Embracing a Diversified Future for US Primary Care
Published Online: January 17, 2013
Timothy Hoff, PhD
While the patient-centered medical home (PCMH) model of care has been suggested to strengthen traditional, physician-delivered primary care within a doctor’s office, the future of primary care is likely to be much more diversified in both its service delivery structures and personnel. This diversification will include retail walk-in clinics, employer-based primary care delivery, concierge care, hospital-affiliated practices, and practices led by nonphysician providers.
The drivers of this diversity include increased patient demand requiring a larger number of primary care access points; the need for lowercost delivery structures that can flourish in a low-margin business model; greater interest in primary care delivery by retailers and hospitals who see their involvement as a means to enhance their core business goals; the increased desire by non-physician providers to gain work independence; and a growing cadre of younger primary care physicians (PCPs) whose career and job preferences leave them open to working in a variety of different settings and structures (Figure). In addition, as several recent PCMH evaluations have shown, the current medical home model remains promising but also unproven in many ways, especially when looking at its ability to control costs, shape a wide variety of clinical outcomes, appeal to the general public, and deliver primary care efficiently on a long-term basis.1-3
The Need for Lower-Cost Primary Care Access Points
The notion of a future primary care delivery system that is diverse in its structural and personnel components makes sense given other trends now unfolding. First, US health reform and our country’s demographics stand to make access a more significant issue in primary care. Despite the promise of the patient-centered medical home (PCMH), for example, a key issue is whether or not this model can ensure a primary care delivery system with enough capacity and access points to satisfy the increased patient demand emanating from more individuals possessing insurance and an increasingly aging and sicker general population. Relying on a physician-centric PCMH model to improve nationwide access to primary care services is unrealistic given the resource, system integration, and other demands associated with establishing and maintaining full-fledged medical homes,4,5 and the model’s strict reliance on a physician-centric approach6 manifested through a more traditional primary care practice structure and reimbursement system. In certain parts of the country and for select demographic groups, other types of primary care delivery structures will be needed and other types of “medical homes” that are not so physician-dependent or require large fixed costs may be called upon to fill the gaps in service delivery.
In this way, an expected surge in patient demand nationally will push the marketplace to establish lower-cost models of primary care delivery that use physicians less and have lower overhead overall.7,8 For example, alternative delivery structures like retail clinics possess both the cost-leadership edge and capital support behind them to provide basic primary care in higher-risk (from a business standpoint) areas of the country such as rural and inner-city locales.9,10 These types of delivery structures may be cheaper to establish and run, meaning that for the same amount of capital investment, more of them are possible, in contrast to traditional primary care practices that rely heavily on physician labor. Their location within retail outlets traditionally found across a wide swath of geographic areas also gives the clinic model an advantage over free-standing primary care practices in reaching more individuals.
Primary Care as a “Loss Leader”
A related trend propelling system diversity is that primary care service delivery continues to have a lower profit margin than other forms of medical care.11,12 Thus, those funding the future expansion of primary care will likely seek to derive additional benefits from their investments. Retailers and hospitals are 2 funding sources for primary care expansion. Some retailers may incorporate primary care services into their businesses to enhance their overall brand, increase consumer traffic, and stimulate purchases of other goods and services within their stores, rather than as a focus for pure profit.13 Their approach to primary care delivery looks different from traditional practice-based primary care.
However, this does not preclude it from gaining popularity among select groups of consumers. For example, not only do the economics favor the retail clinic structure in the delivery of many basic primary care services, there is also evidence that retail clinics deliver some forms of primary care cheaper and on a par quality-wise with traditional delivery structures.8,10 Some patients, especially younger, healthier ones with less allegiance to traditional primary care and preferences for convenient, fast service, also appear satisfied with using these structures to meet various primary care needs.10,14,15 It is an open question as to whether a younger generation used to a world of instant access, excessive variety, and low barriers to information acquisition will embrace a more personally accountable, comprehensive primary care approach like the current PCMH model, or instead spread their allegiances around to multiple delivery structures and providers that are more nimble and meet their immediate needs.
Hospitals also have a renewed interest in primary care as a “loss leader.” This interest stems from the advent of accountable care organizations that require service integration to get paid; the potential inpatient and specialty-care revenue that primary care services could generate for a hospital16,17; and the strategic benefits offered through affiliation with different types of primary care service delivery.18 To these ends, some hospitals have begun partnering with retail clinics to expand their reach into hard-to-access geographic areas, fed by a drive to increase market share for other hospital-based services. For hospitals, the exact look and staffing of the primary care delivery structure with whom they affiliate may be less important than the fact that it performs a dual role as both a brand expander and patient feeder for their operations.
Shifts in the Primary Care Labor Force
Primary care system diversity is also being propelled by shifts in the primary care labor force. A continued shortage of PCPs is expected.19,20 A sizable portion of current PCPs are nearing retirement age, and not enough individuals are going into primary care to stem this large out-migration of older physicians in the near future. Many states have expanded non-physician provider autonomy to keep their primary care systems functioning.21 Nurse practitioners (NPs) and physician assistants (PAs) may provide similar quality when it comes to basic primary care delivery and retain high levels of patient satisfaction, while remaining the clinician of choice for lower-cost structures such as retail clinics.8,22,23 Another labor force–related factor promoting primary care system diversity is the increasing heterogeneity of the primary care physician workforce. For example, the younger physician cohort values lifestyle and a greater work-life balance than older PCPs.24 These preferences will translate into a collective desire for innovative job structures, career flexibility, and a wider array of employment choices. Such preferences may be more difficult for traditional primary care practices to fulfill, especially ones functioning as medical homes because (a) the more complex, continuous, and relational approach typifying patient care in medical homes could limit the variety of physician job structures feasible in these settings, and (b) traditional primary care practices are still staffed heavily by many later-career PCPs who may not share the same value systems or preferences as their younger counterparts.24 Even a percentage of later-career PCPs that are both financially secure yet fatigued from years of employment within a hectic business model of high-volume patient care could willingly transition into lower-intensity jobs that involve part-time or shift work, and more episodic-type care delivery. Such jobs are more likely to be found in emerging primary care delivery structures such as urgent care centers and retail clinics, and in models like concierge care.
Competition or Cooperation in a Diversified Primary Care System?
A key question to ask of a more diverse primary care system is whether or not the delivery structures and personnel infusing them cooperate or compete for consumer loyalties, power, reimbursement, and market share. Both past and current history favors a competitive system. For example, the medical profession generally has sought to protect its exclusive interests over the provision of healthcare to the general population.25 Even while the field of primary care remains less appealing to medical students,20 organized medicine does not favor the expansion of the retail or convenience clinic model of care, and there is stiff opposition to the establishment of independent nursing practice, even as nurses push harder for that independence.26
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