'The little clinic on wheels'

SPOTLIGHT | RURAL AMERICA'S HEALTH CARE

On a hot July morning, customers at the Dollar General along a two-lane highway northwest of Nashville didn't seem to notice signs of the chain store's foray into mobile health care, particularly in rural America.

A woman lifted a child from the back of an SUV and walked into the store. A dog barked from a black pickup truck before its owner returned with cases of soda. Another woman checked her hair in a convertible's rearview mirror before shopping.

Each went right by a sign exclaiming "Quick, Easy Health Visits," with an image of a mobile clinic.

Just after 10 a.m., registered nurse Kimberly French arrived to work at the DocGo mobile clinic parked in the Clarksville store's lot. She checked her schedule.

"We don't have any appointments so far today, but that could change," French said. "Last night we didn't have any appointments and three or four people showed up all at one time."

Dollar General, the nation's largest retailer by number of stores, with more than 19,000, partnered with New York-based mobile medical services company DocGo to test whether they could draw more customers and tackle persistent health inequities.

Deploying mobile clinics to fill care gaps in underserved areas isn't a new idea. But pairing them with Dollar General's ubiquitous small-town presence has been heralded by investment analysts and some rural health experts as a way to ease the health care drought in rural America.

Dollar General's latest annual report notes that about 80% of the company's stores are in towns with populations of fewer than 20,000 — precisely where medical professionals are scarce.

Catering to those who want urgent or primary care, the mobile clinics take private insurance as well as Medicaid and Medicare. The company's website says DocGo's self-pay rates start at $69 for patients without insurance or who are out of network. DocGo officials said Tennessee patients may be charged different rates but declined to provide details.

On the ground in Tennessee, primary care doctors and patients are skeptical.

"Honestly, they don't really grasp, I don't think, what they're getting into," said Brent Staton, a family medicine doctor and the leader of the Cumberland Center for Healthcare Innovation, a statewide organization that helps small-town family care doctors coordinate care and negotiate with insurers, including Medicare.

Michelle Green manages the popular Sweet Charlotte grill about 10 miles south of Dollar General's most rural test site. Green, who was handing out hamburgers and hand-cut fries during a Saturday rush, said she hadn't heard of the mobile clinic. She said with a shrug that Dollar General and health care clinics "don't go together."

"I wouldn't want to go to a health care clinic in a parking lot; that's just me," Green said, adding that someone might go if "you're sick and you can't go anywhere else."

Bumps in the road

The Clarksville-area pilot, which launched last fall, is in a federally designated primary care shortage area for low-income residents.

About 1,000 patients have been seen in the company's clinics, either at Dollar General sites or community pop-up events, and some became repeat visitors, according to DocGo. Payment is taken outside on a mobile device and, once inside, patients meet with an on-site staff member, like French, and connect via telehealth on an iPad screen with a physician assistant or nurse practitioner.

The clinic rotates among three Dollar General pilot sites each week. The stores are in the Clarksville area and, early this summer, the van stopped going to the most rural site, near Cumberland Furnace, because of low utilization, according to company leaders. DocGo moved that location's time slot to busy Fort Campbell Boulevard in Clarksville.

"We do try for months in a given area to see where it makes sense and where it doesn't," former DocGo CEO Anthony Capone said in a July interview. "Our goal is to align the supply we have with the demand of the local community."

Capone, though, said he thought the pilot would work in rural areas when insurers are signed on to refer their members to the mobile clinic. DocGo recently announced a deal with Blue Cross Blue Shield of Tennessee.

Capone abruptly resigned on Sept. 15 after the Albany Times Union reported he lied about having a graduate degree.

Dollar General stores have a "tremendous opportunity" to have "a major impact on health there and really bond themselves as a member of the community," said Tom Campanella, the health care executive-in-residence at Baldwin Wallace University, who has managed mobile clinics in rural places.

Near tiny Cumberland Furnace, south of Clarksville, William "Bubba" Murphy stopped on his way into a Dollar General, paused to wave and holler hello to friends getting out of their cars, and shared that multiple family members — his sister-in law, nephew, and niece's boyfriend — used and liked "the little clinic on wheels."

"We don't have to go to town and fight all that traffic," he said. "They come to us. That's a wonderful thing. It helps a lot of people."

Over on busy Fort Campbell Boulevard in Clarksville, Marina Woolever, a mother of three, said she might use the clinic if she didn't have insurance. Natural health professional Nichole Clemmer glanced toward the clinic and called it a "ploy" to make more money.

Jefferies lead equity analyst Corey Tarlowe, who follows discount retailers, said the clinics will help "democratize" access to health care and simultaneously boost traffic to Dollar General stores.

With its rapid growth in recent years, Dollar General has faced accusations that its stores kill off local grocery stores and other businesses, reduce employment and contribute to the creation of food deserts. More recently, the U.S. Labor Department said the chain "continues to discount safety" for employees as it has piled up more than $21 million in federal fines.

Crystal Luce, senior director of public relations for Dollar General, said the company believes each new store provides "positive economic benefits," including new jobs, low-cost products and its literacy foundation. On the federal fines, Luce said Dollar General is "committed to providing a safe work environment for its associates and shopping experience for its customers." The company declined to provide an interview.

The DocGo pilot, she wrote, is intended to "complement" the DG Wellbeing initiative, which is a corporatewide push. Dollar General wants to increase "access to basic health care products and, ultimately, services over time, particularly in rural America," Luce wrote.

The company's pilot with Dollar General is "supported with funding from the state of Tennessee," DocGo's Capone said during the company's first-quarter earnings call. The Dollar General partnership is cited in quarterly grant reports DocGo's Rapid Reliable Testing LLC submitted to the state, according to records KFF Health News obtained through public information requests.

In the grant filing, DocGo listed Dollar General along with other organizations as "trusted messengers" in building vaccine awareness.

Dollar General declined to respond to a question about its involvement in the grant. Instead, Luce stated, "We continue to test and learn through the DocGo pilot."

'Relational care'

The goal of the $2.4 million grant, funded by the Centers for Disease Control and Prevention and distributed by the Tennessee Department of Health, is to administer COVID-19 vaccines. In a written response provided by DocGo's marketing director, Amanda Shell Jennings, the company said, "Dollar General has no involvement with the TN Department of Health grant funding or allocations."

The grant covers storage and maintenance of COVID-19 vaccines on the DocGo mobile clinics, Jennings' statement said, adding that, as of September, DocGo has held 41 vaccine events and provided 66 vaccines to rural Tennesseans.

Lulu West, 72, was visiting a friend at the Historic Cumberland Furnace Iron Museum when she stopped to consider the mobile clinic. West said she would rather go to her primary care doctor.

"When you say mobile clinic outside a Dollar General it just kind of has a connotation that you may not be comfortable with. You know what I mean?" she said.

That kind of response doesn't surprise Carlo Pike, a doctor who for years has practiced family medicine in Clarksville. He said he's not worried about the competition because providing primary care is about developing relationships.

"If I can do this relationship right," Pike said, "maybe we can keep you from getting a (blood) sugar of 500 (mg/dL) or from Grandpa climbing up a ladder and trying to fix something he has no business with and falling off and breaking his leg."

Staton said the Cumberland Center for Healthcare Innovation, his accountable care organization, has saved Medicare and Medicare Advantage companies more than $100 million by focusing on preventive care and reducing hospitalizations and emergency visits for patients.

"We're just small rural primary care docs doing our jobs with a process that works," Staton said. In another interview, Staton called it "relational care."

DocGo surveyed its patients and found that 19% of them did not have a primary care physician or hadn't seen theirs in more than a year. In the written responses Jennings provided, DocGo said it follows up with every patient after the initial visit, offers telemedicine support between visits and provides ongoing preventive care on a regular schedule.

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.