Week 9 Assignment For this assignment, you will read and analyze a case study which presents a new approach to health care deliv
Week 9 Assignment
For this assignment, you will read and analyze a case study which presents a new approach to health care delivery, pioneered by Walmart, and describes how the growth of their new service was impacted by the COVID-19 pandemic. Marcus Osborne, Vice President for Health and Wellness Transformation at Walmart, was leading the team managing implementation of the new Walmart Health business model. He was also closely involved in the company’s response to the pandemic, not least because Walmart Health was now tasked with offering COVID-19 testing in a safe and effective manner.
Read all materials and follow all instructions. Work the paper according to the Grading Rubric.
Assignment 3: Case – Walmart Health Scaling during a Pandemic
Overview
For this assignment, you will read and analyze a case study which presents a new approach to health care delivery, pioneered by Walmart, and describes how the growth of their new service was impacted by the COVID-19 pandemic. Marcus Osborne, Vice President for Health and Wellness Transformation at Walmart, was leading the team managing implementation of the new Walmart Health business model. He was also closely involved in the company’s response to the pandemic, not least because Walmart Health was now tasked with offering COVID-19 testing in a safe and effective manner.
In your paper, you will analyze the challenges facing the Walmart Health team, as they worked to design and roll out their new service offering, in the context of a global pandemic and an economic recession. You will also examine how Walmart’s service model was impacted by the history of the company and by the changing regulatory environment. While the case study itself is your key resource, you are expected to put it in context by referring to course materials and your own research on the topics in the case study.
Instructions
Write a 5-to-7-page paper that analyzes the Walmart Health case. Use the headings below to create sections in your paper. Use the questions and prompts to cover all the relevant content for each section.
Introduction
• Briefly describe the history of Walmart’s involvement in health services from 2008 to 2013.
I. Innovating through the Bureaucracy
· Identify TWO new risk and compliance issues that Walmart faced, when they expanded beyond pharmacy services into retail health clinics?
· Did changes to Medicaid after passage of the ACA impact the decision on where to locate the first Walmart Care Clinics in 2014? If so, how?
· Describe ONE new approach to health service delivery tested out by Walmart between 2014 and 2018? Was it successful? Why or why not?
II. The Walmart Health Model and Lessons Learned
· How did access to community health workers at the first Walmart Health clinic, opened in 2019, help to attract clients? Why did this result surprise the team?
· After opening a second Walmart Health clinic in 2020, why did Walmart consider replacing the fee-for-service model of payment for care with a subscription model?
· In the light of the current state of the health care market, which of the two reimbursement models do you think Walmart Health should select? Why?
III. Impact of the COVID-19 Pandemic
• Summarize the changes made by U.S. regulators in the three areas below, due to the COVID-19
crisis:
a. use of telemedicine
b. licensing of physicians
c. supervision requirements for nurse practitioners and physician assistants
• How has ONE of these three regulatory changes affected the options open to Osborne and his
team about future development of the Walmart Health model?
• In your view, can Walmart successfully integrate telemedicine into its healthcare clinic model?
What are the pros and cons of this option for Walmart?
IV. Learn Today, Apply Tomorrow
• What do you predict will change for the Walmart Health initiative, as more people get vaccinated and the economy opens up? How should they adapt to these changes?
• Pick ONE of the two options below:
· If you work in a healthcare organization, describe one applicable lesson learned from the
case study that could benefit your organization.
· If you do not work in a healthcare organization, describe one applicable lesson learned
from the case study that could benefit the healthcare sector in your state or country.
Formatting
Your assignment must follow these formatting requirements:
• Typed, double-spaced, using Times New Roman font (size 10-12), with one-inch margins on all sides.
• Include a Cover page containing the assignment title, student’s name, professor’s name, course
title, and date.
• Citations and references must follow the formatting instructions found in the JWMI Writing
Standards Guide. Check with your professor for any additional instructions.
Note: The Cover and References pages are not included in the required page length.
RUBRIC – Assignment 3: Case – Walmart Health Scaling during a Pandemic
Criteria |
Unsatisfactory |
Low Pass |
Pass |
High Pass |
Honors |
1. Introduction: describe the history of Walmart’s involvement in health services from 2008 to 2013. Weight: 10% |
Does not or poorly describe the history of Walmart’s involvement in health services from 2008 to 2013. |
Partially describes the history of Walmart’s involvement in health services from 2008 to 2013. |
Satisfactorily describes the history of Walmart’s involvement in health services from 2008 to 2013. |
Very good description of Walmart’s involvement in health services from 2008 to 2013. |
Exemplary description of Walmart’s involvement in health services from 2008 to 2013 |
2. Answer the questions on how Walmart innovated through the bureaucracy. Weight: 20% |
Does not provide answers to most of the questions on how Walmart innovated through the bureaucracy. |
Partially answers the questions on how Walmart innovated through the bureaucracy. |
Satisfactorily answers all the questions on how Walmart innovated through the bureaucracy. |
Very good answers are provided to all the questions on how Walmart innovated through the bureaucracy |
Exemplary answers are provided to all the questions on how Walmart innovated through the bureaucracy. |
3. Answer the questions on the Walmart Health models and Lessons Learned. Weight: 20% |
Does not provide answers to most of the questions on the Walmart Health models and Lessons Learned. |
Partially answers the questions the Walmart Health models and Lessons Learned. |
Satisfactorily answers all the questions on the Walmart Health models and Lessons Learned. |
Very good answers are provided to all the questions on the Walmart Health models and Lessons Learned. |
Exemplary answers are provided to all the questions on the Walmart Health models and Lessons Learned. |
4. Answer the questions on the impacts of the COVID-19 pandemic and their effect on development of Walmart Health. Weight: 20% |
Does not provide answers to most of the questions on the impact of the COVID-19 pandemic on the development of Walmart Health. |
Partially answers the questions on the impact of the COVID-19 pandemic on the development of Walmart Health. |
Satisfactorily answers all the questions on the impact of the COVID-19 pandemic on the development of Walmart Health. |
Very good answers are provided to all the questions on the impact of the COVID-19 pandemic on the development of Walmart Health. |
Exemplary answers are provided to all the questions on the impact of the COVID19 pandemic on the development of Walmart Health. |
5. Answer the questions in the Learn Today, Apply Tomorrow section. Weight: 20% |
Does not provide answers to most of the questions in the Learn Today, Apply Tomorrow section. |
Partially answers the questions in the Learn Today, Apply Tomorrow section. |
Satisfactorily answers all the questions in the Learn Today, Apply Tomorrow section. |
Very good answers are provided to all the questions in the Learn Today, Apply Tomorrow section. |
Exemplary answers are provided to all the questions in the Learn Today, Apply Tomorrow section. |
6. Clarity, logic, writing mechanics, and formatting. Weight: 10% |
Multiple mechanical errors. Much of the text is difficult to understand or does not flow. Student failed to follow the formatting instructions. |
Several mechanical errors make parts of the text difficult for the reader to understand. The paper is poorly formatted in places. |
More than a few mechanical errors. Text flows but lacks conciseness or clarity. The paper is satisfactorily formatted. |
Few mechanical errors. Text flows and concisely and clearly expresses the student’s ideas. The paper is well formatted. |
Few to no mechanical errors. Text flows and concisely, clearly, and exemplarily expresses the student’s ideas. The paper is excellently formatted. |
,
9 – 6 2 1 – 0 6 1 S E P T E M B E R 2 4 , 2 0 2 0
Professor Robert S. Huckman, Yoonjin Min (HBS MBA 2020), and Marissa Thiel (HBS MBA 2020) prepared this case. It was reviewed and approved before publication by a company designate. Funding for the development of this case was provided by Harvard Business School and not by the company. HBS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management.
Copyright © 2020 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-7685, write Harvard Business School Publishing, Boston, MA 02163, or go to www.hbsp.harvard.edu. This publication may not be digitized, photocopied, or otherwise reproduced, posted, or transmitted, without the permission of Harvard Business School.
R O B E R T S . H U C K M A N
Y O O N J I N M I N
M A R I S S A T H I E L
Walmart Health: Scaling During a Pandemic
Marcus Osborne, Vice President for Health and Wellness Transformation for Walmart, gazed at the long line of cars approaching a makeshift tent in the parking lot of Walmart’s Northlake, Illinois store. Opened just the day before, on March 22, 2020, the Northlake site was the first drive-through testing center run by Walmart, the largest retailer in the United States. As each car approached the tent, a health care provider in full personal protective equipment (PPE) collected a nasopharyngeal swab from a patient in the vehicle and prepared the sample to be analyzed for the presence of COVID-19, a novel coronavirus that had spread across the globe after initial detection in China in November 2019. The number of confirmed COVID-19 cases in the U.S. had ballooned from 13 on February 15th to approximately 3,000 on March 15th and over 65,000 just 10 days later.1 As many noted the lack of testing capacity in most communities, the U.S. federal government announced a public-private partnership, which included Walmart, aimed at rapidly increasing the availability of diagnostic testing.
For much of the week leading up to the opening of the Northlake site, Osborne had been on what seemed to be a continuous conference call with his colleagues to discuss the design and implementation of Walmart’s testing efforts. Prior to being consumed by planning Walmart’s COVID-19 response, Osborne’s team had been fully occupied with planning for the continued expansion of the nascent Walmart Health business. The first two Walmart Health clinics in Dallas, Georgia and Calhoun, Georgia opened to considerable acclaim in September 2019 and January 2020, respectively. Clinic volumes were high, as were consumer satisfaction scores. Patients noted the benefits of the clinics’ proximity to Walmart stores, ease of scheduling, and transparent and low prices.
With respect to COVID-19 testing, Osborne was impressed by how quickly his team was making the decisions necessary to rapidly scale what was essentially a new service (i.e., the collection of potentially highly contagious patient samples) in a new setting (i.e., a drive-through layout in a parking lot). This is precisely what Osborne’s team had been asked to do in developing Walmart Health, so he was not surprised by the rapid progress made on the testing sites. Yet despite the laser focus on COVID- 19 for the moment, Osborne knew that it would not be long before his team would need to return to the topic that occupied all of its time prior to the COVID-19 crisis—planning for the continued expansion of Walmart Health.
Osborne wondered whether and how the team’s experience with COVID-19 testing might impact planning for the growth of Walmart Health. How quickly and where should the clinics scale across the
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country? What services should Walmart offer to address broader gaps in public health exposed by the COVID-19 pandemic? Finally, how could he prove the value proposition of Walmart Health to both customers and the leadership of Walmart? He felt as if each of the cars lined up in front of him contained another question about the future of the new business he and his colleagues were building.
Walmart Overview Sam Walton founded Walmart in 1962, opening its first retail location in Rogers, Arkansas. Walton
was driven by a belief that discount retailing would rise to prominence. Though other retailers focused on larger cities, Walton was convinced that rural settings would allow Walmart, and its everyday low price (EDLP) strategy, to thrive. With an expansion strategy to “put good-sized discount stores into little one-horse towns which everybody else was ignoring,”2 Walmart initially focused on towns with fewer than 9,000 residents, many of which were located in the southeastern United States. In these communities, Walmart became the go-to retailer for basic necessities, including general merchandise, pharmacy, and even grocery.
Walmart’s pursuit of rural markets presented unique challenges. For example, procurement in rural areas was limited, so the company built its own distribution network to support stocking its stores. After placing a distribution center, Walmart would open stores in the surrounding area until that market achieved saturation, at which point it would build another distribution center in a different location.
From the beginning, Walton focused the company on continuous improvement. This involved both rigorous tracking of competitors as well as continuous analysis of internal operations. Though regional vice presidents were all based at Walmart’s headquarters in Bentonville, Arkansas, they travelled weekly to their stores to identify opportunities for improvement. Ideas were then shared with Walton during Saturday meetings in Bentonville.
Walmart was continuously innovating in the area of supply chain management, investing heavily in technical infrastructure to connect its distribution centers with stores in an effort to drive down inventory costs. Similarly, early adoption of point-of-sale scanners, and sharing of this information with suppliers, continued to drive costs down. These savings were passed on to consumers through the EDLP strategy.
Over time, Walmart expanded its footprint into new store sizes and formats. This growth included new brands such as Sam’s Club, with its warehouse-format stores, and Neighborhood Markets, with its urban, small-format stores. In the late 1990s, many of Walmart’s discount stores were replaced with the larger-format “supercenters”, which vastly increased the products offered in any given location. By 2020, Walmart had grown to 5,355 retail locations in the United States, 3,571 of which were supercenters.3 Its network of distribution centers had similarly grown to over 150 locations across the United States, with an additional six relief centers to aid communities in the event of a natural disaster.4 Exhibit 1 provides summary financial and operational data for Walmart.
Walmart’s $348 billion in US revenue5 was supported by a workforce of more than 1.5 million employees, referred to as associates, across the country. As of 2017, this workforce made Walmart the largest private employer in 22 U.S. states (see Exhibit 2). Associates had always been central to Walmart’s success, with profit sharing beginning in the early 1970s. As Walmart grew, it came under the scrutiny of unions for its wage and benefits practices. In 2005, an internal memo that appeared to discuss strategies to limit benefits for employees was leaked to the press.6 While Walmart argued that it, like all other large companies, was seeking to control soaring benefit costs, its public reputation came
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under scrutiny. Walmart took several steps to address these concerns. In February 2015, Walmart raised the starting wage to $9 per hour—$1.25 above the federal minimum wage—for all of its U.S. employees. In 2018, Walmart once again raised starting wages to $11 per hour. Further, the company offered employees extended parental leave (up to 6 weeks), extended maternity leave (up to 10 weeks), and financial assistance for employees seeking to adopt a child.
In 2019, Walmart began its Live Better U program, which enabled associates, for $1 per day, to pursue bachelor’s and other degrees in a range of subject areas including business administration, cybersecurity, health services, and health care administration. As of February 2020, the company reported that more than 12,000 associates had completed more than 88,000 college credits under the program.7
Outside of salary and educational benefits, Walmart introduced new programs related to health benefits for employees. Notable among these was the 2012 introduction of its Centers of Excellence program, which provided employees with full coverage for certain surgical procedures, as long as they were performed at specific partner hospitals (e.g., cardiac surgeries provided at the Cleveland Clinic or orthopedic procedures provided at the Mayo Clinic). The goal was to provide associates with access to top-tier providers who, in return, benefitted from the volume of patients that Walmart could potentially send their way. In 2019, Walmart made the voluntary program mandatory for certain procedures while expanding the list of qualified centers of excellence (see Exhibit 3).
Walmart’s Competitors
In its first 30 years of operation, Walmart competed largely with other big-box retailers including Ames, Kmart, and Bradlees. As Walmart leveraged its scale to lower prices, these other retailers languished, and many went out of business by the early 2000s. After going bankrupt in 2002, Kmart merged with Sears to become the third-largest U.S. retailer, but still continued to struggle. The combined entity, under the Sears name, filed for bankruptcy in December 2018.8
Despite its success in fending off competition from brick-and-mortar retailers, Walmart faced increasing competition online. Online sales still represented a relatively small fraction—only 16%—of total US retail sales in 2019, but that share had grown from 14.4% in 2018.9 Amazon was Walmart’s chief e-commerce competitor with U.S. sales of $144B in FY 2018.10 Like Walmart, Amazon had grown by building its own distribution network to control costs and deliver merchandise efficiently. To keep pace with Amazon, Walmart began to build out its own e-commerce capabilities, with its 2016 acquisition of Jet.com serving as the foundation of those efforts.
Walmart’s Initial Moves in Health Care Big-box retailers had long been part of the health care ecosystem in the U.S., though largely in their
role as pharmacies. The top 5 pharmacy chains in the US (CVS Caremark, Walgreens, Rite Aid, Walmart, Kroger) had over 27,800 stores in 2019. These retailers in turn partnered with the pharmacy benefit managers (PBM) that played an intermediary role between pharmaceutical manufacturers and retail pharmacies. The three largest PBMs in 2019—Express Scripts, CVS Health, and OptumRx— comprised almost 80% of the market.
Walmart had one of the largest pharmacy chains in the U.S., operating over 5,100 pharmacies in Walmart and Sam’s Club stores around the country. Those pharmacies offered prescription services, medication therapy management, and immunizations. In 2019, Walmart held a 4.7% share of national prescription revenues, while its largest competitors, CVS and Walgreens, held 24.5% and 18.9% shares,
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respectively.11 Walmart’s pharmacy had been a leader in encouraging the use of lower-cost generic substitutes for branded drugs, having launched a $4 prescription program for generic medications in 2006. Competitors soon followed suit with similar offerings. Together, these programs helped drive the increase in generic pharmaceutical use in the U.S. In 2018, several PBMs integrated with major health insurance companies (e.g., CVS acquired Aetna, and Cigna acquired Express Scripts). Such consolidations posed a threat to Walmart’s pharmacy business by creating the potential for the chain to be left out of insurers’ preferred pharmacy networks.
Outside of core pharmacy activities, several chains had introduced retail clinic models aimed at providing convenient and affordable access to basic care. One of the first retail-based clinics opened in a Minnesota grocery store in 2000, under the brand QuickMedx, with the promise of bringing health care delivery closer to patients by placing it inside a space they already frequented. QuickMedX eventually became the MinuteClinic chain, which was acquired in 2006 by CVS Caremark, then the largest retail pharmacy in the U.S. By 2014, CVS had 950 retail clinics, Walgreens had approximately 400, and Kroger had roughly 200.12
Walmart entered the retail clinic business in 2008 under the Clinic at Walmart brand. Previously, Walmart had rented out space to independent clinic companies that typically operated in partnership with local health care providers and primarily employed nurse practitioners. “People are willing to receive their health care from the front of a store… but customers also have said they would rather it be delivered by a trusted name, a local health care practice, a trusted local provider of care,” reflected Dr. John Agwunobi, then Senior Vice President of Health and Wellness.13 Though its model of affiliating with health care systems was unique, the Clinic at Walmart service offerings were similar to those of competing retail clinics and were focused on the treatment of common ailments and basic preventative care.
Many of these partnerships were ultimately dissolved over the next five years. Osborne noted that health systems often viewed their partnership with Walmart as an opportunity to broaden the funnel of patient referrals—particularly for high-margin specialty care—to their hospitals and physicians. This tendency interfered with Walmart’s goal of using the clinics to provide affordable and accessible care, particularly to the 55% of its in-store clinic patients who were uninsured. “The problem in partnering with health systems is that their interests are very different from ours,” Osborne reflected. “They are interested in gaining referrals, which creates the perverse incentive for them to pull volume out of the clinics rather than put volume into them.”
In 2014, Walmart launched its first company-owned clinics under the Walmart Care Clinics brand. The first clinics, which aimed to serve both Walmart customers and employees, opened in Texas, South Carolina, and Georgia—three states that did not expand Medicaid coverage after federal healthcare reform and the passage of the 2010 Affordable Care Act.a Walmart Care Clinics offered services related to the management of chronic conditions, such as diabetes and hypertension, not just treatment for the basic acute needs treated in other retail clinics. These expanded services allowed Walmart to serve as a primary care provider, thereby creating a repeat relationship with customers that other retail clinics did not yet provide. Prices were low and transparent: $40 for a walk-in check-up and $4 for the same if the patient was a Walmart associate or dependent. The clinics were staffed by nurse practitioners in
a The Affordable Care Act was a piece of U.S. legislation, passed in 2010, designed to increase the access to and affordability of healthcare coverage. As part of the act, states had the option to increase Medicaid coverage so as to only use income level as a measure of qualification for Medicaid (standard Medicaid coverage had used a combination of income and household size, disability, family status, etc in order to determine eligibility). States that opted to not expand Medicaid coverage had fewer new enrollees in Medicaid and a greater proportion of the population remained uninsured.
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partnership with QuadMed, a provider of on-site primary care for employers. By 2017, Walmart had introduced 19 Walmart Care Clinics in three states and maintained over 100 additional independent in-store, acute care clinics across the U.S. through lease arrangements.
Walmart Tests Other Models
Outside of comprehensive retail clinics, Walmart had a long history of offering a variety of other health services in select stores. For example, Walmart operated over 3,000 vision centers at Walmart stores and Sam’s Clubs. The retailer first offered vision services in 1991 and soon became the largest producer and seller of prescription eyewear in the U.S. Most of Walmart’s vision centers were staffed by independent optometrists who leased retail space. Customers could buy a pair of glasses, with a one-year warranty, for just $38, compared to the national average cost of $274.14
Walmart also offered dental care in certain stores through third-party providers. In Canada, Smile Shapers Dental Clinics had been operating within several Walmart stores since 2014. The clinics ran independently of Walmart, which simply leased space to them.
Sam’s Club offered hearing centers in 450 (approximately 75%) of its warehouse clubs in the U.S. The centers were staffed by state-licensed professionals who would conduct hearing screenings before recommending a device that would best suit a customer’s needs. These hearing aid specialists also provided education on the use and care of products as well as free programming, adjustment, and cleaning of devices. Some Walmart stores also offered free hearing screenings and consultations in certain stores; in New York, a third party, Hearing Health, operated hearing clinics in 13 supercenters. Walmart was constantly testing adjustments to its various models for providing audiology services.
In 2017, Walmart and Quest Diagnostics—one of the three largest laboratory and research companies in the U.S.—announced a partnership to provide laboratory testing services at co-branded sites in Walmart stores. Walmart and Quest worked to redesign the diagnostic testing experience for customers and expand the lab’s capabilities to conduct a broad range of screenings. By 2019, there were Quest Patient Service Centers (PSC) in over 75 Walmart stores.
In partnership with Beacon Health Options, Walmart entered the behavioral health space in 2018 by launching Beacon Care Services, an outpatient provider of mental health services, in select stores. Beacon Care Services employed licensed clinical social workers and trained counselors to support individuals with common behavioral health issues, including depression, anxiety, and grief. The first Beacon Care Services practice opened at a Walmart store in Carrollton, Texas, a state in which only 35% of mental health care needs were being met at the time.15
A consistent finding across all of these health services was that locating them inside a Walmart store drove higher utilization. Volume for services was routinely higher than anticipated at launch and typically stayed at consistently high levels, even when the service was not being heavily marketed or run in the most-efficient manner. The step-change in utilization was most pronounced when comparing the volume from a service that had previously existed in a different site and had been moved into a Walmart store. For example, Quest Diagnostics relocated several of its standalone PSCs to Walmart stores and immediately saw an increase in volume. Osborne noted, “Within weeks the volume was anywhere from 30% to 80% higher, without signing any new contracts with providers.” The volume of tests being ordered by providers was not changing; rather, adherence levels were increasing as patients presumably found it more convenient to have prescribed tests performed.
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Building Walmart Health In 2018, Sean Slovenski was hired as President of Health and Wellness, a role that was elevated from
reporting to the U.S. Chief Merchandising Officer (CMO) to reporting directly to Greg Foran—then President and CEO of Walmart U.S.—who directly reported to Doug McMillon, President and CEO of Walmart, Inc. Daryl Risinger, who was hired by Slovenski into the role of Chief Growth Officer of Health and Wellness, noted, “When you have the President of Health and Wellness reporting directly to the President and CEO of Walmart U.S., you now have an equal seat at the table along with all of the other departments”. This organizational change allowed Walmart Health and Wellness to develop a distinct structure and strategy rather than simply being a service housed within the operations—and thus operating performance—of specific stores.
Risinger emphasized the importance of this restructuring for the potential of Walmart Health. “When Walmart initially dabbled in the grocery business, many people said, ‘No one would ever buy their groceries at Walmart.’ But in 1988, Walmart really leaned forward into the grocery business. Fast forward to today, and we are the largest grocer in the world. So if Walmart made a serious commitment to health care, it would not be hard for consumers and employers to connect the dots and realize that Walmart could have a compelling value proposi
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