Everyone agrees primary care is crucial to a functioning healthcare ecosystem and to a healthy society. Being able to deliver preventive care and intervene early saves lives and downstream costs. But it is just not working as well as it should be, according to providers.
A panel* of primary care experts considered the drawbacks of the traditional model and opportunities for the sector during Fierce Healthcare’s partner program (link to video) at HLTH last month.
“Every community deserves, needs, requires a primary care team,” David Hatfield, D.O., chief physician executive at VillageMD, a value-based primary care provider now majority owned by Walgreens, said during the panel discussion.
In the view of one panelist, what enables efficient primary care is pairing it with urgent care. “We think that having those things integrated and working together are critical to the industry,” Kerem Ozkay, CEO of Carbon Health, said. Carbon offers advanced primary care and urgent care in a singular clinic, allowing patients to be redirected to one of the two as needed.
Patients who are healthier and don’t need to see a PCP regularly could get their one-off needs taken care of in urgent care, Ozkay argued. The triage Carbon performs frees up time for PCPs to focus on sicker patients who could benefit from a longitudinal relationship with more frequent touch points. This approach also allows for smaller patient panel sizes than average, with each provider seeing around 500 to 1,000 patients, Ozkay noted.
For Parsley Health, those panel sizes are even smaller, at around 500 or less. The virtual functional medicine clinic focuses on patients with chronic diseases, a population that needs more than one visit a year to stay healthy. For these patients, an episodic, reactive model of care is not enough: A strong relationship with a PCP is crucial. A recent study found the average annual total cost of patients with a PCP was nearly 30% lower than those without one. However, that is not something the traditional healthcare system encourages.
“Unfortunately, we’ve lost a lot of that in healthcare,” Robin Berzin, M.D., Parsley Health founder and CEO, said on the panel. “We’ve set up the psychology of Americans to think that we just go to the doctor like whack-a-mole and address the latest thing.”
To simplify navigating a complex system of disparate PCPs and specialists, Parsley offers a multidisciplinary team that cares for patients holistically and gets to the root cause of diseases. “Being willing to rethink this one-size-fits-all primary care to something that’s a little bit more heterogeneous … is the answer,” Berzin said.
Because of the range of its offerings, from coaching to mental health interventions to diagnostic tests, the average Parsley member engages five times a month. “The surface area of the relationship of a patient with Parsley is much broader, and so we’re able to really be a part of that patient’s life,” Berzin said.
Parsley has been hybrid from its inception. It has brick-and-mortar clinics in New York and Los Angeles, though most members can do the vast majority of their care online, per Berzin. “If you can FaceTime your mom, you should FaceTime your doctor,” she said. “I firmly believe that the future is hybrid.”
Hatfield agreed, saying VillageMD offers both in-person and virtual care pathways: “We’re going to meet the patient where they are.”
Conversely, Marathon Health, a primary care provider serving employers and unions nationally, is trying to solve primarily for in-person access. What it finds is that up to 15% of virtual appointments still require a visit to a facility in person. What’s more, patient preference indicates a desire for in-person interactions: “When patients are given the chance of either door to walk through, they’ll usually click the physical door,” Nirav Vakharia, M.D., Marathon’s chief health officer, said. “That, to me, is very telling; that if you build it, they will not necessarily come.”
In Massachusetts, Carbon Health runs a virtual-first program where primary care clinics were originally intended as a backup to telehealth visits. Similar to Marathon, Carbon has found its in-person clinics to be popular, with patients split 50-50 in their preference.
Carbon has also built its own electronic health record to reduce admin tasks like charting for providers. Because of the consistency and standardization this EHR provides, the company noticed the communication between care managers and providers improved. But, broadly speaking, interoperability has not yet been fully realized, Ozkay noted. “The piece that we are missing as an industry is my data does not go to any of your companies,” Ozkay said to the other panelists.
Like others on the panel, VillageMD is leveraging tech to help its staff. For example, its providers are adopting AI “at a fever pitch,” per Hatfield. They have an AI scribe that transcribes visits, allowing them to focus on the patient. Eye contact and good listening skills are crucial to a positive patient experience, per Hatfield: “People don’t care how much you know until they know how much you care.”
Hatfield stressed that high-quality primary care is incompatible with a fee-for-service system. “The most profitable patient that you see in the day is the last patient you saw that day,” he said. Value-based care aligns incentives to focus on driving better outcomes and reduced expenses, he argued.
But not every panelist was convinced of the alternative payment model’s efficacy. “It may work one day. It hasn’t worked yet,” Ozkay said. “If it was, everybody would be doing it.”
Hatfield admitted that reimbursement remains a pain point, particularly in the payer-agnostic VillageMD model. Unlike some value-based care companies that only focus on one kind of population, the company does “cradle-to-grave” care for all patients, no matter their health plan. “The challenge is ginormous,” Hatfield said. The company takes advantage of models like ACO REACH that pay for outcomes.
But while VillageMD has already seen success, Hatfield noted, it has evidently not done so quickly enough to satisfy majority stakeholder Walgreens. The retailer is considering selling its stake in the primary care provider, as Fierce Healthcare previously reported.
“We’re doing those things: We see the outcomes changing, we see the cost curve bending,” Hatfield said. “Walgreens just didn’t want to give us enough time.”
In the fee-for-service world, Ozkay sees partnering with CVS Health as a powerful way to scale. Carbon is piloting its primary and urgent care model with several stores. The retailer has more than 9,000 pharmacy locations, making it a logical access point for millions of Americans. “If we can bring in a care model that helps bifurcate both what the urgent care needs are from the primary care needs, and then find them a home downstream to a place like Oak Street … CVS becomes a very valuable partner to do that with,” Ozkay said.
Berzin stressed the importance of addressing wellness factors such as eating, sleeping and stress—all of particular interest to patients. “In medicine, often, we’re originally taught that those things are fluffy and they don’t really matter to your health outcomes, or they matter like 20 years from now. The fact is that those things matter right now,” Berzin said. Because health literacy around things like food is medicine is low even within the medical community, she added, Parsley has developed its own evidence-based training and protocols.
“You can change the technology, you can change the payment structure, but if you don’t change the actual medicine, you will not change the outcome,” Berzin concluded.
The traditional primary care model is not conducive to this type of wellness coaching “or anything we know our patients want and need,” Vakharia of Marathon acknowledged. “There’s a hunger there, and it’s probably the moral distress that primary care providers go home with at night … If we give people that opportunity, I think there’s a lot of people on the sidelines who want to start doing more of that.”