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Primary Care
As part of an ongoing series about the “revolution” in primary care, the Kaiser Family Foundation (KFF) published an article on the rise in smaller employers offering work-site primary care. 1 According to the people interviewed, on-site care allowed people to access primary care without having to take a day off, and, as one CEO put it: “Why did we do this? So my employees would not drop dead on the floor. We had such an unhealthy workforce, and drastic times call for drastic measures.” According to KFF, there are about a dozen companies in the business of providing worksite clinics. The website of the company mentioned in the article, Marathon Health, 2 proclaims: “We empower your employees to improve or maintain their health. We focus on enabling higher engagement, better experiences, and ultimately healthier individuals. Our job isn’t to treat the symptoms like most healthcare providers do. We build trusting relationships with our patients so we can uncover the underlying conditions and heal the whole person. Our care team spends over 30 minutes on average with each patient at each visit, because the best medicine is more than a prescription.
leveraged its work-site clinic into a chain of urgent care clinics sited using the same model they use to locate gas stations. 3 But the article questions if the urgent care model works. “But urgent care and retail clinics may not be a panacea for rising health care costs. A study co-authored by Harvard Medical School health policy professor Ateev Mehrotra shows urgent care clinics reduce less serious visits to the emergency room, yet 37 urgent care visits are needed to prevent a single trip to the ER, increasing total health care spending with all those trips. And ongoing research by Vanderbilt University assistant professor Kevin Griffith suggests that newly constructed urgent care or retail clinics can decrease wait times at nearby private and public sector health centers initially. Eventually, however, the increased access provided by the new clinics increases demand as well, he is finding, and wait times creep back up. 1 Galewitz, P. KFF Health News—Care: Their Own Clinics. 27 October 2023. https://kffhealthnews.org/news/article/small-employers-own-health-clinics-trend/ 2 https://www.marathon-health.com/onsite/ 3 Sable-Smith, B. KFF Health News—Funyuns and Flu Shots? Gas Station Company Ventures Into Urgent Care. 16 August 2023. https://kffhealthnews.org/news/article/funyuns-flu-shots-gas-station-chain-urgent-care- clinics/ “It’s kind of like the ‘build it and they will come’ of health care,” said Griffith, adding that even though the clinics may not decrease wait times long-term or reduce costs, they are getting patients seen. “There is a huge problem with unmet care in the United States. And so ostensibly, these clinics are making a dent into that problem as well.” As with much else about the state of healthcare, there seems to be a series of overlapping goals which don’t mesh well. For the health economist, primary care in the office is cheaper than primary care in the ER. For the payer, keeping costs down is primary, but they depend on the contracting provider organizations, who have different strategies. Some attempt to replicate the feel of the Marcus Welby model, albeit with a group of providers, while others promise to save money by education and activation. Others are simply after efficient production of fee-for-service care for acute minor illnesses. What of primary care physicians? I haven’t done any recent polling, but the original notion of primary care as provision of all routine services from sprains and colds, to pre- natal and chronic disease management has all but evaporated. Most primary physicians I know are overwhelmed by the volume of chronic disease management patients wanting to see them. And every year more guidelines recommend more care with financial penalties to providers if steps are not followed. Going to the hospital? Forget it. That has become a new branch of medicine all its own. I want to share two anecdotes. Many years ago, my group opened an after-hours urgent care center, but we had trouble recruiting physicians. One Sunday evening there was a three hour slot not covered, so, as medical director, I took it. I saw 12 patients, and could not figure out why six of them were there. Two needed work excuses for Monday, two had worsening of chronic symptoms, one had an acute injury and one an acute illness. I guess the others were what we used to call “worried well.” It seems demand is unlimited unless there are financial barriers. During the managed care era, my group was approached by a local manufacturer who wanted to try something different. We agreed to a capitation payment and let employees seek care as before without strings, but reserved “case management” for those who seemed to be high users of care. We also sent a nurse to the plant to do simple screenings, such as BP checks, and encouraged follow up as appropriate. The experiment was a success with the group and the employees, but terminated when the manufacturer consolidated operations elsewhere. How much outpatient volume is driven by systemic factors like how or if paid sick leave is available and how it is handled? Why is a doctor’s note essential? Of course, extended service hour clinics are part of the answer, but are they connected with the larger resources in the community? (I note parenthetically that these are usually located in the wealthiest part of town.) Is there any evidence for a program being able to “activate” more patients to care about their health, or is this just vaporware? Lastly, what do we mean by primary care? And if we think it is important, how do we invest in it so physicians will be willing to do it? The articles note the difficulty of creating disruption in the healthcare industry. Maybe the real problem is we don’t know which questions are more important. 9 November 2023 |
Further Reading
Medical Care as a Commodity Are big data and machine learning likely to solve the problem of uncertainty in medical practice? The Doctor Patient Relationship 2022 Today in the United States, the physician—patient relationship may be more fraught than ever, challenged as it is by greater emphasis on patient autonomy in the context of widespread misinformation and by external forces, constraints, and incentives not aimed at patient benefit. The Primary Care Dilemma When people are well they want convenient care, but when they are sick they want "the best." Is that possible? The Profit Motive The American College of Physicians has published a new position paper on financial profit in health care. The Repair Shop Sinsky and Panzer argue for rebalancing medical practice between solution shop (repair shop) work and production work. |