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Health news Massive changes are taking place in the primary care market. It’s worth looking into.

David Nash MD, MBA, FACP Contributing Writer, MedPage Today

Although they are often overlooked by more important news items, major changes have been made in how, by whom, and where primary is delivered in America.

The decline of traditional primary care physicians (PCPs) has been gradual for decades. However, the extraordinary revenue losses and challenges faced by these practices during the pandemic only increased the problem. This is a time when we most need access to high-quality primary care services. Even if they were to increase in number, many traditional office-based primary care offices are not equipped to provide optimal medical management to this patient population.

What has changed in primary care? How does it compare to today? Let me introduce you to some of the leading “disruptors”.

Integrated Primary Care Delivery

Since the outbreak of the pandemic, integrated primary care delivery models have been increasing in popularity across the country. Many of these models include chronic care management at home. Theoretically, home based primary care (HBPC), allows patient-centric, continuous care (primary and urgent), and reduces stress for patients. It also helps to avoid unnecessary hospital admissions and emergency room visits. The most successful models adapt care to meet the needs of specific populations. The goal is to reduce the cost of care without sacrificing quality. Take, for example:

  • Landmark Health has seen a 33% rise in demand for its 24/7 home-based care management for patients suffering from multiple chronic conditions. The organization offers a range of services, including medical and behavioral health care, palliative and social services. It partners with health plans. Mobile providers can conduct “house calls” in-person and/or telemedicine visits (video, phone).
  • Iora Health’s clinic-based and interdisciplinary team model provides medical care for a wide range of patients with complex conditions. Amazon now owns Iora Health. Iora works with employers, unions and health plans. Iora assumes all financial risk and benefits only from clinical quality improvement and cost control. Non-physician health coaches and physicians can connect with patients to address unhealthy behaviors and manage chronic conditions. They can also advocate for their rights if necessary.
  • Care Management Plus (Intermountain Healthcare), a clinic-based coaching model, embeds a “care manager”, in the PCP office, to improve care for patients with complex medical needs. Care managers are supported by information technology tools and can develop care plans and provide self care guidance for patients and caregivers.
  • Independence at Home is a test program by the Center for Medicare & Medicaid Innovation. This allows HBPC practices to conduct in-home visits with interdisciplinary teams of physicians and nurses. The Centers for Medicare & Medicaid Services will pay incentive payments to practices that meet financial targets and meet quality standards. The program’s first five years saw savings of $100 million in a small number of HBPCs serving a total of 10,000 Medicare beneficiaries each year.

For seniors and Medicare Advantage, integrated, holistic approaches to managing healthcare are especially useful. The prospects for growth in this area are good, and payers have indicated willingness to support PCP care management of these patients.

The Healthcare Sector is dominated by ‘Big Retail’

Another significant change is taking place within the nation’s largest employers and businesses – i.e. Walmart, CVS and Amazon. Recent high-profile acquisitions and partnerships have extended the reach of these retail giants to primary care delivery by increasing patient accessibility at their retail locations and clinics.

Walmart Health recently partnered with Oak Street Health (a value-based primary care service provider for adults — particularly Medicare Advantage participants — in medically-underserved communities) and acquired the multispecialty telehealth provider MeMD. The latter, now called Walmart Health Virtual Care (the latter offers primary, urgent, and behavioral healthcare services through contracts with employers and commercial payers).

Walmart’s partnership with UnitedHealth for a 10-year period allows for collaboration on value-based care strategies. Walmart Health clinicians also benefit from Optum, UnitedHealth’s clinical data subsidiary. Walmart may be able to enjoy broad clinical benefits without having to purchase a pharmacy benefit manager (PBM) or payer.

CVS’s entry into primary care is well-established. Since the early 2000s, CVS has offered walk-in medical services at its retail pharmacies. MinuteClinics at CVS offer routine physicals, screenings and immunizations. They also provide treatment for minor injuries and illnesses. In 2018, the organization acquired Aetna, a major health plan. Its CVS Caremark is one among three large PBMs that collectively control over 80% of the prescription drugs market.

CVS Health Virtual Primary Care was launched by the organization in May 2022. This comprehensive, physician-led primary-care service allows patients to combine the virtual service with in person visits to providers (including MinuteClinics). Patients can also use a virtual care app to facilitate electronic health record interoperability, care coordination among providers. It is easy to see the organization’s next steps, including full-service primary care, chronic disease management, and laboratory services.

In 2019, Amazon began offering hybrid (in-person, and virtual) primary healthcare to its employees. In July 2022, Amazon purchased One Medical, a well-known brand in concierge primary care. It also acquired a network of over 200 brick-and mortar locations and (crucially), One Medical’s payer contracts. Iora Health, the senior/Medicare Advantage primary healthcare provider, was also included in the purchase.

Is Amazon interested in providing value-based care to One Medical’s commercially insured customers? What are Amazon’s intentions regarding Iora Health Only time will tell.

Is this the right path for primary care’s future, or am I wrong? These alternative approaches have a long-term impact on the healthcare system, and on consumers as well. It remains to be seen how they will affect us as consumers.

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    David Nash is the founding dean emeritus at the Jefferson College of Population Health and the Dr. Raymond C. Grandon Professor of Health Policy. Follow

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