Editor’s note: For more on ways that the traditional primary care model could be rethought, see the Health Affairs May 2010 thematic issue “Reinventing Primary Care.”
Although primary care is regarded as the backbone of the healthcare system, there are serious concerns that we will not have enough primary care physicians to meet the needs of the population, particularly given the upcoming expansion of insurance coverage made possible by health care reform. The response to this shortage has been to do all we can to increase the supply of primary care physicians. But there are deep changes underway in technology and society that point to a radically different notion of primary care, one which requires not more primary care physicians, but a fundamentally new approach to providing primary care.
Currently, patients see their primary care doctors about three times a year. Typically, these appointments last 20 minutes at most. If you generously assume an equal amount of consultation time by phone, patients interact with their doctors for two hours a year on average, leaving 8,758 hours on their own. In other words, virtually all decisions patients make about their health take place without their primary care physician. In reality, only patients and their loved ones – not doctors or nurses or anyone else – can manage their health. The job of the primary care physician, then, should be to create and manage a system of care that will provide their patients with the tools to do just that.
Such an approach would align primary care with other major social trends: more and more people resisting having decisions made for them, preferring and demanding to take control of their own health. These trends have been hastened by the availability of new technologies, especially the Internet, which is quickly democratizing access to information.
A recent survey of low-income Californians, commissioned by the Blue Shield of California Foundation, found that an overwhelming majority of patients preferred to see a doctor than any other kind of care provider. But when researchers probed deeper, they found that many patients were open to receiving care from a team of healthcare professionals, and through non-traditional means like text messages, email, and other online tools. In fact, the patients who were the happiest, most loyal, and most proactive about their own health were those who had an ongoing relationship, not with a single doctor, but with a regular care team.
Lessons From Iora Health
Several years ago, I started a company called Iora Health to build new practices from scratch, based on the team model of primary care, with the patient very much a part of that team. Each practice is paid a fixed amount per patient, rather than for each service performed, which enables more flexibility and incentive to manage patients’ health differently.
Under this model, each patient works with their doctor and a personal health coach to come up with a shared care plan, and then receives education and support in person, by email, video, and in groups. Doctors spend more of their individual time managing the teams and tending to the sickest patients. The teams bring in specialists as consultants on an as-needed basis. We also designed an IT system from scratch to streamline coordination across teams and better engage our patients in their own care.
Iora has taught us is that many – if not most – visits to primary care physicians can be: eliminated altogether through guided self-service supported by decision-making tools; dealt with in a different setting, such as in a group; or taken over by another member of the care team. Under this approach, we estimate that each physician could potentially double the number of patients she manages effectively. Even if we use much more conservative numbers, the projected shortage of 30,000 primary care physicians would rapidly turn into a surplus.
Bringing The New Model To Scale: Revamping Medical Education And Power Allocations
Of course, to make this model work on a much larger scale, we need very differently-trained physicians than those we have today. While some degree of science training is critical to understand the body and its illnesses, so is a background in engineering, systems design, statistics, economics, informatics, psychology, management, and leadership – all of which are either missing or covered in cursory fashion in the current medical curriculum. In addition, the teamwork involved in this potentially transformative practice calls into question the separation of doctors, nurses, medical assistants, and other medical professionals throughout their training, and argues for integrating team training at a much earlier stage.
This new vision for primary care requires several fundamental power shifts – from the hospital and specialists to the primary care physician, from the primary care physician to members of her team, and from all of us in the health system to our patients. Power is zero sum. No one likes giving it up voluntarily, and this transition will not come without some pain and disruption. However, it is ultimately in the medical industry’s interest to adapt and innovate with consumer trends, or risk becoming obsolete, as many travel agents, book stores, and stock brokers have learned over the past several years.