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By Monica E. Oss

For the past few years, I’ve been thinking more about future models for primary care. It all started at The 2013 OPEN MINDS Technology & Informatics Institute, when Marci Nielsen, Ph.D., then-Chief Executive Officer of Patient Centered Primary Care Collaborative, delivered a keynote presentation, The Evolution Of Patient-Centered Care & The Future Of Integration In Health Care. She spoke about “key elements” of primary care—”assess, prescribe, and refer.” My initial reaction was that those are functions that could be facilitated using augmented intelligence, freeing up physicians to spend more time with consumers.

Roll forward five years and the primary care market is being reinvented before our eyes. There are five factors that I think are changing the role of primary care in the health and human service system. Collectively, these factors are part of the changing value chain of health and human service delivery (see The ‘Melting’ Value Chain and Unlikely Bedfellows).

First, there is the rapid expansion of retail care. There are more retail health locations now than ever—with an estimated 2,800 clinics in the U.S. in 2017. And in 2016, total U.S. retail clinic revenues were estimated at $1.4 billion, marking an increase of 20.3% per year from $518 million in 2010 (see Retail Clinics 2017: The Game-Changer In Healthcare).

There is lots of recent news from the retail health sector. At the very end of 2017, pharmacy operator CVS Health announced plans to acquire and merge with health insurer Aetna in a deal valued at $77 billion (see CVS Health To Buy Aetna For $77 Billion and We’re In The Third Inning). And, just last week it was finally approved (see Aetna-CVS Merger Approved).

This summer, we saw Humana Inc. and Walgreens announce a partnership in the Kansas City, Missouri area to open in-store primary care health clinics at two Walgreens pharmacy locations (see Humana Partners With Walgreens To Provide ‘Senior-Focused’ Primary Care In Missouri). Additionally we’ve seen Walgreens open pilot MedExpress Urgent Care Clinics in 15 stores across the United States (see Walgreens Opens MedExpress Urgent Care Clinics In 15 Stores). And, just last week, Walgreens also announced plans to add 600 new health care locations in their stores (see Walgreens To Expand In-Store Health Services Across 600 Stores). In addition to those dominant chains, Target Corporation and Kaiser Permanente expanded their retail clinic partnership in California (see Target Partners With Kaiser Permanente On 31 Southern California Clinics); and Walmart sign a deal with Anthem to provide more Medicare enrollees over-the-counter medications and health supplies at Walmart locations (see Walmart Wants To Bring Its ‘Everyday Low Prices’ To Health Care).

Second, primary care practices are the focus of some new (and interesting) investors. United is now the second largest employer of primary care physicians through its many recent acquisitions (see UnitedHealth’s Optum Unit Makes Big Push Into Urgent Care In Minnesota, Optum Plans To Acquire Massachusetts Reliant Medical Group, and UnitedHealth Acquiring Four Clinics Through Its Purchase Of Peoples Health). This summer we saw a few big deals close, including the $100 million acquisition of DaVita’s Paladina Health by venture firm New Enterprise Associates (see Venture fund buys DaVita’s primary care business for $100M), and a $350 million investment in primary care provider One Medical by private equity firm The Carlyle Group (see One Medical Raises $350 Million From Carlyle Group). And OptumHealth and an investment consortium led by private equity firm Summit Partners (Summit) recently purchased a controlling interest in Sound Inpatient Physicians Holdings, LLC (Sound) from Fresenius Medical Care for $2.15 billion (see Sound Physicians Sold To An Investment Group Led By Private Equity Firm Summit Partners & Optum).

Third, there has been a new resurgence in “house calls” in health care. New players are making physicians available to consumers in their homes—Heal, an on-demand physician service, is offering home visits in eight markets for a $99 flat fee or insurance copayment (see Heal Offers $99 Physician Home Visits). Additionally, Clover Health has announced a new primary care offering (see Clover Health Launches New In-Home Primary Care Program Supported By Genomic Testing Capabilities). But, there is another angle—delivery of primary care services in the home via telehealth. New studies confirm the cost effectiveness and clinical effectiveness of primary care telehealth for consumers with chronic conditions (such as diabetes, high blood pressure, heart failure, and/or COPD). After one year, consumers showed weight loss, lower blood pressure and improved HbA1c levels, a marker for diabetes (see Telemedicine In Primary Care For Patients With Chronic Conditions: The ValCrònic Quasi-Experimental Study).

Then, we have the changing perceptions of primary care by the younger population. A recent Kaiser Family Foundation (KFF) survey found that 26% of consumers don’t have a regular primary care provider organization, with the upshot being that the younger the consumer, the less likely they were to have a primary care provider (see Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model). Those without regular primary care included 45% of 18 to 29-year olds, 28% of 30 to 49-year olds, 18% of 50 to 64-year olds, and 12% of those consumers aged 65-plus.

Finally, the fifth factor reshaping the primary care market is a new payer preference for “specialty” primary care (and specialty medical homes). Health plans are looking for a best practice model that integrates care coordination with LTSS, medical, pharmacy, behavioral health, and social services—and coordinates/provides primary care. We’re seeing specialty medical homes emerge for everything from cancer to irritable bowel syndrome to intellectual and development disabilities (see I/DD & Managed Care? There Will Be Requirements, Amerigroup Texas & CareMore Health Launch A New Enhanced Primary Care Service For Medicaid Beneficiaries With Chronic Illness and Keystone First & Woods Services Partner For New PCMH That Will Serve As A National Model).

As you think about the future of primary care and your organization, think about the “primary care function” as defined by the American Academy of Family Physicians—”Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses” (see Primary Care). And then think about the functions of primary care—access and continuity, care management, comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health—that are now embraced by a wide range of organizations in a wide range of settings (see Primary Care Functions and Measures). Many of these functions are being provided by specialty provider organizations and new virtual health service systems. Like much of the health and human service field, the concept of “primary care” is being dis-aggregated and reconstituted with a new array of organizations and consumer-centric technology. I’m just not sure what the winning model will be. For more, check out these resources in the OPEN MINDS Industry Library:

  1. 31% Of Youth With Special Health Care Needs In Patient-Centered Medical Home Models
  2. Medicare Beneficiaries Report Fewer Problems Finding New Primary Care Physicians Than Those With Private Insurance
  3. Focus On Models, Not Conditions
  4. Illinois Medicaid Selects Performance Measures For Integrated Health Home Program
  5. Data Brief, No. 311. Mental Health-related Physician Office Visits By Adults Aged 18 & Over: United States, 2012-2014
  6. Primary Care Physician Median Compensation At $257,000 In 2017
  7. The Medicare Comprehensive Primary Care Initiative Reduced Emergency Department Use
  8. Fulcrum Equity Partners Announces Formation Of City Line Behavioral Healthcare & Acquisition Of Life Of Purpose Treatment Centers
  9. GreenShoot Capital Partners With Medical Home Development Group On Multi-State Expansion Investment For Opioid Collaborative
  10. L.A. Care Health Plan Commits Up To $31 Million To Recruit Primary Care Physicians

And for more, join Deb Adler, Senior Associate, OPEN MINDS & Former SVP Network Strategy, UnitedHealth Group/Optum on February 13 at The 2018 OPEN MINDS Performance Management Institute for her session, The OPEN MINDS Health Plan Partnership Summit: A Guide To Developing & Negotiating Partnership Agreements With Health Plans.

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