Primary care is at the vortex of massive change driven by cost-control pressures and reimbursement transformation. Accountable care and value-based care require patients to have primary care clinicians, who are held accountable for managing and documenting high-quality care, reducing medical expenses, and ensuring outstanding patient experiences. However, the technical and practice-related systems that are required to provide comprehensive and proactive care reliably, effectively, and efficiently are not commonplace. Without streamlined systems, most primary care providers are drowning in the “mechanics” of primary care that are required to meet patient care and value expectations, resulting in the development of a slew of unstandardized and inefficient workflows. These collective inefficiencies require providers to spend increasingly more time on administrative tasks rather than on actual care, thus further eroding value for patients.
The Four Core Elements of Primary Care Defined
To break this negative feedback loop, primary care practices must find a way to rapidly evolve their systems of care without sacrificing the collective synergy of the four key elements of the primary care value proposition, defined by Barbara Starfield as (1) first contact, (2) comprehensive, (3) coordinated, and (4) continuous.
First-contact care highlights the value of easy patient accessibility for a new problem or concern. Continuous care highlights the value of longitudinal, person-focused relationships in navigating the uncertainties of health and health care. Comprehensive care underscores the value of being able to recognize and manage a broad array of concerns. In the context of population health management, comprehensive care must include early patient identification of risky conditions (e.g., hypertension, hyperglycemia, addictive behaviors), patient engagement to address these risk factors, and/or specific proactive measures (e.g., exercise, weight loss, wellness training) to prevent the development of a chronic disease. These conditions and risks could be identified by leveraging data analytics. Coordination of care highlights the value of (1) helping patients to safely navigate a complex, fragmented delivery system and (2) grounding specialty care with a whole-person perspective. This collective value proposition has endured and served as the foundation of the Joint Principles of the Patient Centered Medical Home.
The Four Core Elements of Primary Care Disrupted
Today, as patients and consumers experience a steady decline in primary care value, discontent has opened the door to new entrants looking to exploit innovation opportunities to address gaps in value. These disruptors include telemedicine providers and urgent care centers seeking to create access value, medical apps designed to empower patients to self-manage routine chronic conditions, mobile paramedical programs designed to meet home-based acute-care needs, and many other initiatives that are still in development. Nearly every large technology company is actively exploring ways to gain entry into the health care space, including Verily (a Google company), IBM Watson, Amazon, Apple, Fitbit, and Facebook.
These disruptors from outside health care are seeking to identify and attack inefficiencies and thereby simplify the complexity and dysfunction that we have come to accept. Their goal is to eliminate non-value-added tasks, reduce system fragmentation, automate workflows, and improve process reliability across every link of the primary care value chain. All these innovators presume a steady march toward value-based care models.
Disruptors occasionally have been characterized as threats to primary care. Rather than assume the risk of managing all four of Starfield’s elements, they seek to optimize one or two. However, we propose that primary care providers who are able to thoughtfully combine all four of Starfield’s elements with disruptive innovations into an integrated system of care will offer greater value than the summative value that is achieved through standalone services provided by disruptors. If we take a step back with focused commitment to the core value proposition of primary care, then embracing these disruptive innovations actually may help to accelerate the successful evolution of primary care and better meet the needs of our patients.
Creating Value Through Disruption
Storefronts Replacing Doctor’s Offices
New disruptors are purposefully deconstructing the four elements of primary care and are breaking existing paradigms for how each part can be more reliably, efficiently, and effectively created. For example, at the May 4, 2018 regional meeting of ACHE of Massachusetts (an independent chapter of the American College of Healthcare Executives), Dr. Troy Brennan reported that he believes that CVS pharmacies can ultimately provide 80% of the care now provided by primary care clinicians. CVS has 10,000 retail stores across the United States, employs thousands of pharmacists, and has a distributed delivery system of urgent care (MinuteClinics), telehealth, and home care infusion (Coram) services at its disposal. One could envision that a percentage of the high-volume daily tasks that are currently completed by traditional primary care systems (e.g., prior authorizations or routine chronic medication refills) could be facilitated through CVS. Transformation could be accelerated if CVS were to invest its considerable resources to tackle other low-risk, high-volume inefficiencies rampant across traditional primary care medical homes, uncovering new capacity to create value for patients.
Telemedicine and retail clinic disruptors seek better ways to create first-contact care value. For example, American Well and Carewell Urgent Care seek to optimize access for a limited set of straightforward conditions (e.g., sore throats, colds), are unencumbered by the need to ensure continuous or comprehensive care value, and meet consumer-driven desires for immediate access at a lower cost. Population health management disruptors such as Optum Labs are working to augment primary care value by introducing novel asynchronous team-based workflows using artificial intelligence–augmented decision-making to organize reams of data. Done well, these innovations could enable comprehensive care and could improve proactive care coordination in today’s fragmented delivery system.
Automation technologies can remove high-volume, low-skill tasks (preauthorization forms, simple electronic medical record [EMR] documentation, etc.) from the workflow, enabling primary care clinicians to focus on higher-value activities, thereby improving efficiencies, reducing work burden, and improving care reliability and outcomes. Given the current level of dysfunction and stress, any and all efforts to enhance primary care workflow and value are likely to be embraced by frustrated providers, even at the risk of optimizing one type of value at the expense of another.
Opportunities for Collaborative Investment
Despite longstanding evidence that effective primary care leads to better clinical outcomes and lower health care costs, the limited deployment of global budgets (and capitation reimbursement) has only stimulated pockets of redesign across the country. Existing primary care providers are constrained by a lack of available funds that would allow for rapid transformation. Effective and meaningful redesign of frontline workflows requires the support of expensive and limited IT resources to adapt EMR systems, integrate third-party tools, and so on. Even with the rapid proliferation of consulting firms such as Evolent and Navigant to assist with primary care transformation, there is a lack of clinical, technical, and financial expertise to successfully transform from a fee-for-service world to a value-based delivery world.
The sluggish changes in traditional primary care models is disheartening, contributing to clinician burnout and care that increasingly falls short of patient expectations. With a shared collective vision that prioritizes patient value, the growing legion of external disruptors are poised to offer meaningful help and hold the potential to return the luster to primary care, once again making it a specialty in high demand.
It is a near certainty that the practice of primary care will change. Trends in consumerism and technology suggest that patients will find their own solutions if we don’t. The trick is to channel the growing energy, capital, and enthusiasm in innovation to enhance the core value proposition of primary care. The speed with which we realize these changes will be a function of how rapidly we commit resources: people, technology, political will, and capital. Whether primary care clinicians will survive as independent practitioners is an important question but distracts from the critical importance of reengineering, enabling, and radically improving practice for both clinicians and patients.
While traditionalists may abhor the potential for these innovations to disrupt the face-to-face visit and the sacred patient-clinician trusted relationship, the integration of modern connectivity innovations to augment our system of care could enable and enhance the development of longitudinal trusted relationships in an increasingly mobile, fast-paced 21st-century society. Many of these innovations will make care more accessible, more reliable, more evidence-based, more cost effective, and more transparent.
Disruptive innovations have the potential to rapidly provide new snippets of value for patients and communities. However, the true potential will be fully realized only when they are systematically repatriated and integrated back into the primary care medical home and into an organized system of care. The collective augmentation of the four synergistic elements of the primary care value proposition holds the potential for exponential improvement in the value of primary care services. It will be an uphill battle that will be hard to resist.