Primary care in transition: Convenience versus commitment

Oct. 22, 2018 / By Steve Delaronde

Loyalty to one’s doctor and following medical advice was rarely questioned in the 20th century.  When managed care reached its zenith in the 1990s, having an assigned primary care physician (PCP) did not seem out of the ordinary, nor was it questioned by HMO members. A lot has changed in the last 20 years. Chronic condition management, care coordination, and value-based care have made the role of a clinical coordinator more valuable. This shift has occurred while Americans have been prioritizing convenience over commitment when it comes to health care.

Convenience and commitment have not shared the same space since the days of the house call. House calls comprised 40 percent of all U.S. doctors’ visits in the 1940s, but now account for only 1 percent of patient encounters. This shift has benefited the provider, but not the patient. Medical care in the United States has an opportunity cost that amounts to $43 per visit or $52 billion annually according to a 2015 AJMC article. The average total time for a medical visit was 121 minutes, but only 20 minutes of face-to-face time with the physician. The remainder was travel time (37 minutes) and time at the clinic not face-to-face with the doctor (64 minutes).

There are increasingly more options available to patients that make more efficient use of their time. These include urgent care centers, retail clinics, work site and school-based care, and telemedicine. While the convenience of non-traditional and low-commitment approaches to medical care have often been associated with a younger generation of Americans, convenience has broad appeal across all age and demographic groups. Retail clinics have experienced a 445 percent growth rate from 2006 to 2014 and private insurance claim lines for urgent care centers increased by 1,725 percent from 2007 to 2016.

These trends not only represent a shift towards convenient care, but also a move away from primary care. Primary care models have not kept pace with American expectations of convenience and “delivered-to-your-doorstep” service.  While this may not be a serious threat to the well-being of younger or healthy populations, it is a concern among those with chronic conditions and serious mental health issues.

Alternative approaches to health care address the issues of cost and convenience. However, they are not designed to promote the coordination and continuity of care that are critical for managing the nearly 60 percent of American adults with at least one chronic condition that account for 90 percent of healthcare spending. The fragmentation resulting from medical encounters that occur across providers and locations can result in missed services such as screenings and immunizations, duplicative or unnecessary care such as imaging and diagnostics, or missed opportunities for education and lifestyle coaching that are based on a provider’s knowledge and understanding of the patient.

As Americans continue to value choice, flexibility, convenience and cost savings offered outside of the traditional patient-doctor relationship, primary care must respond. The first step is to make primary care relevant to the patient’s needs. This does not just include monitoring blood pressure and cholesterol levels but addresses other areas that are critical to well-being such as mental health, nutrition, and pain management. Additionally, primary care does not need to be physician-centric to be effective. There are other healthcare professionals and other methods that can effectively be used to engage the patient, including community health workers, diabetes educators, nutritionists interacting through non-office-based settings that include telephone, email, texting or social media.

Most importantly, primary care must change now. Americans are increasingly becoming responsible for their healthcare costs, especially as high deductible health plan enrollment increases. Americans will also continue to have more options for where and how they receive health care, which will continue to expand beyond immunizations and acute care into areas of mental health and chronic conditions. Coordination and continuity of care must keep pace with cost and convenience for the healthcare system to continue to serve those patients that need it most.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.