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On call at the mall: a mixed methods study of U.S. medical malls
Organization, structure and delivery of healthcare
The decline of the traditional U.S. shopping mall and a focus on more consumer- centered care have created an opportunity for "medical malls". Medical malls are defined as former retail spaces repurposed for healthcare tenants or mixed-use medical/retail facilities.
We aimed to describe the current reach of healthcare services in U.S. malls, characterize the medical mall model and emerging trends, and assess the potential of these facilities to serve low-income populations.
We used a mixed methods approach which included a comprehensive literature review, key informant interviews, and a descriptive analysis of the Directory of Major Malls, an online retail database.
Six percent (n = 89) of large, enclosed shopping malls in the U.S. include at least one non-optometry or dental healthcare tenant. We identified a total of 28 medical malls across the U.S., the majority of which opened in the past five years and serve middle or high income populations. Stakeholders felt the key strengths of medical malls were more convenient access including public transportation, greater familiarity for patients, and "one stop shopping" for primary care and specialty services as well as retail needs.
While medical malls currently account for a small fraction of malls in the US, they are a new model for healthcare with significant potential for growth.
Shopping malls are not traditional settings for healthcare delivery, but that may be changing. As economic trends threaten the long-term viability of large, enclosed shopping centers, mall developers are increasingly looking to new and innovative uses for existing spaces
The medical mall model offers many potential benefits to both patients and providers. It is consumer-centric due to the convenient locations, ample parking, extended hours, easy access to non-medical services, and a one-stop healthcare experience for specialty and primary care services. In addition, hospitals or physicians in medical malls may benefit from expanded clinical and office space, higher visibility in the communities served, and an increased patient referral base
While there appears to be growing interest in medical malls, to-date there is no analysis on the current reach of these malls and the strengths and limitations of this model. To address these gaps, our study aimed to use quantitative and qualitative methods to: 1) describe the current reach of healthcare services in U.S. malls; 2) characterize the medical mall model and emerging trends; and 3) assess the potential of these facilities to increase healthcare access and serve the needs of low-income populations.
To accomplish our study aims we used a mixed methods approach that included quantitative data analyses using a large database of U.S. malls, literature reviews, and qualitative interviews with key informants. This study was approved by RAND's Institutional Review Board.
Defining, identifying, and characterizing medical malls
Database searches: directory of major malls
To describe the current state of healthcare delivery at U.S. malls, we accessed the Directory of Major Malls (DMM), an online database representing the full universe of the approximately 7,200 large (200,000+ square feet) shopping malls currently in operation in the U.S. and Canada
In addition to describing healthcare delivery at U.S malls more broadly, we also sought to use the DMM to identify medical malls and construct a database of these malls in the U.S. There is currently no formal definition of a medical mall. The term has been used to refer to large multi-specialty outpatient centers, multiple healthcare entities located in former enclosed or open-air (strip) malls, and mixed-use healthcare and retail facilities
Literature review
Using the following keywords: medic*, hospital, healthcare, delivery, shopping, mall, and retail, we searched databases of the peer-reviewed (PubMed, Google Scholar) and grey literature (New York Academy of Medicine Grey Literature Database, Google, Scopus, and OAIster). In addition, the database Lexis-Nexis was searched to identify news and magazine reports. Articles were considered relevant if they discussed a specific medical mall or discussed medical malls or mixed-use retail and healthcare facilities in general. If the article mentioned a medical mall not included in the DMM, we added it to our database of medical malls. 601 articles were included in the final review.
Typology of medical malls
The medical malls identified in the mall database and literature review were categorized into four possible categories: 1) fully healthcare-focused mall with no retail presence; 2) healthcare-focused mall with some retail tenants; 3) retail-focused with mall multiple medical tenants; and 4) mixed-use medical complex with retail components. Malls were considered category 1 if a healthcare entity bought or took over a former shopping mall and fully converted the space to healthcare services. Category 2 consisted of those malls that were healthcare-owned with some space leased to retail. In contrast, category 3 consisted of retail-focused malls that leased space to multiple medical tenants. Finally, category 4 represented a model of healthcare/retail blending where medical complexes or medical villages were originally built to include retail elements in the design. In addition to medical mall type, we collected data on the year each mall opened, its location, the median income in the surrounding community, and its tenant mix.
Qualitative characterization of medical malls
Key informant interviews
We used the results of our literature review to identify potential stakeholders to recruit for key informant interviews. The specific research question that guided the qualitative component of the research was: what is the role as well as strengths and weaknesses of the medical mall model? Semi-structured interviews were determined to be the appropriate approach because they allowed us to discuss concepts in depth and to accommodate changes in the interview protocol depending on the emergence of new themes and specific areas of expertise of participants. We selected informants using purposive sampling to achieve maximum diversity; our aim was to capture a range of experiences and perspectives regarding the use of medical malls.
Potential informants were identified through literature reviews and snowball sampling. They were contacted by email and phone by the lead author. Sixty percent of contacted individuals agreed to participate. We do not know reasons for non-participation, because non-participants did not respond to interview requests (i.e., there were no direct refusal).
We conducted 45-minute phone interviews with representatives of three medical malls and five additional stakeholders representing healthcare organizations, healthcare consulting companies, and retail lease managers (Table
Data analysis
We generated descriptive statistics on healthcare delivery at U.S. malls. In addition, qualitative data collected from the text of articles identified from the literature review and stakeholder interviews were thematically coded using MAXQDA 10 qualitative analysis software
Landscape of healthcare delivery at U.S. malls and medical malls
Of the 1,395 enclosed malls in the U.S., 870 (62.4%) leased space to one or more optometry tenants and 241 (17.3%) to one or more dental tenants. We identified 89 (6.4%) malls with other types of health care services. The most common types of non-dental or optometry tenants within the subset of malls with other types of health care services were primary care/general medical clinics (n = 35, 18.7%) and chiropractic offices (n = 29, 15.5%) (Table
Through DMM searches and our literature review, we identified a total of 28 medical malls, with higher numbers found in the Southeast (10) and Midwest (7) as compared to the Northeast (5), West (4), and Southwest (2) (Table
The 28 medical malls we identified offered a full range of outpatient services including primary care and specialty outpatient services (e.g., dialysis, psychological services, imaging, women's health, acute care, and laboratory). Kingwood Medical Center, set in the former site of the Deauxville mall in Kingwood, TX, also offered inpatient rehabilitation services
Drivers of interest in medical malls
Just under half of the stakeholders we interviewed described the growth of medical malls as indicative of the growing interest of hospitals and health-systems in consumer-focused healthcare and an interest in "healthcare retail". Healthcare retail refers to both bringing retail to a health care site (e.g. hospital campus) and offering healthcare services off-site in a retail space (e.g., in a mall or retail pharmacy). One stakeholder mentioned the Mayo Clinic's presence in the Mall of the Americas as an example of healthcare's growing interest in retail environments
Model specifications
Stakeholders mentioned a number of key factors that were necessary for the success of model. According to two stakeholders, although healthcare tenants benefit from being co-located with retail stores, retail tenants are not essential. Stakeholders also noted that too much integration represents a problem for both retail and healthcare tenants. For healthcare tenants, too much integration can "tarnish their reputation and image", especially in cases where the retail establishments cater to a different demographic (e.g., discount stores). The converse is also true. For example, restaurant customers may react negatively to the site of an acutely ill person entering an urgent care center. According to one stakeholder, "The GAP is never going to move into a mall that is dominated by healthcare players because of perceptions [that creepy crawly feeling you get when you are surrounded by sick people]". Stakeholders agreed that mixed use spaces can thrive as long as separation is maintained. Two of the three medical malls we profiled discussed the need to maintain physical separation. In one medical mall, all healthcare tenants occupied the building's second floor and in another, medical tenants were located in a strip center adjacent to the enclosed (exclusively retail) mall. One stakeholder also noted, however, that although retail is not critical to the success of a medical mall, retail elements could still be important for creating a comfortable environment and encouraging patients to be active participants in their healthcare.
Strengths and limitations of the medical mall model
Stakeholders generally agreed that medical malls have numerous advantages for patients, providers, mall operators, and the wider community. For patients, medical malls increase access and convenience. Several interviewees used the term "one-stop-shop", referring to a patient's ability to run errands and attend to a variety of medical needs at the same time. In addition, one stakeholder discussed the benefits to family members who accompany patients undergoing time-intensive procedures such as chemotherapy. Friends and family appreciated having somewhere to walk as well as shop. Another stakeholder noted that a mall setting is familiar and thus, may be less intimidating than receiving care at a large academic medical center. There was some controversy over the true "convenience" of medical malls; stakeholders generally compared medical malls to a variety of sites for care and evaluated their convenience vis-à-vis different alternatives. For example, a medical mall with ample parking may be preferable to a large parking deck at a hospital, but it is inferior to driving up to a storefront to receive care at a clinic within a drug store in a strip mall. As three stakeholders pointed out, medical malls (that require you to walk long distances and navigate a complex mall directory) may be very convenient for a routine office visit but challenging for the provision of acute care. Furthermore, acutely ill patients are unlikely to take advantage of shopping opportunities.
One key advantage for providers is that placement in a medical mall can increase their visibility in the community since a clinic in a mall is likely to be seen by more potential patients than one in a medical office building. For mall operators, bringing in healthcare tenants is a great way to get "empty space leased" and increase traffic. In addition, healthcare tenants are attractive because they tend to have good credit and sign long-term leases. Finally, communities benefit from medical malls. One stakeholder noted that since the mall was renovated to include healthcare tenants, residents reported "feeling safer". The introduction of a medical mall in an underperforming retail space can help revitalize the community. Finally, one stakeholder explained that communities often have emotional ties to the run-down mall in their town (that has had a historical presence) and they welcome opportunities to restore it.
While three stakeholders noted some limitations of the medical mall model, two stakeholders noted that there were not many disadvantages. One stakeholder cautioned against rushing to build medical malls because of lessons learned from retail clinics (i.e., many were not profitable): "You must be careful when going into a retail space. They are designed differently and customers behave differently in those environments. The healthcare sector has learned a lot from retail clinics regarding moving too quickly". Furthermore, from the perspective of retailers, healthcare tenants take up valuable parking spaces for long periods of time and may in fact reduce demand for their services and merchandise. A key drawback that is not well understood is the costs associated with leasing space in a mall or converting an underperforming mall into a healthcare space. Two stakeholders and one media source explained that locating in a mall is in fact more expensive for providers than a traditional medical building but additional costs were offset by advantages such as increased traffic and visibility. One stakeholder decided not to move healthcare tenants into an existing mall because he was concerned about profitability.
Role of medical malls in serving low-income communities
Two of the three malls we profiled served low-income populations, and one was explicitly created for the purpose of expanding access within a low-income community. If the focus of the mall is expanding access to reduce health disparities, stakeholders discussed the importance of obtaining buy-in from the community (e.g., creating a community advisory board), understanding its needs (e.g., ensuring the mall is on public transportation routes), and reflecting its demographics in the selection of providers and retail establishments. One mall used a foundation to promote its development, and it was generally felt that nonprofits and/or public-private partnerships are needed to extend reach to low-income populations. Stakeholders also generally agreed that partnerships were necessary because those in private business are "not going to open up a mall solely to improve access to care". Several stakeholders explained that lessons learned from experiences with retail clinics applied to the use of malls for healthcare delivery. To support this point, they explained that market forces resulted in the placement of retail clinics in more affluent areas. According to one stakeholder, "If left to the market, medical malls- like retail clinics- are unlikely to increase access to low income individuals".
Two of the medical malls in our study described the impact of taking over an underperforming (retail) mall on the economic wellbeing of the larger community. As explained by one stakeholder, "The medical mall transformed the community [brought in new businesses and reduced crime] although that is not what we originally intended to do". Another stakeholder observed that the introduction of a medical mall could be part of a comprehensive urban renewal strategy.
Future trends for medical malls
Of the five stakeholders who commented on the future of the medical mall model, three enthusiastically claimed that medical malls were poised for growth and felt existing success stories had generated interest from domestic and international players. Others expressed skepticism and noted that too much is unknown related to the impacts of the Affordable Care Act, patient preferences, and the degree to which technology will support e-visits and telemedicine to predict the future of the medical mall. In general, numerous stakeholders noted that the success of this particular model was community-dependent. As one stakeholder noted, "A medical mall may work somewhere but flop somewhere else". Factors such as the design of the mall, demographics of the community, and alternatives for care all affect the likelihood of success.
Medical malls have received significant media attention, and experts have described the potential of healthcare to save the dying American mall
The stakeholders we interviewed highlighted numerous benefits of medical malls as compared to more traditional sites for healthcare delivery such as medical office buildings. These included the ability to provide "one-stop" shopping and convenience for patients and greater visibility for providers. Medical malls, furthermore, reflect the growing interest among healthcare providers in creating a more consumer-centric experience. However, we found that only some types of healthcare services may be suited for a medical mall. Primary care and specialty services which require routine visits are ideal. Women's health and pediatrics are also attractive given that women are more likely to take advantage of the shopping opportunities at the mall. In contrast, acute care services may not be well suited to a mall setting. A note of caution is also warranted. While there is great interest in medical malls, there is also the possibility that enclosed malls will fail to attract healthcare providers for the same reasons that they increasingly fail to appeal to retailers.
Proponents argue that medical malls like the Jackson Medical Mall improve access to low-income communities and can serve as an engine of local economic growth. Unfortunately, it appears that malls like Jackson remain the exception, not the rule. Most medical malls in the U.S. serve middle to high-income populations. The stakeholders we interviewed believed medical malls would not open on their own in low-income communities. Rather, it is critical to engage the community, creating partnerships and understanding community concerns to promote trust, reduce crime, and enhance economic development.
There are several limitations to our study. First, our DMM search strategy could fail to identify some medical specialties not represented among our keywords as well as healthcare tenants with general, non-descriptive names. Second, because there is no standard definition of medical mall, we had to develop and apply a novel definition for the purposes of identifying and characterizing medical malls. Similarly, very little is written about medical malls in the peer- reviewed literature; thus, we must draw conclusions about medical malls from a comprehensive search of grey literature and from stakeholders who shared anecdotal evidence. We confronted this challenge by employing a mixed methods design and through triangulation of research methods and sources. Finally, we did not interview patients for this study and thus cannot directly represent their perspectives; however, three stakeholders referenced the results of focus groups and surveys (conducted as market research) with patients on their experience with and impressions of the local medical mall.
While our exploratory study uncovered many new insights about healthcare delivery in medical malls, there is a great deal that we do not understand about this topic. For example, the success of a particular medical mall seems to be dependent on a range of (thus far unspecified) community factors such as alternatives for care, the mix of tenants, and the populations served. While stakeholders argue that the mall is not suited for the provision of acute care and makes more sense for primary and specialty care that is received on a routine basis, there is no empirical evidence to support this claim other than the fact that retail clinic operators have found enclosed mall locations to be less profitable than alternative locations over the past several years. It should be noted that although this review was limited to medical malls in the U.S., there are numerous examples of medical malls across the globe, most notably in Asia
Future research is also needed to understand the precise conditions that contribute to the success and impacts of medical malls on costs and quality of care. At present, medical malls only have a great deal of
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
LUP and RC conducted the literature review and interviews, analyzed interview and secondary data, and drafted the manuscript. AM helped to design the study, secured funding for the work, and revised the manuscript. All authors read and approved the final manuscript.
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Pre-publication history
The pre-publication history for this paper can be accessed here:


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Creative Directors: Alvaro Ramos
Art Director: Alvaro Ramos
Copywriter: Flavio Pantigoso
Highest Rated
i think its the line that bothering me...'beat the blank paper?'...i think they should have been more specific about the fear of sitting in front of this blank piece of paper and how its all in your mind...just like those silly monsters that dont really exist..no need to be afraid....coulda worked better...
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subset: commoncrawl


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|This location exists primarily or exclusively within the Sonic the Comic continuity.
Information in this article may not be canonical to the storyline of the games or any other Sonic continuity.
- Not to be confused with the Sun Valley Zone from Sonic the Comic #127.
The Sunshine Valley Zone is a location that appears in the Sonic the Comic series published by Fleetway Editions. It is a Zone of Mobius.
The Sunshine Valley Zone was once subject to a Badnik attack, but the citizens were saved by new hero, Ultra-Duck. It later transpired that the duck had built these fake Badniks so he could humiliate the real heroes.[1]
- ↑ Sonic the Comic #128, "Yesterday's Heroes"
External links
- Sunshine Valley Zone at the Sonic the Comic Wiki


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In fact, Executive Director Shirley Bishop told the council, Roxbury is in good shape for the next round of low and moderate income unit requirements, which is due to be announced this year. According to Boonton attorney Paula DeBona, who works with the township's CO AH program, the current certification for the township expires on Nov. 5, 2003. This is the second round of low and moderate income requirements the state has mandated, and, DeBona said, the township has already met the requirement of 375 u nits. In fact, she told the mayor and council, Roxbury has built up a credit of 13 additional units for the third round of COAH requirements. "You right now ha ve a surplus of 13 units," she said, adding that the requirements have been fil led with four group homes for disabled citizens, new construction of low and mod erate income units, low cost rental units, senior citizen rental units and low a nd moderate income home rehabilitation.
"As of today, 327 of that 375 have been constructed, and the rest are certified and waiting to be constructed," DeBona said. "The town also has zoning in place to meet future obligations," she added.
According to Bishop, the township has until June of 2003 to comply with the second rounds numbers; 375 in this case. "You have basically already complied. You have 327 built, and the others are either in the works or are approved," Bishop said.
COAH's task force, Bishop said, is looking at new formulas which will be easier for municipalities to understand for the third round. "We needed the 2000 census numbers, and we now have those," she said. She also said that instead of a six year COAH certification, the state legislature is looking into creating a 10 year certification. A vote is expected late this month, she said. "We have to hold off on creating the third round numbers until we see if its going to be for six or 10 years," she said.
"We expect to have the new formula available in April, so the towns know what is being planned for the third round. Input is going to be solicited. We want to know what the towns want and what their concerns are. We will list the policy issues, and we will form focus groups to work on them," Bishop said.
"Your current certification is good until 2003. You will have at least a year to bring in a new plan to COAH for certification," Bishop said. She said she expects the township will know its new requirement by this summer. "You will have a year and a half or so to come up with a new plan. We want to meet with each town to give them all the assistance you will need. For example, a lot of towns have never looked at the potential of using group homes to fulfill some of their requirements, " Bishop said. "We are seeing more and more towns coming in with proposals for group homes," she said. Another new idea towns are bringing to COAH, she said, is a plan to construct new homes, with some being set aside as affordable units. "For example, if 25 new homes are built, one of them will be anaffordable unit," she said.
With COAH certification in place, Bishop said the township is protected from being sued for not having enough low and moderate units. "You are under COAH jurisdiction. If you are sued, COAH goes to court with you," she said.
Projections Made
Bishop said that the formula for determining a towns' COAH obligation involves projecting the population 10 years in the future, then projecting the number of new households based on that 10 year population. "About 40 percent is required to be low and moderate income units," she said.
"How you are allocated that number is what the council is looking at now," Bishop said.
Councilman Richard Herzog questioned whether or not the township can be held liable if it creates the right environment by approving low and moderate income units, but they are never built.
In response, Bishop said the town would be safe from a lawsuit, in that case. "The Fair Housing Act says that a municipality can not place any barriers. It does not say they have to be built. If the building market falls apart, you won't be responsible for that," she said.
Deputy Mayor Jim Rilee said the township already has three large sites set aside for future COAH housing. Bishop said she expects the township will have at least two years from the time the new requirement number is released until the time that a plan must be in place and approved.
Mayor Sandy Urgo said the crux of Roxbury's concern, however, is bringing the township's COAH requirement down. "I spoke at one of our schools, and we have children having classes in closets. Our whole purpose is to reduce our number and have less housing units built," Urgo said.
Bishop said that is a common concern expressed by many towns statewide. "COAH is very aware of that. We have to be. New Jersey is the only state that is projected to be at complete built out in 20 years, so we are very aware of that," she said.


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Wasabi Power Battery (2-Pack) and Charger Kit for Nikon EN-EL3E.
- Price: RM184.00 - In stock
This Wasabi Power Battery and Charger Kit includes:
1) Two (2) Wasabi Power ENEL3e batteries; each with 7.4V, 2000 mAh, Japanese cells
2) One (1) Wasabi Power ENEL3e Mini Rapid A/C Charger with fold-out plug
3) European plug and car adapter
4) 3-year manufacturer warranty
Availability: In stock
*Orders placed after 12PM will be shipped the next day
Before: RM360
Special Price RM184
The Wasabi Power battery and charger kit includes 2 batteries and one charger with a European plug and car adapter. All items meet or exceed OEM standards and come with a 3-year manufacturer warranty.
Batteries replace: Nikon EN-EL3e
Charger replaces: Nikon MH-18, MH-18a.
Compatible with the following models:
Nikon D50
Nikon D70
Nikon D70s
Nikon D80
Nikon D90
Nikon D100
Nikon D200
Nikon D300
Nikon D300S
|Accessories Type
|Battery with Charger
|Wasabi Power
|Warranty Period
|3 Year Manufacturer's Warranty
|Manufacturer's Suggested Retail Price
Wasabi Power Battery (2-Pack) and Charger Kit for Nikon EN-EL3E.
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