The Accelerating Trend Toward Big-Box Primary Care


 

Amazon just announced that it will be expanding its Amazon Care program across the U.S. this summer. Originally only available to its employees, Amazon will now offer Amazon Care to other companies. The Amazon Care model uses a dedicated app to provide direct live chats between patients and either a doctor or a nurse. In-person care is handled by house calls from medical professionals who are licensed in the appropriate disciplines. Any prescriptions ordered for the patient would be delivered by Amazon to the patient's home.

Amazon joins the likes of CVS, Walgreens and Walmart in leading the charge toward corporatized primary care. Apple and Google have also signaled their intentions to be players in the primary care space. These corporatized primary care ventures promise to deliver value and convenience to patients due their integrated structures, but at what cost? Although companies like Amazon, CVS and Walgreens enjoy enormous purchasing power that can drive down costs, they also have enormous corporate overhead. These corporate primary care ventures are in their infancy, and how successful they will be is yet to be determined, but many commenters are skeptical of whether these integrated models of care can actually reduce costs or improve health outcomes.

As Marni Jameson Carey, Executive Director of the Association of Independent Doctors, observes, "Regardless of what the merging parties say about streamlining care and greater efficiencies, when health care entities merge, costs only go one way: up, way up. Ask those trying to convince you of the benefits to point to one study that shows costs go down after a merger, or that quality goes up. They can't."

Corporatized primary care ventures are also soaking up large numbers of primary care practitioners who, as we know, are in very short supply. These ventures can provide certain attractive features to providers, such as better control of lifestyle and personal time off. On the other hand, employment contracts with such large entities tend to be standardized and prescriptive, often leaving practitioners feeling as though they have little opportunity or incentive to employ creativity in how they do their jobs. This can lead to a reduced sense of loyalty and connection between providers and employers and a greater tendency for providers to switch jobs.

Perhaps the greatest question mark in this emerging era of corporatized primary care is how these models will affect the physician-patient relationship. With our country's aging population, more patients present with complex medical histories and multiple chronic conditions. A model of care that fails to emphasize the primary care provider's role in coordinating the patient's overall health care would seem to be ill-suited to provide optimal health outcomes to these complex patients. Some have called this type of care "assembly line" or "band-aid" medicine because it relies heavily on pharmaceuticals to put out fires and deemphasizes disease prevention and lifestyle counseling.

So, how can smaller or independent medical practices compete with the big-box primary care providers? First, smaller or independent primary care practices can focus on knowing their patients and maintaining the sanctity of the physician-patient relationship. There is still value in patients having confidence that their physicians have a solid understanding of their overall condition, their medical history and their social history, all of which goes much deeper than the patient's presenting complaint. Second, despite the financial pressures on physician practices, practices can strive to create compensation systems and personnel policies that balance the need for productivity with lifestyle factors. This can reduce burnout and turnover, both of which can impose tremendous costs on the practice.

Over the longer term, physicians can support legislative and regulatory reforms that focus on patients as the most important stakeholders in the delivery of health care. One helpful initiative would be to allow patients additional flexibility in their health savings accounts to pay for alternative models of care, such as direct primary care, periodic fee, and membership subscription services, which would encourage patients to choose providers who emphasize individualized care. Physician practices can also support initiatives to reduce paperwork requirements that are put in place simply for the purpose of data gathering by Medicare and private insurers. Streamlining prior authorization requirements is another worthwhile initiative.

The trend toward corporatization of primary care seems to only be increasing. By focusing on the physician-patient relationship and physician retention, along with supporting legislative and regulatory initiatives favorable to patients in small practices, physician practices can position themselves to compete with the big boxes in this new era.

James F. Henry practices in the Phelps Dunbar healthcare industry group.

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