Friday, October 14, 2022

Can Amazon cure all that ails U.S. primary care?

This summer, Amazon purchased the One Medical national chain of primary care practices for nearly $4 billion. As David Blumenthal and Lovisa Gustafsson recently wrote in the Harvard Business Review, the success of the online retail giant's health care venture is hardly assured. One doesn't need to be a practicing family physician with health policy expertise to know that U.S. primary care is chronically overworked and underfunded, and as a result, medical student interest in primary care specialties has been anemic for the past two decades. As I discussed in a previous Medscape commentary, international primary care comparisons are less than flattering. The "fundamental question," asserted Blumenthal and Gustafsson, is: "Can profit-driven entrepreneurship and bottom-up innovation make the U.S. health care system work anywhere nearly as well as those in places like France, Sweden, Norway, Australia, the Netherlands, New Zealand, Germany, and Switzerland?"

A new analysis of the time needed to provide all recommended preventive, chronic disease, and acute care to a hypothetical adult primary care panel of 2500 patients produced a mind-boggling (and mathematically impossible) estimate: 26.7 hours per day, with more than half allocated to preventive care. (It's no wonder that urgent care facilities, staffed largely by primary care physicians and advanced practice clinicians, are growing like weeds everywhere.) Even in a team-based primary care model where medical assistants and nursing staff take on much of the preventive and chronic disease care and the physician only handles the really hard stuff, the authors estimated that 9.3 hours per day would be needed, with nearly one-third allocated to documentation and inbox management. How many aspiring doctors envision a future where they spend 3 hours per day on electronic health record (EHR) tasks?

Oh, but it gets even better (and by better, I mean worse). A fascinating history of time organization in U.S. outpatient medicine published in the Annals of Internal Medicine traced the evolution of physician practice from sporadic home visits or open "office hours" to appointments based on standard 15-minute blocks. As appointment schedulers migrated from individual doctors' front offices to distant call centers, personalized time allocation based on the complexity of the patient and his or her specific concerns became a thing of the past:

The centralization and standardization of outpatient scheduling have lessened the system's ability to acknowledge and accommodate the individual needs and natures of specific patients and physicians. This tradeoff creates special challenges for primary care, a field whose effectiveness relies heavily on strong relationships and trust. Without the ability to accommodate patients and physicians as individuals, health care systems risk robbing primary care of its value and losing the trust of both parties.

A commentary about primary care burnout in Health Affairs Forefront  noted that our singular talent for building relationships - frequently, the reason we are drawn to generalist specialties like family  medicine - is being wasted in the design of the current health care system:

The focus of primary care has become largely administrative, sending results electronically, clarifying and approving refills, responding to patient messages, closing care gaps, addressing billing inquiries, and, of course, documenting everything by midnight. ... The result: It is increasingly rare to have those magical moments between a primary care provider and patient in which time flies because we are listening intently to each other, bearing witness, and offering a steadfast presence and commitment to longitudinal care. Instead, exchanges are increasingly composed of a two-sentence request in Arial font (“My knee still hurts. I need a referral to ortho.”) followed by a single word response (“Done.”). Our greatest skills are in listening, connecting, and collaborating within and across highly complex systems. It is a skill we rarely get to use.

Dr. Thomas Bodenheimer, a longtime general internist and Professor of Family and Community Medicine at UCSF, argued in a recent essay that the two keys to "revitalizing primary care" are a substantial increase in the percent of health expenditures dedicated to it and building fully-staffed inter-professional teams that are able to care for large primary  care panels and reduce physician burnout. No more tinkering around the edges with initiatives like "patient-centered medical homes" and financial incentives for "transitional care" and "care management." Rhode Island and Oregon have led the way by mandating that commercial insurers increase their percentage of primary care spending. Federal action will be required to equalize the monetary value of a 30-minute office visit with a 30-minute colonoscopy (currently, the former is valued at 40% of the latter).

So can Amazon cure all that ails U.S. primary care? I imagine a customized health shopping homepage where a percentage of every purchase is funneled directly to One Medical, where vans with Amazon's distinctive emblem drop off colorectal and cervical cancer self-screening tests at all hours, where the subscription Prime channel airs a hit show starring two attractive and empathic family physicians who emphasize relationship-based care like their predecessor, Marcus Welby, MD. You won't see them spending hours in the EHR after hours. Instead, their every word will be documented by attentive scribes - either real-life or artificial intelligence-enabled versions. Medical students will clamor to be them. Family medicine departments and residency programs will perpetually expand to keep pace with demand. And our primary care system will be the envy of the world.