April 5, 2019

Primary Care 2.0

Commentary
Hanna Phelan
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Primary care services internationally are undergoing change. These frontline services are the cornerstone of healthcare systems worldwide, predominantly the first port of call for a consumer seeking healthcare, and therefore demand significant reform and optimization in order to stay afloat and optimally serve populations. In the US alone it is forecast that 52,000 more primary care doctors will be required by 2025 in order to serve aging populations and address general population growth. In India, workforce shortages are even more substantial - over 8% of 25,300 primary health centers in the country are lacking a primary care doctor, in addition to 22% who have no pharmacist. These are just two regions of the globe, but this storyline is replicated widespread.


When primary care functions as it should it is a shining beacon for connecting populations with essential services and recommendations, but when it doesn’t the very foundation of our health systems are at risk. Some of the key challenges facing primary care systems today include:

  1. The limited bandwidth of primary care physicians (PCPs) to focus on patient experience and patient outcomes
  2. Recruitment and retention of PCPs
  3. Managing patient demand and costs
  4. Long wait times and limited accessibility out of hours

In this week’s blog, we examine some of the new trends in Primary Care, and aspects of Primary Care as we know it that may stand to benefit from digital interventions - workload and demand management, smart diagnostics and triage; and self-management and improved access.

Next Gen Primary Care Clinics

Many primary care disruptors are emerging who engage with employers and insurers, and health systems to provide their own practices enabled by a suite of technology solutions and an awareness of holistic care needs. Iora Health for example, who raised $100M Series E in 2018, serves Medicare patients over 65 years of age with a high impact, relationship-based care model (a team of a doctor, nurse and a health coach works with each patient, enabling them to become active participants in their own well-being) that includes designated clinics, health coaches and telemedicine offerings. Parsley Health charges a subscription fee of $150-a-month to get 1.5 hour consults with your PCP, access to lab diagnostics, and a full understanding of your care plan (that is co-designed with you). Another US-based disruptor of this breed is One Medical, who offers practices and telemed services with the aim of making appointment booking and consultations as convenient as possible and,like Iora, stress their contrast to many public primary care dynamics where patients face long wait times and rushed consultations.

Many of these emerging organizations recognizing the primary care shortfalls, and essentially trying to build their own, work closely with employers and have started to attract sizeable investments. Eden Health who recently closed a $100M Series A Round is gearing up for a nationwide rollout of their primary care and insurance navigation platform.

While these solutions and new disruptive practices are showing early potential, do we run the risk of creating more accessible care only for those who are lucky enough to be covered by their employers further fragmenting the healthcare access and provision?

Cityblock for one realizes that the digital revolution in primary care needs to reach the masses delivering primary care, behavioral health care, and social services with a strong recognition of the social determinants of health. Their approach to care  includes those who access Medicaid, are dually eligible for Medicaid and Medicare, and others living in underserved neighborhoods. City Block’s Community Health Practitioners partner with members and their families to create and manage a plan uniquely tailored to each individual’s needs.

At the crux of these models is this: Effective care starts with understanding and addressing social challenges; Patients need to be involved in the process of designing their treatment plan; Healthcare needs to be hyper local.

Pharmacy for Primary Care

Pharmacists have the expertise to help patients at the point of care, in disease management and medication management. We should really be looking at them as Primary Care Providers, and therefore, Pharmacy as a potential Primary Care Center. From a logistics perspective as well, it only makes sense - 67,000 pharmacies in the United States, and almost half (33,000) are located within drug stores, grocery stores, hospitals, department stores, medical clinics, surgery clinics, universities, nursing homes, etc. From 2010- 2016, 223,630 pharmacists were employed in the United States.  Accessibility wins. This, in addition to the 209,000 practicing primary care physicians in the U.S. (in 2010, according to research commissioned by the Agency for Healthcare Research and Quality) could significantly improve accessibility and the delivery of primary care.

A Harvard Business Review article from earlier this year highlights how CareMore Health, a division of Anthem that serves Medicare and Medicaid beneficiaries, launched a program designed to leverage the clinical expertise of pharmacists to identify the root causes of non-adherence and hyper-personalize solutions to better support the patients they serve.

They started the pilot program by identifying about 250 non-adherent patients and then dividing them into two groups: an “intervention” group and a “control” group. These were patients who typically have multiple chronic diseases and many prescriptions — who were not taking them because they either didn’t fill their prescriptions or irregularly refilled them. Pharmacists were told to use “any reasonable means” to support patients in the intervention group in improving their adherence. The pharmacists conducted educational meetings with patients — both in person and over the phone — to understand why they weren’t taking their medications as prescribed and designed personalized care plans to improve adherence. The experiment improved medication adherence among the patients in the intervention group by 46% compared to people in the control group, who received usual care from their doctors and nurses but no special interventions from pharmacists, demonstrating the instrumental role pharmacists might have in care management in the future.

Walgreens and CVS Ahoy!

Retail drugstore giants are establishing competitive strategies by working with healthcare companies to bring new, innovative services to their patients and customers. So, think about these initiatives as the above two buckets combined.

Walgreens FindCare Now: Last year, Walgreens release Find Care Now, a digital platform and marketplace that helps connect the company’s millions of mobile and online visitors to health care services at Walgreens stores and to a growing selection of recognized providers in the community, offering services such as neighborhood health care clinics, urgent care, telehealth, lab testing, physician second opinions, and even physician house calls and optical and hearing services in select markets.

Walgreens - Propeller Health: Earlier this year, Walgreens announced that the ‘My Pharmacy’ section of Propeller Health’s app will link COPD patients to Walgreens pharmacists. My Pharmacy will enable patients to refill prescriptions, find the closest Walgreens, speak with a pharmacist through Walgreens Pharmacy Chat, and get updates on Walgreens Balance Rewards points.

CVS HealthHub: As part of CVS' $70 billion acquisition of health insurer Aetna, they have renovated their pharmacies to include CVS' HealthHUBs, which offer more health services at their MinuteClinics and more health-focused products. Within these HealthHubs are on-demand health kiosks where consumers can measure and track their blood pressure, weight and BMI. There is also availability of a Care Concierge, a professional responsible for customer engagement. The hubs also have Wellness Rooms for CVS professionals and community partners to host group events, including health classes, nutritional seminars and benefits education. There are Learning Tables that include iPads for customers to explore health and wellness apps.

Tech Enhanced Primary Care Clinics

a). Primary Care Workload and Demand Management.

Leveraging tech solutions can help to forecast demand on primary care services and to better equip primary care practices to perform optimally. Workflow management tools such as Canvas Medical are allowing PCPs to optimize their workflow management with visit notes, prescription information and appointment schedules brought together in one electronic epicenter with added clinical quality and revenue cycle reports that aim to help practices understand their performance. With many primary care practices still operating with a paper-based system, centralized electronic records could make a substantial difference, particularly if integrated with an appointment reminder to prevent drop-offs.

In our recently released Q1 report on virtual health assistants, we discuss the potential role these solutions may have in tackling the growing challenge of administrative burden on HCPs.


Image Source: http://notablehealth.com/product.html



b).Testing and Diagnosis

Primary care services are largely dependent on acute care counterparts for diagnostic testing in many cases which can add substantial waiting times in addition to cumbersome administrative tasks for primary care practices to stay on top of.

Solutions emerging that provide quick and effective diagnostic testing within the primary care remit may serve to alleviate some of this burden in the future in addition to smarter triaging of patients who may be better off foregoing a visit to a primary care practice altogether.

Portable ultrasounds such as the Butterfly Network, and smart stethoscopes such as the Eko offering are championing digitisation of tools that have long been doing the rounds on the primary care circuit with the benefit of added flexibility in terms of where care is delivered in addition to added diagnostic insight. But is this just the tip of the iceberg? With the rapid development of AI clinical decision support tools and rapid blood based diagnostics such as Athelas and Sight Olo it is possible that we will be seeing reduced referrals for basic diagnostic tests in primary care clinics sooner rather than later.

While improved diagnostic support tools to aid PCPs are promising there is the question is whether their scale in primary care will actually serve to offset burden. This will have to be closely evaluated at a systems level to make sure we are really moving forward and not just redistributing existing burden or creating new issues for providers and patients.


Image Source: https://www.sightdx.com/


Telehealth is one of the most natural offerings when it comes to the optimization and support of primary care practices allowing for patients to gain a consultation on demand from the comfort of their own home with a qualified clinician, access prescription scripts or a referral where necessary. There still remains some way to go before solutions such as Doctolib, American Well and KRY have a clear view of where they stand in terms of regulation with many geographies undergoing reviews and reforms for the provision of virtual care. However, despite the intricacies of telehealth solutions still being ironed out, those offering remote consultations and appointment booking services have seen significant uptake in the past few years with the market estimated to reach $19.5 billion by 2025.

Primary Care 2.0

Redistribution of specialization in primary care and the broader question of human resources for health must also be addressed when examining the interplay of digital health solutions and the primary care need. This is something that clearly requires intervention far beyond digital solutions. As in the vast majority of healthcare challenges, the human resource for health distribution requires systems change from incentivizing new medical students to specialize in primary care.

Primary care is the healthcare provided in the community for people making an initial approach to a medical practitioner or clinic for advice or treatment. And we must empower the community aspects of it and not just seek tech enablement.


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