Tom Sullivan | August 11, 2021
There is little doubt that primary care is changing quickly. The pressure on traditional providers of all sizes began long before the pandemic, but it has certainly not lessened since COVID-19 entered the world. Pharmacy and retail giants CVS and Walgreens are ratcheting up efforts in the field, new entrants are entering the market in force, longstanding fee-for-service models have been exposed as problematic during the pandemic and, what’s more, the crises of 2020-2021 have highlighted needs in the physician workforce.
“One way or another, I believe the future of medicine is at stake. We are burning out doctors on the fee for service treadmill,” said Christopher Chen, MD, CEO, ChenMed. “They want a purpose like improving health — and, to advance health equity, we need better care models for the neediest.”
Many physicians are anticipating significant adjustments to primary care moving forward. Half are expecting “a great deal of change in the next 10 years,” with those having practiced medicine for more than 30 years most likely to expect differences, according to research from Deloitte.
Chen sees two fundamental shifts at play right now: the transition from fee for service volumes to value-based arrangements and the evolution of patient care as a one-size fits all approach into more customized and personalized models of care.
Shift 1: Volume to value
Early in the pandemic it became clear that organizations relying on fee for service were struggling compared to those already taking on risk under value-based contracts. In June of 2020, former Acting CMS Administrator Andy Slavitt and former CMMI Director Adam Boehler said during a Health Evolution Executive Briefing webcast that more organizations entering risk-based arrangements could both bolster their own profitability and increase overall health system resilience.
Slavitt, in fact, explained that continuing to operate as heavily reliant on fee-for-service amounts to reverting to a system that doesn’t work well and, as such, will ultimately prove to be unsustainable. And he cautioned that those organizations should anticipate losing revenue. Regarding the upfront expenses viewed as an obstacle to transitioning to value-based care, Boehler added: “I’ll share a secret from my experience running a large value-based group. There isn’t that much investment.”
Now, a year and half into the pandemic, the question of how many organizations will more rapidly transition to value-based care and how much revenue will come from risk remains unanswered. Another persistent issue is whether physicians are truly prepared for value-based care.
“We see doctors coming to us more attuned to FFS maximization skills than ever – it’s where they’re trained after all. They don’t know how to build a relationship with a patient, how to be a health coach, how to talk about lifestyle and diet, how to coordinate with social services, how to lead a multi-disciplinary care team, or how to take accountability for an outcome,” Chen said.
In other words: Chen has found that too many physicians are lacking the attributes necessary to embrace value-based arrangements and more personalized care.
Christopher Chen, MD, ChenMed
Shift 2: Evolving beyond one-size-fits-all to customized care
Deloitte’s research also determined that 65 percent of physicians are expecting that in five to 10 years consumers asserting control over their own health data will become standard practice. The implication is that granting consumers greater access to their data will enable new levels of customization and personalization not widely available.
“What we need to optimize new modalities is the data to inform the right care. That means knowing everything that has to happen at a visit and getting it all done in one shot. When patients reduce in-person frequency, you can’t miss your opportunity to do the things that require in-person presence,” Chen said. “The other thing data can do is make sure you know who needs a higher level of care so someone who wants telehealth can be convinced it’s time for an in-person check in.”
New data illustrates that patients want more from their relationship with physicians than is common today. Accenture’s Health and Life Sciences Experience Survey 2021, published this week, found that 55 percent of participants rank as the most important factor “a medical provider who explains the condition and treatment clearly,” while 52 percent cited “a provider who listens, understands patient’s needs and provides emotional support,” and 35 percent listed well-coordinated communication and organization as important to them. Those three attributes outranked having a clean office and a nice staff.
Chen said that ChenMed’s patient population of lower income seniors with high levels of health complexity, which often includes isolation and loneliness, are most successfully managed when physicians conduct significant levels of physical engagement. As such, the organization is increasing its virtual touchpoints between visits and exploring a virtual first strategy with a more tech savvy, slightly less complex population.
ChenMed is not alone. Other innovators include CareMore Health, Crossover Health, Oak Street, Privia Health, VillageMD as well as OneMedical, which announced its intention to acquire Iora Health in June of this year.
“The disruptors have broken out of Stockholm Syndrome. They’re not held captive and then convincing themselves FFS is good and risk is dangerous,” Chen said. “If ChenMed and other peers publish 30-50 percent or more savings on hospitalizations, that could be an industry-wide norm and hospitals could become truly specialized experts at real trauma care and major unavoidable procedures.”
The intersection of personalized care and advanced equity
The crises of 2020-2021 have highlighted the systemic and structural ways that health care and other systems have disadvantaged lower income populations and communities of color. Rethinking how physicians approach value-based care and alternative payment models and engage with consumers also positions primary care to address those existing inequities.
“If we can reposition what it is to be a primary care doctor, I believe the training can be fixed, the compensation can be fixed, the ‘low man on totem pole’ problem can be fixed, and we’ll actually see primary care make a difference in closing health equity gaps,” Chen said.
In addition to the aforementioned Deloitte research finding that physicians are broadly anticipating significant changes in the years ahead, Fellows in the Health Evolution Forum Work Group on Reinventing Primary Care and Preventative Care Models agreed during a virtual meeting earlier this year that considerable change is coming within three years.
Forum Fellows are expecting a growing number of providers to optimize new care modalities supported by artificial intelligence, consumer tools, digital health and risk-based models. “There are going to be so many more tools than we all thought were possible that become a routine part of care,” said Sean Morris, CEO, Privia, during the Forum meeting.
Chen added that health care cannot wait for other sectors to fix its problems and noted that physicians are primed to contribute because many originally decided to enter the field of medicine to help people.
“Primary care can play a role in the solution. Not because these populations need more pills and procedures, but because they need more support, education and trust. We can’t live in a world where we go into medicine to help people, then stand by when we see huge disparities,” Chen said. “We are betting that the right kind of primary care – where we empower doctors to be true partners with their patients, train them to impact the most important drivers of changing health, and equip them with cutting edge technology to reinforce, even predict, the right care — will help with improving health and closing disparities.”