regarding the delivery Provider Regulation of care. States should also be aware that existing laws and According to retail clinic representatives, the state regulations regarding corporate practice of medicine may regulatory tools most strongly affecting their operations affect the proliferation of retail clinics. are the scope-of-practice regulations that govern nurse 2  |  California HealthCare Foundation practitioners and other non-physician medical personnel. Both physician groups interviewed in this study consider Most retail clinics are staffed by nurse practitioners. the supervision laws to be an important aspect of Eleven states allow nurse practitioners to practice safeguarding public health. In contrast, the nursing independently, without physician oversight, but all others organization interviewed sees this kind of supervision require some degree of supervision.6 Some states specify as counterproductive, especially in light of the shortage an upper limit on the number of nurse practitioners that of primary care providers. Retail clinic operators share a single physician may supervise. Some states also regulate the nurses’ views and find the supervision requirements the frequency and proximity of that supervision, requiring largely an unnecessary burden with no impact on quality the physician to be on-site for a certain number of hours of care. They cite a few small studies that have compared or within a certain radius of a nurse practitioner-staffed adherence to treatment guidelines in retail clinics with clinic. (See Table 1 for a six-state comparison.) These other settings and found retail clinics compare favorably.7 kinds of regulations can greatly affect the cost structure of They also point out that nurse practitioners follow retail clinics and may influence where these clinics locate, protocols embedded in and prompted by the electronic their staffing, and their hours of operation. medical records that all retail clinics employ. In addition, all retail clinic operators contacted in this study report Additionally, regulations that govern the scope of practice strong internal quality control that includes physician for nurse practitioners have a potentially large impact on review of charts. the services that retail clinics offer. Most states allow nurse practitioners to diagnose and treat illnesses, order tests, State Systems for Monitoring Patient Safety and prescribe medications following a written clinical Many states monitor patient safety and quality of care protocol or physician collaboration, but they also place by requiring health facilities, though not physicians or limits on these practices. Because nurse practitioners are other private provider offices, to report patient safety the primary providers in most retail clinics, restrictions data. However, only Massachusetts collects data from on their scope of practice affect the care provided in retail retail clinics. States are able to indirectly monitor quality settings. of care at retail clinics through licensure of providers Table 1. Physician Oversight of Nurse Practitioners in Six States R at i o ( N P : M D ) O t h e r R e g u l a t i o ns California 4:1 • Physician supervision required. Florida 4:1 • Physician may not supervise more than four offices in addition to the physician’s primary practice location. Illinois None stated • Physician delegation required. • Physician must be on-site once per month. Massachusetts None stated • Physician supervision required. • Physician must review charts once every three months. New Jersey None stated • Physician collaboration required. • Physician must review charts (percentage or frequency not specified). Texas 3:1 • Physician delegation required. • Physician must be on-site 20 percent of the time (less in underserved areas). • Physician must review 10 percent of all charts (less in underserved areas). Source: Adapted from State-By-State Guide to Regulations Regarding Physician and Nurse Practitioner Practice. Convenient Care Association, 2008. Retail Clinics: Six State Approaches to Regulation and Licensing  |  3 Retail Clinics Report Internal Quality Controls in this study also revealed the following measures of Some retail clinic operators find that regulations limiting consumer satisfaction: nurse practitioner scope of practice are unnecessarily strict. In support of their position that the clinics  According to Take Care Health, patient satisfaction themselves provide sufficient quality control, several data compiled by Gallup reveals overall satisfaction clinics reviewed in this study cite specific examples of with care at its clinics has been about 96 percent. internal training, supervision, and tracking of quality of care:  HealthRite retail clinic system in New Jersey reports • Take Care Health clinics track and trend Healthcare consumer satisfaction ranking in the 85th percentile Effectiveness Data and Information Set (HEDIS)* when compared with other urgent care centers. scores against the national average for streptococcal infections, bronchitis, and upper respiratory infections.  According to RediClinic in Texas, 97 percent of its • HealthRite clinics send all their nurse practitioners consumers would recommend the clinic to friends to a Federally Qualified Health Center (FQHC) “boot and family. camp” where they practice clinical guidelines for 30 days. This provides intensive orientation at a full-scope primary care facility, exposing the nurse practitioners Access for the Underserved to a wide range of patients and medical conditions. In addition to adding convenience for insured patients, • HealthRite conducts a 100 percent file review for the retail clinics may expand access to limited types of care first 90 days of a new employee’s work; this tapers to for some populations. For the underinsured — those 10 percent by the end of the first year. with health insurance but with high deductibles or other • MinuteClinic receives accreditation from the Joint high out-of-pocket costs — retail clinics may provide an Commission for meeting the ambulatory care affordable way to receive some basic health services. For standards applicable to services provided in retail settings.† other groups, retail clinics represent a culturally familiar * he Healthcare Effectiveness Data and Information Set (HEDIS) is a tool T health care delivery site where they may be more likely for defining and measuring health plan performance with comparison to to seek care. For example, MediGo clinics in Navarro national or state benchmarks. † ource: Khoury, Nicole. “MinuteClinic Receives JCAHO Accreditation.” S Pharmacies in Florida seek to serve Hispanic patients who MinuteClinic press release, Sept. 20, 2006 (www.minuteclinic.com/ documents/press-releases/minue_clinic_receives_jcaho_accreditation.pdf). are culturally familiar with receiving health services in a pharmacy.9 Whether retail clinics can improve access for the and consumer complaints. But some physician groups underserved depends on several factors, including contend that states should also monitor how retail clinics accessibility of the clinics, Medicaid participation, and are affecting matters such as continuity of care. out-of-pocket costs to patients. To date, many retail clinics are located in suburban or metropolitan areas, States investigate consumer health care complaints on a rather than in rural areas where there is limited access to case-by-case basis but do not compile data specifically primary care providers. with regard to retail clinics. Anecdotally, this study’s interviews with state officials revealed few complaints Medicaid Participation by Retail Clinics about retail clinics. Independent national surveys When retail clinics first began operating, most of them regarding retail clinics have rated consumer satisfaction in did not accept any public or private insurance, requiring the areas of quality of care, convenience, and cost each at immediate cash payment instead. This has changed about 90 percent.8 Interviews with retail clinic operators dramatically: Consumers’ share of out-of-pocket costs for retail clinics fell from 100 percent in 2000 to 15.9 4  |  California HealthCare Foundation Costs at Retail Clinics Versus Community there. However, Medicaid officials in the six study states Health Centers believe it is unlikely that many Medicaid beneficiaries With regard to access for the underserved, retail clinic are receiving services at retail clinics. (Actual figures are providers note that charges at their clinics are lower not available because most Medicaid billing systems than at most doctors’ offices, urgent care centers, and certainly emergency rooms. Uninsured patients do not distinguish retail clinics from physician offices.) may benefit from these lower out-of-pocket costs. In Retail clinics in most states simply do not accept particular, patients who do not qualify for sliding scale Medicaid patients; the reason often cited is low Medicaid fees at community health centers may find lower reimbursement rates. And in Illinois, a newly introduced prices for certain services at retail clinics. However, representatives of community health centers in managed care model for Medicaid enrollees may make California and Massachusetts contend that low-income, retail clinic use impractical (this issue is included in the uninsured patients who do qualify for sliding scale fee wider discussion of Illinois policies in the state-by-state arrangements may find that their out-of-pocket costs are section later in this report). lower at community health centers than at retail clinics. In Massachusetts, the Medicaid agency is developing the technical capability to recognize and therefore directly percent in 2007,10 with most retail clinics now accepting reimburse retail clinics rather than requiring individual private insurance and some accepting Medicare. Only a providers to seek reimbursement. MinuteClinic has been very few, however, accept Medicaid: Just one of the six working directly with the state to become a Medicaid retail clinics interviewed for this study, Take Care Health, provider. The advantage for retail clinics to be recognized currently accepts Medicaid payments, and not in all the as a Medicaid provider would be from an accounting states where it operates. Other retail clinic operators are in perspective: When there is turnover at their clinics, cash negotiations with state Medicaid agencies. flow would continue regardless of the change of providers. From the standpoint of public payers such as Medicaid, Price Advertising retail clinics offer the significant attraction of diversion Low costs for both consumers and payers is a large part of from other, more expensive settings, especially the what makes retail clinics attractive. A related element of emergency room. One study found that the average total retail clinics pricing is transparency: Prices are commonly cost for a retail clinic episode was $51 less than in the advertised, both at the door and in other advertising urgent care setting, $55 less than in the physician office, forms, so that customers can make informed decisions. and $279 less than in the emergency department.11 (The Price advertising by retail clinics was debated in two of same study cautioned, however, that retail clinics might the states researched for this study. Both Illinois and potentially increase the overall cost of care by increasing Massachusetts introduced legislation or regulations that demand from consumers who might ordinarily self-treat would have restricted the scope of advertising by retail or might delay preventive care.12) Although retail clinics clinics. In each state, the Federal Trade Commission do not provide emergency care, they may divert patients (FTC) advised against the proposed provisions.13 (See the with acute non-emergency conditions from going to an discussion of various FTC positions regarding retail clinics emergency room, thus substantially reducing the costs of in the Illinois part of the state-by-state section, later in care. this report.) Medicaid-enrolled practitioners who provide care in retail clinics can submit claims for services delivered Retail Clinics: Six State Approaches to Regulation and Licensing  |  5 Care Fragmentation Conflicts of Interest Some physician provider groups argue that retail clinics This study examined concerns raised in some states about are sometimes medical home-wreckers and assert that potential conflicts of interest regarding retail clinics. states should play a larger role in their oversight. The Because retail clinics are often located within a store that physicians believe that a retail clinic is a poor substitute includes a pharmacy, there is concern that retail clinic for a medical home, a patient’s regular source of providers might overprescribe or selectively prescribe both comprehensive primary care. A recent study found that prescription and over-the-counter medications that are most people who seek care at retail clinics do not have a for sale at the host store. For example, CVS pharmacy medical home.14 Physician groups would like to see retail recently introduced its Rx Health Savings Pass program clinics help these patients make a connection to a regular by which customers who enroll receive both discounted source of primary care. generic drugs and discounts on visits to MinuteClinics, which are located within CVS facilities.15 Retail clinic For those patients who do have a medical home, operators, however, report that clinic patients are physician groups are concerned that retail clinics do informed that they can purchase their medications at any not communicate well with primary care providers location of their choosing. about services delivered, and thus ultimately undermine the doctor/patient or medical home relationship. Compounding this is a perceived lack of follow-up care Alcohol and Tobacco Sales at Retail Clinic Locations following a patient’s visit to a retail clinic. Clinic operators Some stakeholders believe that alcohol and tobacco emphasize that clinics provide all patients with a copy of products should not be sold in stores that also provide their visit record and, if consent is given, also fax a copy health care. In Illinois, the state medical society to their primary care provider’s office. Clinic operators supported a bill prohibiting retail clinics statewide from operating in stores that sell alcohol and tobacco. A also stress their efforts to help patients find a primary care letter of opinion from the Federal Trade Commission provider if they do not have one; some clinics report that criticized components of this bill as anticompetitive and they keep lists of nearby providers who are accepting new pointed out that cigarettes are already for sale at many patients. Physician provider groups, however, do not feel drugstores and grocery stores that house a pharmacy.* The Illinois bill was introduced in the state legislature in that these efforts are uniformly followed. 2008 but was not enacted into law. * ource: Federal Trade Commission letter to Elaine Nekritz, May 29, 2008. S Policymakers who share these physician concerns might consider developing regulations that promote retail clinic efforts to assist patients in follow-up and continuity of care. With the exception of Massachusetts, none of the Corporate Ownership and Organizational Issues states in this study has developed this type of regulation. The “corporate practice of medicine” is a legal doctrine As one state legislative director noted, states may have few that seeks to prohibit anyone who is not a licensed appropriate mechanisms to influence what individuals medical provider from “interfering with or influencing do after they leave any medical provider’s office, and the physician’s professional judgment.”16 Corporate continuity of care remains largely up to the individual practice of medicine laws ban for-profit and not-for-profit patient. corporations alike from directly employing physicians. The intent of this doctrine is to ensure that physicians, rather than corporate employers, retain ultimate responsibility over the practice of medicine.17, 18 In some 6  |  California HealthCare Foundation states, corporations are expressly prohibited by law from regulatory structures. As retail clinics establish staying employing physicians; in other states, a corporate practice power, policymakers may consider other options. of medicine rule is derived from multiple sources of law. The six states in this study were selected because of the Because corporate practice of medicine rules vary from lessons and approaches they offer for consideration by state to state, the ownership structure of a particular retail other states. Texas was selected because of its attention to clinic system may determine whether that system’s clinics nurse practitioner oversight regulations; Illinois because are able to operate in a given state. Thus, retail clinics of recent legislative activity; Florida because of its unique have adopted various ownership configurations to fit into licensure structure; New Jersey because of how its retail a state’s existing regulatory structures. For example, in clinics reorganized to fit into the existing regulatory response to New Jersey’s corporate practice of medicine system; Massachusetts because of recent regulations to laws, one retail clinic operator reorganized two years ago create a separate licensure category for retail clinics; and to remove its clinics from under a corporate umbrella. California because of its interest in exploring how retail Today, each retail clinic in this system is independently clinics fit into its health delivery system. owned and operated by a physician or group of physicians—thus, for regulatory purposes, each clinic is Texas considered a private practice of medicine,19 even though There are 79 retail clinics managed by several operators in they all remain within one retail clinic “chain.” Texas.20 Under Texas law, for-profit corporations, unless exempted, cannot directly employ physicians. However, Lessons Learned from Six States’ corporations may directly employ other clinicians, Approaches including nurse practitioners. Thus, corporation-owned Few states directly regulate retail clinics’ organization and retail clinics directly employ nurse practitioners and enter operations. Only Massachusetts has written regulations into independent contractor arrangements with physicians specific to retail clinics. Many states are allowing market who supervise those nurse practitioners.21 forces to dictate retail clinic survival within their present Table 2. Potential State Policy Levers R e g u l a t o r y M e c h a n i sm Imp a c t E x a mp l e Create a separate regulatory category for Regulations for retail clinics could be written as broadly or Massachusetts retail clinics. narrowly as needed to accomplish state policy goals. Provide options for retail clinics to comply with Retail clinics could more easily develop ownership structures New Jersey corporate practice of medicine restrictions. that comply with state laws. Texas License retail clinics like other licensed health Facility standards, such as size and sanitation requirements, Florida care facilities. would apply. Loosen or streamline oversight of nurse Nurse practitioners and physician assistants would require Illinois practitioners and physician assistants. less physician supervision, making it easier and less costly to New Jersey operate retail clinics. Impose marketing and advertising restrictions. Retail clinics could not advertise comparative pricing or Illinois connections to larger health care systems. New Jersey Develop Medicaid reimbursement policies Retail clinics could be directly reimbursed by state Medicaid Massachusetts (in progress) specific to retail clinics. program at rates set specifically for retail clinics. Require retail clinics to make referrals to Continuity of care could be facilitated by improving connections Massachusetts primary care providers. of retail clinics to the existing health care system. Retail Clinics: Six State Approaches to Regulation and Licensing  |  7 Texas’ requirements for physician supervision of nurse department, however, this may change: As the number practitioners are strict relative to other states and vary of retail clinics grows, the state will examine whether and in different regions of the state.22 Generally, for a nurse how to regulate them so that they fit into the existing practitioner to have prescribing authority, a physician service delivery system. must be at the clinic with the nurse practitioner 20 percent of the time; in medically underserved regions, Scope of practice regulations that apply to clinicians at often rural areas, this rule is relaxed to one physician retail clinics are handled through the Illinois Department oversight visit every 10 business days. Retail health clinic of Financial and Professional Regulation. Current state operators in Texas believe that this requirement increases law requires physicians to meet once per month with the their costs without improving quality of care. The nurse practitioners they supervise, but does not specify Coalition for Nurses in Advanced Practice also sees these any duration of time for that meeting.26 In addition, regulations as a significant hindrance. nurse practitioners must have a written collaborative agreement with a physician in order to make diagnoses Texas lawmakers introduced a bill in 2007 to loosen the and prescribe treatment and medications.27 According to nurse practitioner oversight regulations.23 Lawmakers who the Illinois Society for Advanced Practice Nursing, there supported the bill hoped that less restrictive regulations is no limit on the nurse practitioner-to-physician ratio, would encourage the expansion of retail clinics that could although there have been attempts by the state’s medical provide convenient sites of care and curb unnecessary use society to alter this. of emergency departments. The bill did not pass, but a similar bill may be introduced in 2009. With regard to Medicaid, individual providers at retail clinics have been reimbursed for care of Medicaid None of the Texas retail clinic operators interviewed patients. But a new state program, requiring that for this study accepts Medicaid, though some Medicaid Medicaid-covered services be delivered through managed managed care plans in Texas are exploring the option care, may eliminate most retail clinic treatment of of including retail clinics in their networks. The Texas Medicaid patients. Under the new mandate, most Medicaid agency reported that individual providers Medicaid beneficiaries (as well as uninsured children working in retail settings could participate in Medicaid under the All Kids program28) who are not enrolled in through the regular enrollment process. a managed care organization must receive health care through Illinois Health Connect.29 This is a managed Illinois care program in which beneficiaries select a primary Illinois presents an instructive example of potentially care provider who provides or coordinates most patient complex relations between Medicaid and retail clinics, services. The purpose of this program is to align Medicaid and also demonstrates how efforts to regulate clinics policies with medical home principles. The state’s might run into opposition from the Federal Trade Medicaid agency is finalizing a referral process, but initial Commission (FTC). plans are to pay for services only from the primary care provider or a clinician with a referral from the primary There are approximately 55 retail clinics in Illinois.24 The care provider.30 (According to Illinois Medicaid, the clinics are considered physician offices and therefore are referral could be backdated up to 14 days, which would not licensed or subject to oversight by the Department allow primary care physicians to approve care at a retail of Public Health, and do not require certificate of clinic after the fact.) Retail clinic representatives in Illinois need licensure.25 According to the state’s public health 8  |  California HealthCare Foundation believe that this referral process will result in the loss of Shortly after House Bill 5372 was introduced, the CVS their Medicaid and All Kids business. pharmacy company approached Rep. Elaine Nekritz, asking her to voice concerns to the FTC over what CVS In response to the increasing number of retail clinics in perceived to be anticompetitive provisions in the bill. the state, the Illinois State Medical Society advocated for She communicated CVS’s concerns to the FTC, which the introduction in February 2008 of House Bill 5372, came out strongly against many provisions of the bill the stated purpose of which was to “ensure patient safety (see below). During an interview with Rep. Nekritz by and adequate follow-up care.”31 The new law would have this study’s researchers, she expressed her sense that “the authorized the Department of Public Health to issue purpose of the bill was to slow the growth of clinics and a separate permit for each individual retail clinic, with regulate them to the point that made them no longer exceptions for certain owners (for example, physician- viable.” She said she feels there is a role for retail clinics owned or hospital-owned clinics). Inspections would have to play in serving underserved populations, and that these occurred after 90 days from the application date, and if alternative systems of care are worth pursuing. approved, a one-year permit would have been granted. The bill also would have banned the sale of tobacco Florida and alcohol in facilities that housed retail clinics.32 The Florida has 139 retail clinics, more than any other state. Department of Public Health opposed the legislation due Although Florida allows nurse practitioners to own retail to “fiscal problems” and the bill was not passed out of the clinics, the state requires that they be closely supervised Rules Committee. by physicians. Florida has recently tightened physician Federal Trade Commission Concerns Regarding Illinois Retail Clinics Legislation The FTC is charged with preventing unfair methods of competition and unfair or deceptive acts of practice in or affecting commerce.* With regard to Illinois’ proposed House Bill 5372, the FTC expressed concerns over provisions that might cause undue burdens on retail clinics, thereby limiting their ability to compete. These concerns are summarized below. a r e a o f c o nc e rn F T C C o mm e n t s Advertising Prohibition on clinics advertising comparison May prohibit or impede consumer access to truthful and non- of their fees for available services with the misleading information about prices for basic medical services. fees of other facilities. Clinic Restriction that physicians may be medical Undue and costly limitation; could give larger institutional health Operations director of no more than two retail clinics.† providers an unfair advantage if they use existing physician staff to fill this role; supervisory requirements for advanced practice nurses would be different in this setting than in other settings.‡ Insurance Subjecting retail clinics to the same copayment This “non-discrimination provision” restricts the ability of Payments and deductible requirements as other providers third-party payers to negotiate favorable terms and to manage for a similar service in a different setting. costs for health services. Alcohol and Prohibition against a clinic being located in any Restriction could limit the supply of retail clinics or significantly Tobacco Sales store that has alcohol or tobacco products for raise clinics’ costs and prices; no similar prohibition exists for sale to the public. other health care facilities offering the same services or staffing, or for pharmacies and pharmacy services. Sources: *Federal Trade Commission Act, 15 U.S.C., §45 (2007). †Illinois HB 5372 (2008). ‡Federal Trade Commission. Letter to Elaine Nekritz, May 29, 2008. Retail Clinics: Six State Approaches to Regulation and Licensing  |  9 oversight of nurse practitioners and physician assistants, New Jersey including those who work at retail clinics. In 2006, the New Jersey provides an example of retail clinics — several Safe Supervision bill was enacted, limiting the number chains operate a total of 28 clinics — legally organizing of clinic sites where a physician may supervise physician in such a way that they are exempt from state regulation assistants or nurse practitioners to no more than four of their facilities.38 The state’s Department of Health satellite offices, in addition to the physician’s primary and Senior Services regulates ambulatory care clinics place of practice.33 with regard to the physical facility and infection control measures, but exempts private physicians’ offices from Florida also has a unique licensure structure for corporate- regulation or licensure. Thus, retail clinics in New Jersey owned clinics (60 MinuteClinics and 36 Little Clinics, have chosen to organize as private physicians’ offices, for example, have this license).34 This was a secondary using a “closely held physician captive” model in which consequence of an anti-fraud campaign regarding the each clinic location is owned by an independent physician automobile personal injury insurance industry, in which and staffed by nurse practitioners, but with all clinics inappropriate diagnostic testing, inflated charges, and managed by a larger corporate entity. The management overutilization of treatments had resulted in soaring services include hiring staff and billing patients and costs. In 2003, the legislature passed a law that required insurance companies. non-provider-owned health care clinics to be licensed, and established the Health Care Clinic Unit within the The HealthRite clinics provide an example of how Bureau of Health Facility Regulation at the Agency for this model works. These clinics were originally Health Care Administration.35 The Health Care Clinic organized as part of the non-profit AtlantiCare health Unit is charged with denying, revoking, or suspending system. However, this arrangement conflicted with licensure of clinics that bill insurance companies for New Jersey corporate practice of medicine laws, so fraudulent claims.36 A corporate-owned clinic must pay in 2006 HealthRite restructured. HealthRite clinics a $2,000 two-year license fee, which is payable again at are now independently owned by physicians in the renewal or change of ownership. Applicants must provide for-profit AtlantiCare Physician Group. HealthRite has evidence of sufficient assets, credit, and projected revenue a management contract with AtlantiCare to provide to cover liabilities and expenses for the first 12 months billing and other services for the clinics. State regulations of operation.37 The renewal process consists of field visits prohibit HealthRite from advertising its affiliation with and inspections that focus on the “business side” of the AtlantiCare hospital system, but the two entities link clinics; concerns regarding actual care are referred to the to one another’s Web sites. HealthRite’s CEO reports that state medical board. almost everyone who uses HealthRite retail clinics also accesses other parts of the AtlantiCare system. He believes Florida’s Medicaid agency does not recognize retail clinics that integrated models of care will benefit both patients as a separate type of provider. As in other states, Medicaid and health systems by facilitating treatment of all patients reimburses practitioners who submit claims under their in the most appropriate settings. Both the HealthRite own Medicaid provider numbers, but the agency does retail clinics and its after-hours clinic at an FQHC not track this data. Nor has Florida Medicaid queried (see below) may help divert patients from AtlantiCare managed care organizations to see if they are paying hospitals’ emergency departments. claims from providers at retail clinics. (A spokesperson from WellCare, the state’s largest Medicaid managed care plan, said its organization is not.) 10  |  California HealthCare Foundation Expanding Care to the Underserved Extensive Stakeholder and Public Input Led to One New Jersey retail clinic chain also operates an New Clinic Regulations after-hours clinic at a federally qualified health center. When CVS MinuteClinic requested permission to open Nurse practitioners who provide care at the HealthRite several retail clinics in 2006, the Commonwealth of retail clinic site are encouraged to also work paid shifts Massachusetts realized that its existing clinic regulations at the FQHC’s after-hours clinic. The retail clinic provides did not match the retail clinic model. The retail clinic only limited services and does not accept Medicaid. would have needed a full clinic license, which would However, the after-hours clinic offers a wider array of have required multiple waivers and left the state without health services and accepts Medicaid reimbursement. the ability to limit the scope of services offered. As these waivers were being considered, other interested stakeholders began to convey their concerns. It became clear to the state that new regulations needed to be Massachusetts promulgated in order to address multiple issues, raised Massachusetts is the only state in this study that has primarily by the medical community. promulgated extensive regulations specifically intended to The Department of Public Health’s Bureau of Health fit retail clinics into its health service delivery system, to Care Safety and Quality developed proposed LSC limit the scope of services that clinics may offer, and to regulations and convened two public hearings at which address the issue of fragmentation of medical care. they received comments from stakeholders (including the FTC) and advocates. Although the legislature was not directly involved in writing the regulations, many Limited Service Clinics letters of support for the retail clinic model were The Massachusetts regulations establish what they refer to received from state representatives. Public health as limited service clinics (LSCs). The state’s Department advocates expressed concern regarding tobacco sales, of Public Health provides a full-time nurse practitioner to corporate profits, and fragmentation of care, among other issues. The Massachusetts Medical Society cited review all clinic policies and procedures in order to verify quality and safety concerns with regard to supervision compliance with the regulations, including site visits to of nurse practitioners. Input from the Massachusetts verify that construction and operations are consistent with Academy of Family Physicians and the Massachusetts submitted plans. These clinic regulations include: Medical Society helped shape regulations that, for the first time by any state, addressed strengthening retail  LSCs must make referrals to primary care clinic ties to primary care. Following the implementation practitioners, including physicians, nurse of these regulations, CVS MinuteClinic opened its first LSC, in Medway, Massachusetts on September 17, practitioners, and community health centers; 2008, and plans to open several more in the near future.*  Clinics must maintain rosters of primary care providers who are accepting new patients; * ource: “MinuteClinic Opens First Retail Clinic in Massachusetts Inside S CVS/pharmacy Store.” Press release, September 17, 2008 (www.reuters.com/article/pressrelease/idUS116475+17-sep-2008+  Clinics must develop a process to identify and limit, prn20080917). if necessary, the number of their repeat encounters with individual patients; Safety Net Issues  With patient consent, LSCs are to provide a record The role of retail clinics in providing health care to safety- of each clinic visit to the patient’s primary care net populations was discussed during interviews for this practitioner; and study. The Massachusetts League of Community Health  Clinics must provide a toll-free number that will Centers was concerned that the emergence of retail clinics enable a caller to speak with a live practitioner during in an area served by community health centers might off-hours. affect that area’s Health Profession Shortage Area (HPSA) Retail Clinics: Six State Approaches to Regulation and Licensing  |  11 designation, which triggers federal assistance to recruit can enroll people in Medicaid, connect them to a primary scarce primary care practitioners and other federal grants care doctor, and help ensure that they get there. to health centers.39 With nurse practitioners in short supply in the state, the league also expressed concern California about health centers vying with retail clinics for the same Four clinic chains are operating successfully in California, scarce practitioners and being unable to compete with the using various organizational models and reimbursement higher salaries likely to be offered by retail providers. strategies. During interviews for this study, the governor’s health care adviser indicated that the current state According to the Department of Public Health, the administration is supportive of the retail clinic model. commissioner of health has encouraged health centers to The governor, it was reported, believes that retail open their own LSCs. Representatives from the league clinics might help curb the growth of health care costs stated that they would want an LSC operated by a by providing affordable primary care in an accessible community health center to be part of its cost structure setting, while also alleviating the burden in the state’s and therefore receive Medicaid cost-based reimbursement overcrowded emergency rooms. encounter rates for FQHCs.40 Medicaid is expected to pay LSCs a rate that reflects their overall lower cost Patient Safety and Quality of Care structure but this, according to the league, would not be Some clinics in California, such as primary care clinics, sufficient to support a health center’s costs. Cost-based specialty surgery clinics, and birth centers, are licensed reimbursement would allow a community health center by the state while others, including those owned by to cover services for all patients regardless of their ability individual physicians, groups of physicians, or hospital to pay, and to provide comprehensive services. The systems, are exempt from licensure.41 Retail clinics are decision about whether an LSC would qualify for FQHC exempt. cost-based reimbursement, however, ultimately would be made at the federal rather than state level. At the time of California allows nurse practitioners to provide health this report, some health centers have indicated interest in services and order medications under a standard opening LSCs but none has done so. protocol, if under the supervision of a physician. Nurse practitioners may diagnose conditions, order tests and Medicaid and Limited Service Clinics drugs, and refer patients to other providers, according Massachusetts Medicaid has been developing ways to to specific written protocols developed jointly with enroll LSCs as Medicaid providers; the agency plans to supervising physicians. This scope of practice falls have this process in place in 2009. The state League of approximately in the middle of what other U.S. states Community Health Centers expressed concern about allow.42 However, California has relatively strict standards LSC staff dealing with the complicated Medicaid for the supervision of nurse practitioners by physicians. eligibility and enrollment process and wondered what The supervisory ratio in California was increased recently, a clinic would do if a patient presents unsure about his so that one physician may now supervise up to four nurse or her eligibility. Would the LSC direct a patient to a practitioners. The governor has proposed increasing the community health center for Medicaid enrollment or ratio further, to one physician supervising up to six nurse eligibility verification and then have the person return practitioners. Some provider organizations have expressed to the LSC to receive care? The league felt that the best concerns about this proposed expansion. The governor’s model would have retail clinics staffed with community office is also studying the issue of nurse practitioner health workers who, together with nurse practitioners, supervision of unlicensed medical assistants. 12  |  California HealthCare Foundation The California Retail Clinic Landscape a convenient point of acute care for Medicaid patients, There are more than 80 retail clinics in California, many Medicaid beneficiaries have chronic conditions that operating under various models and offering different are not managed at retail clinics. Also, representatives of types of services.* the California Department of Public Health noted that, • One of the largest clinic chains is MinuteClinic, with for the most part, retail clinics have been locating in 61 locations in Southern California. MinuteClinic in metropolitan areas in the state rather than in rural areas, California provides the typical array of retail clinic services—treatments for common illnesses, chronic which have a high proportion of the underserved. disease screening, vaccinations—and provides tuberculosis testing. MinuteClinic accepts some Care Fragmentation insurance.† The California Primary Care Association would prefer • The QuickHealth retail clinic chain operates in nine that retail clinics be explicitly connected to the larger locations in Northern California. QuickHealth is staffed health care delivery system. It favors regulations that by physicians as well as some mid-level practitioners, and therefore provides a wider scope of acute and require retail clinics to refer patients to a regular source of chronic care services. QuickHealth does not accept care, such as a community health center, and to inform any type of insurance, but provides consumers low-income patients about other treatment options. with a receipt they can submit to their insurers for The California Academy of Family Physicians similarly reimbursement.‡ worries about continuity of care between retail clinics and • Lindora Clinics has been operating in California since 1971. With nine locations in Rite Aid pharmacies, primary care providers. Lindora Clinics focus on weight loss and chronic disease management plus a limited range of acute Corporate Ownership and Organizational Issues care services. They do not currently accept insurance, California’s corporate practice of medicine laws43 prohibit but are negotiating with Blue Cross/Blue Shield. not only the direct employment of physicians by • Sutter Express Care is the retail clinic arm of Sutter Health, a non-profit network of hospitals and corporations but also management services organizations physicians in Northern California, offering the typical arranging for or advertising medical services, even where scope of retail clinic care. Sutter Express Care clinics physicians own and operate the business.44 However, accept private health insurance and Medicare, but not retail clinics are permitted to organize as a “professional Medicaid.** medical corporation” — the Lindora Clinic operates under Sources: *Merchant Medicine. April 1, 2008. this model — in which only physicians and other licensed † inuteClinic. “Locations” (www.minuteclinic.com/en/USA/CA/Clinics.aspx) M and “Treatment and Cost at MinuteClinic” (www.minuteclinic.com/en/ professionals own shares.45 USA/Treatment-and-Cost.aspx). ‡QuickHealth (www.quickhealth.com). **Sutter Express Care (www.sutterexpresscare.com). Conclusion Most policymakers in the six states of this study believe there is a role for retail clinics in expanding access to Access for the Underserved health services and an opportunity to lower medical Many stakeholders in California are cautious about the care costs through reductions in unnecessary emergency ability of retail clinics to extend access to those who are department visits. underserved in traditional health care settings. Retail clinics in California do not currently accept Medicaid. Patient Safety and Quality of Care A representative of the California Department of Health Direct licensing of health care facilities and providers Care Services, which administers the state’s Medicaid gives states the ability to monitor and enhance patient program, noted that while retail clinics might provide safety and health care quality. Most states exempt private Retail Clinics: Six State Approaches to Regulation and Licensing  |  13 physician offices from licensure and rely instead on to be a barrier to retail clinics accepting Medicaid as individual provider licensing to assure quality of care payment. in these settings. Massachusetts has taken the step of licensing retail clinics separately, distinguishing them from State policymakers may consider costs to the state as well private physician offices and other health care facilities. as to consumers when thinking about support for retail This allows the state to tailor regulations to retail clinics clinics. Consumers who appropriately use retail clinics in without affecting other health care providers. lieu of emergency rooms may reduce their out-of-pocket costs at the same time they reduce a health system’s States also have decisions to make about the extent of overall costs. One study cautioned, however, that retail oversight and scope of practice for health care providers, clinics might increase the overall cost of care by increasing especially nurse practitioners, as they relate to retail demand from consumers who might ordinarily self-treat clinics. Greater practice restrictions can increase retail or who might have delayed care. In addition, out-of- clinics’ operating costs and may dissuade or limit some pocket costs for patients without insurance may be higher clinic chains’ business in the state. With regard to if they receive services at a retail clinic rather than at a stakeholders on these issues, physician groups tend to community health center where services are provided on a argue that relatively stringent physician supervision of sliding scale for certain income levels. nurse practitioners is necessary to maintain quality and ensure patient safety. Nurse associations and clinic chains, Care Fragmentation on the other hand, tend to see things differently: They There is concern that retail clinics would create or claim that retail clinics’ use of evidence-based guidelines exacerbate fragmentation of care by deterring regular ensures the delivery of appropriate care and that nurse primary care or by not coordinating care with a patient’s practitioners at these clinics are operating well within primary care provider. As part of its direct regulation their scope of practice. of retail clinics, Massachusetts discourages care fragmentation and promotes medical homes by requiring Access for the Underserved retail clinics to connect systematically to primary care The ability of retail clinics to reach the underserved providers. is a function of several factors, including geography, services provided, cost, and payment structure. One Conflicts of Interest of these elements is the willingness of clinics to accept As retail clinics have proliferated, some physician groups Medicaid payments. To date, it appears that few Medicaid have become concerned that the model encourages beneficiaries use retail clinics. But this could change if overuse of medications sold at retail clinic host stores. states make payment arrangements that recognize retail Other stakeholders have objected to retails clinics clinics as direct Medicaid providers. In Massachusetts, being located in stores that also sell tobacco or alcohol. the Medicaid agency plans to recognize retail clinics as Policymakers who wish to limit sales or advertising at separate entities; they should be able to submit Medicaid retail clinics should be aware that the Federal Trade claims sometime in 2009. In Illinois and Florida, retail Commission has advised against regulations that are clinic operators are discussing payment issues with anticompetitive. Medicaid agencies. There are also Medicaid managed care plans in some states that allow beneficiaries to seek care Corporate Ownership and Organizational Issues at retail clinics. Low reimbursement rates may continue State regulations restricting the corporate practice of medicine may limit the proliferation of retail clinics by 14  |  California HealthCare Foundation requiring physician involvement at each clinic location. A c k n ow l e d g m e n t s However, retail clinics in several states that prohibit The authors wish to thank the California HealthCare the corporate practice of medicine have found other Foundation for its support of this project. organizational structures that allow them to operate. This report benefited greatly from the thoughtful input of States that desire to promote retail clinic growth may Neva Kaye, Senior Program Director of NASHP, and from the wish to clarify which organizational structures are legally research assistance of Chris Cantrell of NASHP. permitted. Our deepest thanks go to the following people, who gave generously of their time and expertise during background interviews and subsequent review of the draft of this About the Authors document: Mary Takach, R.N., M.P.H., is a policy specialist at the National Academy for State Health Policy (NASHP), where California: Kathleen Billingsley, Gina Henning, Cheryl she works on projects focused on primary care, specifically Munir, Anna Ramirez, and Belinda Whitsett, Department of medical homes, federally qualified health centers, workforce, Public Health; Richard Figueroa, Office of Governor Arnold and quality issues. Schwarzenegger; Elia Gallardo, California Primary Care Association; Sandra Newman, California Academy of Family Kathy Witgert, M.P.H., is a policy specialist at NASHP, Physicians; Stan Rosenstein, Medicaid. where her projects focus on expanding health care coverage and improving access to care. She joined NASHP in 2008 Florida: Brady Augustine and Michael Bolin, Medicaid; with a background in health policy and public health, having Christa Calamas, Florida House of Representatives Healthcare previously worked in state and federal agencies implementing Council staff; Tad Fisher, Florida Academy of Family and evaluating public health and Medicaid programs. Physicians; Jeff Gregg, Bureau of Health Facility Regulation, Agency for Health Care Administration. Illinois: Bill Bell, Department of Public Health; Peter Kale, About the F o u n d at i o n Illinois Society for Advanced Practice Nursing; Rep. Elaine The California HealthCare Foundation is an independent Nekritz; Steve Saunders, Medicaid. philanthropy committed to improving the way health care is delivered and financed in California. By promoting Massachusetts: Paul Dreyer, Massachusetts Department innovations in care and broader access to information, our of Public Health; Patricia Edraos, Massachusetts League of goal is to ensure that all Californians can get the care they Community Health Centers; Caroline Fisher, Office of Sen. need, when they need it, at a price they can afford. For more Richard Moore; Bill Ryder, Massachusetts Medical Society; information, visit www.chcf.org. Bill Schmidt, Medicaid. New Jersey: John Calabria, Department of Health and Senior Services. Texas: Judy Devore and Garry Walsh, Medicaid; Matthew Miller, Office of Rep. Rob Orr; Nance Stearman, Department of State Health Services; Lynda Woolbert, Texas Coalition for Nurses in Advanced Practice. Retail Clinic Representatives: Web Golinkin, RediClinic; Cynthia Graff, Lindora Clinics; Lisa Loscalzo, The Little Clinic; Don Parker, AtlantiCare HealthRite; Caroline Ridgway, Convenient Care Association; Sandy Ryan, Take Care Health Systems. Retail Clinics: Six State Approaches to Regulation and Licensing  |  15 Endnotes 9. Dolan, Pamela Lewis. September 22/29, 2008. “Retail clinic targets Hispanic population, cultural 1. Laws, Margaret and Mary Kate Scott. 2008. “The differences.” American Medical News (www.ama-assn.org/ Emergence of Retail-Based Clinics in the United States: amednews/2008/09/22/bisc0922.htm). Early Observations.” Health Affairs 27: 1293. 1 0. Mehrotra, Ateev, et al. 2008. “Retail Clinics, Primary Care 2. Thygeson, Marcus, et al. 2008. “Use and Costs of Care Physicians, and Emergency Departments: A Comparison in Retail Clinics Versus Traditional Care Sites.” Health Of Patients’ Visits.” Health Affairs 27: 1276. Affairs 27: 1287–1288. 1 1. Thygeson, et al., “Use and Costs of Care,” 1287-1288. 3. A study that looked at visits for one retail clinic found better than 99 percent adherence to clinical guidelines in 1 2. Thygeson, et al.,“Use and Costs of Care,” 1290. the care of acute pharyngitis. Woodburn, James D., Kevin 1 3. The Massachusetts Department of Public Health proposed L. Smith, and Glen D. Nelson. 2007. “Quality of Care regulations to require prescreening for all advertising for in the Retail Health Care Setting Using National Clinical Limited Service Clinics. The Federal Trade Commission Guidelines for Acute Pharyngitis.” American Journal of commented that the proposed prescreening requirement Medical Quality 22: 457–462. Another study found 99.15 for all LSC advertising may be overly restrictive and percent adherence to clinical guidelines for negative strep recommended that it be struck. The FTC suggested that tests. Costello, Daniel. 2008. “A Checkup for Retail the department would be on “firmer regulatory ground Medicine.” Health Affairs 27(5): 1299–1303. if it merely prohibits false or misleading advertising.” 4. Scott, Mary Kate. Health Care in the Express Lane: Federal Trade Commission letter to LouAnn Stanton, The Emergence of Retail Clinics. California HealthCare 2007. Foundation, July 2006 1 4. Mehrota, “Retail Clinics, Primary Care Physicians, and (www.chcf.org/topics/view.cfm?itemid=123218). Emergency Departments,” 1276. 5. Some physical space regulations addressed placement of 1 5. Girion, Lisa, and Andrea Chang. Oct. 31, 2008. toilet facilities and cleaning supply closets, minimum “CVS Slashes Generic Drug Costs; Escalates Price War.” examination room space to accommodate wheelchairs, Los Angeles Times. and adequate space for reception and waiting. Letter to Massachusetts Department of Public Health Commissioner 1 6. The Medical Board of California. Corporate Practice of John Auerbach and the Public Health Council, December Medicine (www.medbd.ca.gov/licensee/corporate_practice. 12, 2007. html). 6. Christian, Sharon, and Catherine Dower. Scope of Practice 1 7. Jones, John W. June 2007. “Corporate Medicine in 21st Laws in Health Care: Rethinking the Role of Nurse Century Health Care.” Physician’s News Digest Practitioners. California HealthCare Foundation, January (www.physiciansnews.com/law/607jones.html). 2008 (www.chcf.org/topics/view.cfm?itemid=133568). 1 8. The Medical Board of California. Corporate Practice of 7. See note 3. Medicine. 8. “New WSJ.com/Harris Interactive Study Finds Satisfaction 1 9. New Jersey does not regulate private medical practices. with Retail-Based Health Clinics Remains High.” Harris The State Board of Medical Examiners, Division of Interactive press release, May 21, 2008 (www.harris Consumer Affairs, Department of Law and Public Safety, interactive.com/news/allnewsbydate.asp?newsid=1308). licenses individual providers. N40 N.J.R. 702(a), January 22, 2008, p.6. 2 0. Merchant Medicine. April 1, 2008. 16  |  California HealthCare Foundation 2 1. Texas Medical Board. Corporate Practice of Medicine 3 7. Florida Agency for Health Care Administration. (www.tmb.state.tx.us/professionals/physicians/licensed/ Instructions for Completing the Application for Health cpq.php). Care Clinic Licensure (www.fdhc.state.fl.us/mchq/ health_facility_regulation/healthcareclinic/docs/6-2008- 2 2. Texas Occupations Code, §§157.051–157.060. licenseapplication--instructions--pfa-3110-003july06.pdf ). 2 3. Texas HB 1096, 2007. 3 8. Merchant Medicine. April 1, 2008. 2 4. Merchant Medicine. April 1, 2008. 3 9. The U.S. Department of Health and Human Services, 2 5. In Illinois, a certificate of need is required for facilities at Health Resources and Services Administration, stated that a level beginning with ambulatory surgery centers; retail mid-level practitioners are not counted toward Health clinics are exempt. Professional Shortage Area designations. Email from Andy Jordan, October 22, 2008. 2 6. Convenient Care Association, 2008 state-by-state guide to regulations. 4 0. The Omnibus Budget Reconciliation Act of 1989, which established the Federally Qualified Health 2 7. Pearson, Linda. 2008. “The Pearson Report.” The Center (FQHC) reimbursement designation, was passed American Journal for Nurse Practitioners 12: 1–80. because Congress was concerned that, due to inadequate 2 8. All Kids is a comprehensive healthcare program for reimbursement rates, health centers were shifting federal every uninsured child in Illinois, regardless of medical grant funds meant to care for the poor and uninsured conditions or income. to cover the costs of caring for Medicaid and Medicare patients. Health centers and other qualified health clinics 2 9. Illinois Health Connect. What Is Illinois Health Connect? receiving the FQHC designation began receiving enhanced (www.illinoishealthconnect.com/default.aspx). Medicaid and Medicare reimbursements for actual 3 0. Illinois Health Connect. Primary Care Provider Handbook costs — including overhead expenses such as mortgage (www.illinoishealthconnect.com/files/downloads/ihc_pcp_ and utilities — regardless of whether these expenses were handbook.pdf ), p.15. covered by other sources. Previously, they had received 3 1. Illinois State Medical Society. Press release, February 19, reimbursement according to a predetermined fee schedule. 2008. 4 1. California Health and Safety Code, §1206 (2008). 3 2. Illinois HB 5372 (2008). 4 2. Christian, Sharon, and Catherine Dower, Scope of 3 3. Florida Statutes, §458.346 (2008); House Bill 699 (2006). PracticeLaws in Health Care. 3 4. Florida Agency for Health Care Administration. 4 3. California Medical Practice Act, California Business and Health Care Clinics — Number of Months Continually Professions Code, §2400 (2008). Licensed as of 10/1/08 (www.fdhc.state.fl.us/mchq/ 4 4. Medical Board of California. Corporate Practice of health_facility_regulation/healthcareclinic/docs/pip_ Medicine (www.medbd.ca.gov/licensee/corporate_practice. clinic_report-october_1_2008.xls). html). 3 5. Florida Statutes, §§400.900 – 400.995 (2008). Florida 4 5. Medical Board of California. Fictitious Name Permit —  Senate Bill 32A (2003). Frequently Asked Questions (www.medbd.ca.gov/licensee/ 3 6. Ibid. fictitious_name_questions.html#26). Retail Clinics: Six State Approaches to Regulation and Licensing  |  17