Trend is occurring as employers shift more cost to workers.

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NASHVILLE -- Carl King once used alligator tweezers to dislodge a piece of cotton from deep within the ear canal of an Israeli soldier traveling through Nashville.

King is a physician's assistant at the CareHere clinic near Terminal C at Nashville International Airport. CareHere has 140 clinics in 22 states, most of them built for employers who offer on-site care as a perk to employees. But the airport clinic is special, said Ernie Clevenger, the company's president, because it is the first airport clinic that treats airport personnel and passengers.

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It is also the only one of CareHere's clinics with a retail component: Its three exam rooms are attached to a store that sells products ranging from Burt's Bees lip balm to high-end health bars. And that retail store has led to surprising returns — generating 48% of the clinic's total revenue.

Traditionally, health care and retail haven't mixed well together. Typically, health care companies haven't sold products to people. Instead, insurers sold coverage plans to employers and hospitals negotiated payment with insurers.

But that is changing. The Affordable Care Act is accelerating several trends that spotlight individuals as stakeholders in their own health care. For one, employers, uncertain of the ACA's impact, are offloading more of the cost of care onto employees through high-deductible plans and health savings accounts. According to a study by the National Institute for Health Care Management, 69% of employers plan to shift even more of the cost of care onto consumers over the next four years.

That shift will have an impact on the industry.

"If you're an individual, you're buying for you and your family. The things that are important to you are different than the things that are important to a group administrator at a large employer who's trying to satisfy many," said Henry Smith, chief marketing officer for Blue Cross Blue Shield of Tennessee.

Second, the government will push hospitals to act more like other service industries. The Centers for Medicare & Medicaid Services will hold hospitals responsible for the quality of care. Hospitals must monitor not only patients, but also how patients experience their care.

Finally, traditional retailers are moving into the health care space. If hospitals want to attract patients and insurers want more "lives" on their plans, companies in both industries will have to think a lot more like retailers than they do now.

"Imagine people going into an Abercrombie & Fitch and having no idea what these different products are suited for," said Nancy Puccinelli, a consumer marketing fellow at Oxford's Said Business School. Imagine that shoppers couldn't figure out whether a shirt was made to wear in the winter or summer, or if they should shop for socks versus cologne. For the health care consumer, she said, "That's really what you're looking at right now."

Market research

Granted, Puccinelli said, health care will never function completely like a retailer in the free market, because of the ethical argument that societies are obligated to treat people who can't afford the product.

But even programs designed to help financially stressed people are following age-old retail adages. For example, some use market research to deliver products to consumers, in a way they can access them, where demand is high.

The state of Tennessee has tasked UnitedHealthcare to better serve members of TennCare, Tennessee's iteration of Medicaid, said Darren Hodgdon, chief operating officer for UnitedHealthcare's Community Plan of Tennessee.

To do so, United is building centers in high-need areas and working with nearby providers to track members' care. The idea is to help doctors reach patients who need follow-up appointments, which cuts down on emergency visits down the road. The company has a 92 percent success rate of finding patients within two days, Hodgdon said.

As to why the company wasn't doing this before, Hodgdon said, "Sometimes personalization and local community focus get lost in scale," but efforts to center care in communities have taken off in the past two years.

"The best part about the whole program is that the members' response to this has been a real surprise. They have been so appreciative that somebody's been out there looking for them and helping them coordinate their care," Hodgdon said.

Think like retailers

Hospitals also must think like retailers. Beginning with patients discharged in 2012, hospitals' Medicare reimbursement rates are linked to patient satisfaction scores, courtesy of the Affordable Care Act. A hospital visit is a much more complex encounter than trying on clothes at a store, but that's not an appropriate excuse, said Kevin Gwin, vice president of communications for Nashville-based provider Ardent Health Services: "Welcome to retail — the customer doesn't care."

And patients do vocalize their satisfaction or lack thereof, Gwin said.

"They're in the hospital bed, and they're posting on our Facebook pages, they're telling us what room they're in, they're naming names, and they're just letting us have it," Gwin said.

While some companies' knee-jerk response may have been to yank negative posts, Gwin said, Ardent didn't. Instead, like Blue Cross and retailers everywhere, the company increased its social media efforts, flagging patient concerns and addressing them offline.

Hospitals need good street cred with patients to battle against new and emerging competitors.

Retail pros such as Walgreens are colonizing the health space, too. The drugstore chain has built 370 on-site health clinics for employers. Like the CareHere clinics, those facilities keep patients away from primary care doctors at hospitals.

Perhaps even more threatening to hospitals, Walgreens has folded 400 retail health clinics, called Healthcare Clinics, into stores across the country. The company plans double-digit percentage growth in the number of these clinics during 2014, said a spokesman.

It is tumultuous times for insurers and hospitals, and they have a bigger cross to bear than other retailers.

After all, it's hard to trigger the same serotonin hit selling a sensible insurance plan or a throat culture that you do selling a brand-new Audi Q5 or a pair of Jimmy Choo shoes.

On the other hand, these companies have a leg up in that they offer products that either improve people's lives — the soldier at the airport was extremely grateful to get the cotton out, the caregiver said — or, in some cases, save them.

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