Primary Care In an On-Demand World: Is the Primary Care Physician Making a Comeback?

While researching this article, I came across the following quotes: one from a doctor and one from a patient:

From the doctor: “The inability to control the way we practice medicine and deliver care to patients is the reason that physicians are leaving medicine in record numbers. I can tell you that on an ordinary working day, if I didn’t have a single patient to see, I would still be busy for eight or nine hours doing nothing but paperwork and phone calls that are directly related to managed-care issues.”

From the patient: “I doubt that a single doctor I have seen over the last 10 years would know me if he or she fell over me on the street, including my current ‘primary care physician’ whom I have probably seen six or seven times over the past two years. The feeling I get is that I am just another widget coming down the medical care assembly line.”

The quotes above seem particularly relevant to primary care medicine. These points of view would have you believe nobody is happy and that the American healthcare system is a hopeless mess. And many would argue this situation is a direct result of the Affordable Care Act, better known as Obamacare.

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There are two problems with that argument.  First, these two quotes were from an article published in the New York Times on December 16, 2001. George Bush was still president; Barack Obama wouldn’t be elected for another seven years; the Affordable Care Act wouldn’t go into effect for more than a decade. Second, problems in primary care medicine are and always have been prone to hyperbole and exaggeration.

Don’t forget that on-demand medicine – urgent care, retail clinics, telehealth – evolved from primary care medicine. And it would be unwise and premature to think primary care medicine is dead because of urgent care, retail clinics, telehealth and a whole host of other disruptions.

What primary care medicine will look like a decade or more from now is a subject we will explore at our next ConvUrgentCare Strategy Symposium in January. And we will have speakers who make a living exploring that subject.

Tom Beauregard is executive vice president and chief innovation officer at UnitedHealth Group (UHG). He drives UHG’s innovation efforts at the highest level of the company and oversees a portfolio of diversified assets and high-performing teams.

Michael Rabovsky, M.D., is chair of the Department of Family Medicine at Cleveland Clinic. He is one of the key leaders at an organization that does more to integrate its on-demand offering with primary care medicine than just about any health system we have seen.

Each will have the opportunity to present his view in the morning session on January 23, followed by an interactive panel discussion with the audience. The session will no doubt create a mix of insightful commentary and uncomfortable controversy, not only on primary care medicine, but on the direction of the U.S. healthcare system in general. But insight and discomfort are probably necessary ingredients to plotting an on-demand strategy that tracks with what seems unpredictable at best.

Framing the Future

Primary care medicine is a topic that could span several volumes of essays and commentary. Our primary purpose is to frame it in a way that informs a health system or urgent care operator’s strategic planning efforts. So the first question is whether primary care will evolve synergistically with on-demand medicine. Many would argue that urgent care, retail clinics and telehealth do nothing more than cannibalize visits to primary care physicians, creating competition and discontinuity in the patient-provider relationship. But that would not be the case at Cleveland Clinic.

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I now enjoy working in a model where the business isn’t what we worry about. It’s the patients. Everything else is provided and taken care of.
— Michael Rabovsky

“In primary care, I don’t think any of our providers are feeling that competition,” says Dr. Rabovsky. “They feel like there are ample patients and we can continue to grow with more providers.”

Dr. Rabovsky began his career in a solo private practice, which eventually grew to four providers.

“It was Marcus Welby medicine,” he says. “I had a small office where I knew all of my patients personally. I did rounds at the hospital.”

But he also had to worry about payer contracting, hospital privileges, real estate, malpractice insurance, staff turnover and all of the minutia of running a business. Eventually, he says, he realized the advantages of joining a larger entity.

“We decided we were tired of fighting with payers and hospitals for privileges,” he says. “I now enjoy working in a model where the business isn’t what we worry about. It’s the patients. Everything else is provided and taken care of.”

Indeed, 30 years ago primary care was a very different situation, according to Tom Beauregard from UHG.

“It was a highly fragmented cottage industry,” he says. “Consumers still looked at the PCPs as the quarterback. Care was delivered in a small office.”

Beauregard says the world of health care has changed dramatically. The world works at a faster pace, people are distracted. Chronic conditions are more prevalent and more complex to manage. More specialists are needed.

“People are more connected with technology, but less connected in terms of their primary care relationship,” he says. “PCPs fell out of that quarterback role.”

So how does on-demand medicine intersect with taking care of patients? Cleveland Clinic is perhaps one of the best examples of how that intersection is going to take shape around the country: large organizations, lots of technology, lots of partnership and lots of teamwork.

Cleveland Clinic surrounds primary care with three elements of on-demand medicine: a retail clinic partnership with MinuteClinic, a walk-in model staffed by advanced practice providers (APPs) called Express Care, and a telehealth model built upon the American Well platform.

Originally signed in February 2009, the MinuteClinic-Cleveland Clinic partnership is now entering a new phase. Under the original agreement, the two organizations agreed to integrate medical records and have Cleveland Clinic physicians act as collaborators with MinuteClinic’s APPs. As part of the new phase, CVS Health has joined Cleveland Clinic's Quality Alliance, one of the largest clinically integrated networks of providers collaborating on quality measures that focus on chronic disease management. The two organizations will share standard protocols and quality metrics and review population health data through integrated, secured systems.

"This will allow us to oversee patient care more seamlessly than we do today," said Dr. Rabovsky. "As part of our Quality Alliance, CVS Health joins our clinically integrated network, which means we can share treatment guidelines and protocols and puts the patient at the center of a larger system of care when they need it."

Cleveland Clinic also operates Express Care clinics at most of their family health centers in Northeast Ohio. These clinics have access to a full lab and imaging suite and are backed up by family practice and internal medicine physicians.

“People come in with an acute episode,” he says. “But the idea is to capture those who need a primary care doctor. We have or are developing walk-in access at all of our practices. At one practice, a family practice physician partners with an APP, and each day they switch from all walk-in to all appointment. Every day patients can walk in without an appointment and know they’ll see one of those two providers.”

On the telehealth front, things are still evolving. Cleveland Clinic has a partnership with American Well, initially focused on acute episodic illnesses. The organization now is also scheduling PCP visits for acute and chronic conditions and developing remote monitoring programs for hypertension, and diabetes.

Like Cleveland Clinic, Optum is no stranger to primary care and on-demand medicine. At UnitedHealth Group, there are two primary divisions: Optum and UnitedHealth Care (UHC). UHC is the health benefits business while Optum is the technology-enabled health services business. Optum provides a broad range of services to health systems, employers, government and non-profits. In recent years, Optum has acquired medical practices, including primary care and multispecialty groups. Some of the primary care and multispecialty groups under the Optum umbrella operate retail clinics. And two years ago Optum acquired MedExpress, the largest pure-play urgent care operator in the United States. Optum has also been involved in telehealth, including an early partnership with Rite Aid that put telehealth kiosks inside retail stores.

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We’re talking about building care models on connected devices and using artificial intelligence, with a PCP at the center of it. Payment reform is critical if we are going to deliver results on a large scale.
— Tom Beauregard

The Cleveland Clinic partnership with CVS Health has been written about many times over the years. But one retail partnership has been largely under the radar.  MedExpress, the urgent care division of Optum, has begun opening 2,500-square-foot urgent care centers inside Walgreens stores, taking up to a third of the store footprint. These combined MedExpress-Walgreens sites have shown up in Nevada, Nebraska, Minnesota, Virginia and West Virginia.  MedExpress is also an important participant with Optum’s various telehealth initiatives. How these new Walgreens-MedExpress sites intersect with Optum’s primary care and telehealth initiatives remains to be seen.

But Mr. Beauregard says the investments in primary care are all around us, driven largely by a sicker population that needs more attention. He is the first to admit that one of the things that needs attention is how to pay providers and provider organizations under these new models. But he also says there is lots of opportunity to test things when you have both the services arm and the insurance arm under one roof.

“If we are asking a PCP to monitor a person with diabetes' blood sugar levels on a day-to-day basis, we have to move away from a fee-for-service, office-visit mentality,” he says. "We’re talking about building care models on connected devices and using artificial intelligence, with a PCP at the center of it. Payment reform is critical if we are going to deliver results on a large scale.”

Mr. Beauregard sees a world where care will be delivered in the traditional office and in retail centers. Sicker patients will be treated in the home setting through connected care using FDA-approved monitoring devices.

“I see all of this as a major opportunity for primary care providers to come back to the center again,” he says.

Listening to Dr. Rabovsky and Mr. Beauregard, you almost get the impression that practicing medicine could become fun again.  Five years ago Dr. Rabovsky did a presentation at the AMGA conference talking about Cleveland Clinic’s application to become a patient-centered medical home. One slide showed gaps that needed to be overcome on various measures.

“Five years later most of those gaps are now closed,” he says. “During the past year, there’s been a fundamental shift in how we’re practicing at the primary care level. We have care coordinators now. We use Optum to risk-stratify our patients. Doctors have gone from a one-to-one relationship with their patients to a team-based approach that includes APPs, nurses, medical assistants, PharmDs and care coordinators.  We’re seeing payment reform start to show up. We’re using registries to reach out to patients and have those integrated into our daily work. Not everyone is accepting, but it is happening quite rapidly.”

Mr. Beauregard says primary care is making a comeback, largely because it is less fragmented, which means more resources coming together to help deliver care more effectively. He says primary care physicians are better equipped in many ways because they are still a trusted source.

“Primary care physicians and their office staff will play a key role,” he says. “Why would there be such a focus on primary care if it wasn’t strategic? If we can arm clinicians with data, that’s the key to better chronic care management. A lot of chronic patients have multiple conditions. So you want to treat the person, not the disease. At the end of the day with all the information and data, people still need people.”


Implications for Operators

So what does all this mean to an on-demand practice like urgent care, retail clinics or telehealth? Following are several of the initiatives we are presently pursuing with clients:

Think holistically – If you have one takeaway from this article it should be to look at primary care, retail medicine, urgent care, telehealth and occupational medicine holistically rather than as individual silos in your organization. Patients want predictability, but they won’t get it if you manage these service lines without continuity. That is the idea behind the ConvUrgentCare concept. If you are a private urgent care operator, think about how your practice can be a logical extension of a local hospital’s service line. Study those service lines before you start having conversations with the local hospital.

Payer discussions – Despite the ease and promotion of online scheduling, there will always be patients who want care without an appointment. Payers still struggle with how to intersect payment reforms with on-demand services. Health systems tend to bury on-demand services on their list of topics with payers. And private operators tend to go into those discussions lacking not only confidence but a well thought out rationale for saving the plan money and increasing member satisfaction.

Telehealth suites – We are now recommending all new urgent care center developments include a telehealth suite. As we move to a more digital world and connected care, those suites will become the connection point between the on-demand access point and the larger platform for patient continuity.

Scope of services/available market – When developing a new on-demand center or network of centers, deciding what services you offer is more critical than ever. This is where planning for the future squares off with present-day decisions. Remember, scope of services plus geographic reach plus population demographics is the fundamental calculus that informs the top line of your pro forma financials. If you can’t answer the question, “What is the annual available market of visits for my service offering at that new center?” you have made a fundamental mistake in your planning efforts. It is the most common reason planners get their patient volume forecasts wrong.