Mental Health Care in Walmart: Increasing Access or Shortchanging the Profession?

A recent Medium article titled “Walmart’s Mental Health Clinics Could Be a Game Changer” described a plan by the big-box mega chain to use its vast network of stores to host mental health clinics where self-paying patients could pay $1 per minute to see a mental health clinician. At $60 for an hour-long intake or $45 for a follow-up appointment, Walmart would put mental health services on par with the cost of an oil change. Two Walmart stores in Georgia recently opened “Walmart Health” Clinics that include behavioral health care among other primary care services.

Walmart’s plan would markedly increase access to mental health care for a wide swath of Americans living in rural areas who currently lack access to services. (Reportedly, 90% of Americans live within 10 miles of one of the 5000 Walmart stores in the United States.) This lack of access to mental health care may be contributing to a mounting suicide rate in these areas, according to a recent JAMA review by Steelesmith et al. Particularly in rural states that have refused to increase their access to Medicaid under the Affordable Care Act (aka Obamacare), it is estimated that 2.5 million people remain without health insurance, which is why Walmart is targeting this demographic with a cash-and-carry model.

As a provider, I am in favor of people with mental health issues having greater access to care, especially in the rural parts of our country that have not had the services available in more populated areas.

But an obvious question arises: will consumers feel confident utilizing mental health services from the same merchant that provides their groceries and back-to-school supplies? The growth of primary care clinics embedded within big-box pharmacies (e.g. CVS’ “Minute Clinic”), largely staffed by nurse practitioners,  would indicate that consumers like this one-stop shopping model. To some degree, it mimics the practice in many pharmacies around the world where the pharmacy is the first stop for common complaints and pharmacists are permitted to diagnose and prescribe for some ailments.

A second question also arises: who will staff these clinics? The United States is already facing a shortage of mental health professionals, particularly psychiatrists, which is expected to worsen over the next decade. Widespread additional demand would be placed on a workforce that is already spread thin attempting to meet the existing needs. While psychiatric nurse practitioners and psychiatric physician’s assistants might fill some of the additional demands that a chain of Walmart mental health clinics might create, unless Walmart is planning on subsidizing the salaries of these mental health professionals, the proposed fees for service would not even cover the average salaries for most psychiatry professionals. Is Walmart planning on creating market forces that drive down wages for health professionals in the same way that they have driven down wages for retail workers? If Walmart succeeds in lowering or even flattening wages for health care workers across the marketplace, there will be even less of an incentive for people to go into these professions, further exacerbating the problem of staffing and access to care.

The federal government already has a program designed to provide mental health services to underserved rural areas – the Federally Qualified Health Center (FQHC) program. Through incentives such as loan forgiveness, rural clinics can attract mental health clinicians. If Walmart were to penetrate the mental health marketplace in these same rural communities, what would this mean for these FQHCs trying to recruit and maintain staffing?

Walmart has identified an opportunity to expand into the rural mental healthcare marketplace and serve those who have been impacted by the resistance to health care reform (in the form of refusing Medicaid expansion), the dropping of the individual mandate in the Affordable Care Act, and the inability to draw health care providers to rural areas. However, to lower costs, one can first be more efficient, but after that is accomplished, it requires shifting money from one group of people to another. Walmart has a longstanding history of moving into small communities, undercutting the prices of local retailers and driving them out of business. Once small businesses go under, Walmart becomes the only employer in town and can pay low wages and provide poor benefits. Will this race to the bottom be the fate of health care providers, too?

Andrew Penn, RN, MS, NP, CNS, APRN-BC was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. He has completed extensive training in Psychedelic Assisted Psychotherapy at the California Institute for Integral Studies and recently published a book chapter on this modality in The Casebook of Positive Psychiatry, published by American Psychiatric Association Press. Currently, he serves as an Associate Clinical Professor at the University of California-San Francisco School of Nursing, where he teaches psychopharmacology, and is an Attending Nurse Practitioner at the San Francisco Veterans Administration. He has expertise in psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. As a steering committee member for Psych Congress, he has been invited to present internationally on improving medication adherence, cannabis pharmacology, psychedelic assisted psychotherapy, grief psychotherapy, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice.