Timothy Hoff, PhD

The US primary care system is ground zero for growth of the retail health consumer approach. Less examined is how specific retail health tactics, such as market segmentation and price transparency, do not align well with physician preferences, values, and ways of delivering care.

Several retail health tactics must be modified during implementation or they will face resistance by primary care physicians.

Understanding the mind-sets, value systems, and patient care preferences of primary care physicians is critical to the success of retail health tactics.

Greater physician voice and input into how retail health approaches are implemented has benefits for the primary care system.

The commodification of healthcare in the United States continues.

 This commodification involves the evolution of healthcare delivery into what some call a restaurant experience, emphasizing service aspects such as convenience and speed, as well as the use of technology, standardization, big data, and more nonphysician workers in care delivery.

 Central to this trend is the successful transformation of the patient into a “retail healthcare consumer” who is willing to shop for and purchase services within corporatized models of care delivery that possess the scale to create large, integrated healthcare marketplaces.

 reflects its ongoing adoption by existing organizations and high-tech innovators seeking to promote retail tactics in the healthcare space.

 Examples include large, well-branded nonhealthcare companies just entering healthcare, like Apple, Google, and Amazon

; existing healthcare entities, such as information technology companies that make electronic health record (EHR) software,

 medical device and pharmaceutical firms,

 integrated delivery systems (eg, Kaiser Permanente, Geisinger), insurance companies, and national pharmacy chains; and start-ups eager to gain acceptance in the healthcare marketplace.

Primary Care as Ground Zero for the Retail Health Consumer Approach

The US primary care system is ground zero for growth of the retail health consumer approach. The early period of primary care system disruption bears this out. For example, expanding distribution outlets for some forms of primary care, like retail clinics and urgent care centers, possess attributes that many observers believe healthcare consumers want above all else: convenience and speed, ease of access, and lower-cost care.

 In addition, innovations such as Zocdoc serve as market makers, bringing together patient “buyers” and physician “sellers” quickly and for the purpose of transacting a face-to-face visit. New models of primary care delivery, such as Iora Health, aim to deliver efficiency-driven primary care by using technology and nonphysicians as the chief caregivers with whom patients interact.

These are all examples of primary care disruptions that classify patients as retail health consumers, capable of making informed choices about the services they wish to access and when and how they wish to obtain them. But such disruptions create a host of intermediaries coming between individual doctors and their patients, much as Amazon has become the intermediary between individual product sellers and their customers: controlling the traffic of buying and selling, shaping customer decisions about which products they should consider for purchase, and influencing the sellers of those products in ways that undermine the latter’s autonomy and ability to develop direct connections with the buyer. Primary care physicians may be less comfortable seeing their patients as retail health consumers because they are less accepting of the notion of yet another intermediary coming between them and their patients. This discomfort may also arise because some primary care physicians cannot be convinced easily, given the paucity of evidence at present, that retail health tactics lead to improved patient health, reduce their own workloads, improve their reimbursement, or enhance their job satisfaction.

One major retail tactic involves delivering greater transparency in order to gauge the price-quality trade-off for various goods and services and allow buyers to comparison-shop, among other potential advantages. Price competition—pressuring sellers to lower the prices for their services&mdash;is a related component of this retail tactic, perfected by companies like Walmart and Amazon, and one that many primary care physicians could seek to resist. This is because they already have seen portions of their patient care duties diminished by what they believe is unfairly low reimbursement for clinical interactions that are multifaceted and time-consuming, such as complex chronic disease management, care coordination, and behavioral health care.

 This resistance is already seen in the “direct primary care” trend in which some primary care doctors are establishing stand-alone practices that no longer deal with insurance and instead require a smaller panel of patients to pay monthly subscription fees to receive more on-demand care.

This transparency also involves a highly quantitative focus on performance measurement, touching on every aspect of the buying-and-selling process, and the copious use of public reporting, both of which already cost doctors and their practices a lot of time and money.

 Physicians question the merit of many performance measures used to assess their work.

 Too much performance measurement increases physicians’ work hours and the administrative demands upon them and makes them feel less autonomous, and these circumstances in turn decrease physician well-being.

 Primary care physicians may also perceive the tactic of greater transparency, achieved through an abundance of standardized metrics, as being out of alignment with the attributes they believe matter most in providing their patients with good care. For example, retail health consumer transparency prefers efficiency-focused measures of aspects like wait times and how long a service takes from start to finish. Conversely, primary care physicians prioritize elements of their work with patients that often are less “efficient” or take more time, including establishing interpersonal trust; extended listening; mutual respect, emotional support, and friendship; and gaining insights into the social and behavioral contexts of patients’ lives.

 The performance measurements used in retail healthcare, which involve simplified process measures and outcomes that may have less clinical significance for doctors, often undervalue these harder-to-measure, complex aspects of relational excellence and the intangibles of a strong doctor-patient relationship.

Greater performance measurement of the kind delivered by retail health thinking also depends on the EHR and information technology inserted in heavy doses into everyday clinical practice. For many doctors, using the EHR remains an unattractive part of their workday, creating dissatisfaction.

 They believe that the EHR often interferes in their relationships with patients, takes away from more important activities in their workday, increases workloads unnecessarily, and undermines their well-being.

 Many primary care doctors have experienced the heavy documentation burden that the EHR thrusts upon them.

 At this point in time, relying on the EHR or its equivalent as the centerpiece of promoting price and quality transparency, or on other technology like electronic patient portals or care delivery apps as tools making care more convenient or accessible for patients, remains a risky proposition for primary care doctors, especially if they do not see appropriate reimbursement for using such technology.

The Transactional Focus in Retail Tactics

Another retail health consumer tactic is that of “volume selling,” which means getting patients to purchase or access lower-cost, often more trivial health services on a frequent basis. Mass production of these types of services, using technology and highly standardized workflows, facilitates this type of selling. In this way, a retail-oriented healthcare system focuses on excelling transactionally.

 This tactic presents a challenge generally for the field of primary care. This is because in a highly transactional care delivery system, there is less emphasis on building relational excellence of a human-to-human nature, which is critical for effective primary care medicine in the eyes of primary care doctors.

What this means is simple: When the focus is on perfecting a system of volume selling rooted in “lowest-cost” production flows—such as those seen in various wellness services like fitness monitoring or low-level primary care visits to walk-in clinics&mdash;investing in strongly relational and time-lasting doctor-patient relationships is less emphasized. In such a system, relational dynamics like building trust, engaging mutual respect, and possessing deeper knowledge of patients’ social and emotional circumstances may at times “slow down” what is meant to be quick and convenient care delivery, but to physicians, these are crucial aspects of practice that define strong doctor-patient relationships.

Using patient data on a “big” scale to create homogenous groupings of like patients possessing similar needs, wants, and preferences is another retail health tactic that presents challenges to primary care physicians. This is called market segmentation, and its main purpose is to target appropriate services to the right patients (ie, patients whose unique features suggest that they may be targeted to purchase and use those services).

 This retail tactic presents at least 2 challenges to primary care physicians. The first is that market segmentation may be used by sellers of healthcare services to bypass the doctor and go directly to the patient to convince them to buy particular items, some of which, like wearables, then place greater demand on the physician for their expertise—expertise that may or may not be reimbursed appropriately.

A second challenge is that the profession of family medicine still rests on the bedrock of individualized care and understanding the patient’s unique social, behavioral, and emotional contexts that drive their health status.

 A self-perceived “competent” family doctor might say that beyond the most basic acute care and chronic disease management delivery, segmenting groups of patients, and making them less different from one another in the process, undermines what good primary care is all about, which in turn also lessens some of the joy of practice for these professionals.

Reconciling retail health consumer tactics with what primary care physicians see as relevant for good patient care and their own well-being is not insurmountable. Yet, it suggests a protracted period of time during which primary care physicians’ specific version of good care is integrated appropriately with the retail health consumer version. Primary care physicians need more of a voice in defining what a consumerist approach to primary care delivery means and where its limits lie. Otherwise, there is potential for these physicians to be less motivated to partake in much of what the retail health consumer perspective seeks, which will bring only more confusion to a primary care system currently suffering an identity crisis in American healthcare.

D’Amore-McKim School of Business, School of Public Policy and Urban Affairs, Northeastern University, Boston, MA; Saïd Business School and Green Templeton College, Oxford University, Oxford, UK.

 The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; provision of patients or study materials; and administrative, technical, or logistic support.

 Timothy Hoff, PhD, D’Amore-McKim School of Business, Northeastern University, 360 Huntington Ave, Boston, MA 02115. Email: t.hoff@northeastern.edu.

1. Abelson R. When hospitals merge to save money, patients often pay more. 

. November 14, 2018. nytimes.com/2018/11/14/health/hospital-mergers-health-care-spending.html. Accessed February 25, 2019.

. August 13, 2012. newyorker.com/magazine/2012/08/13/big-med. Accessed February 25, 2019.

3. Landi H. Google patent indicates plans to develop EHR to predict patients’ clinical outcomes. Fierce Healthcare website. fiercehealthcare.com/tech/google-patent-indicates-work-doctor-facing-interface-to-provide-predictions-clinical-outcomes. Published February 4, 2019. Accessed February 4, 2019.

4. Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. 

. 2010;29(5):893-899. doi: 10.1377/hlthaff.2010.0440.

5. Moloney TW, Paul B. The consumer movement takes hold in medical care. 

. 1991;10(4):268-279. doi: 10.1377/hlthaff.10.4.268.

6. Farr C. Amazon’s vision for the future of health care is becoming clear. CNBC website. cnbc.com/2018/12/17/amazon-vision-future-health-care.html. Published December 18, 2018. Accessed February 25, 2019.

7. Apple announces effortless solution bringing health records to iPhone [news release]. Cupertino, CA: Apple; January 24, 2018. apple.com/newsroom/2018/01/apple-announces-effortless-solution-bringing-health-records-to-iPhone. Accessed January 25, 2019.

8. DeepMind Health UK. Helping clinicians get patients from test to treatment, faster. Google Health website. health.google. Published February 27, 2017. Accessed February 25, 2019.

9. McGrane C. Amazon unveils new service to mine and decode medical records using artificial intelligence. Geekwire website. geekwire.com/2018/amazon-unveils-new-service-mine-decode-medical-records-using-artificial-intelligence. Published November 27, 2018. Accessed January 25, 2019.

10. Murphy K. Epic eyes specialists, insurers, and businesses to expand reach. EHR Intelligence website. ehrintelligence.com/news/epic-eyes-specialists-insurers-and-businesses-to-expand-reach. Published January 2, 2019. Accessed February 25, 2019.

11. Medical device companies: trends in reported net sales and profits before and after implementation of the Patient Protection and Affordable Care Act. US Government Accountability Office website. gao.gov/assets/680/671094.pdf. Published June 30, 2015. Accessed June 30, 2019.

12. The empowered healthcare consumer. BlueCross BlueShield website. bcbs.com/articles/empowered-healthcare-consumer. Accessed February 25, 2019.

13. Cohen JK. Epic, Cerner make up 50% of hospital EHR market share, ONC data shows. Becker’s Hospital Review website. beckershospitalreview.com/ehrs/epic-cerner-make-up-50-of-hospital-ehr-market-share-onc-data-shows.html. Published July 17, 2018. Accessed February 25, 2019.

14. D’Ambrosio D. Boston startup aims to change how primary care is done in America. 

 website. forbes.com/sites/danieldamrbosio/2018/11/30/boston-startup-aims-to-change-how-primary-care-is-done-in-america. Published November 30, 2018. Accessed February 25, 2019.

15. About us. Iora Health website. iorahealth.com/about-us. Accessed February 25, 2019.

16. Geisinger Health System launches new digital experience for consumers utilizing patient access platform from Kyruus [news release]. Boston, MA: Kyruus; December 19, 2018. kyruus.com/news/geisinger-health-system-launches-new-digital-experience-for-consumers-utilizing-patient-access-platform-from-kyruus. Accessed February 25, 2019.

Next in Line: Lowered Care Expectations in the Age of Retail and Value-Based Health

. Oxford, UK: Oxford University Press; 2017.

18. Filer WD. Letter to Andrew M. Slavitt, Acting Administrator for Centers for Medicare & Medicaid Services. American Academy of Family Physicians website. aafp.org/dam/AAFP/documents/advocacy/payment/medicare/feesched/LT-CMS-MPFS-122216.pdf. Published December 22, 2016. Accessed February 25, 2019.

19. Casalino LP, Gans D, Weber R, et al. US physician practices spend more than $15.4 billion annually to report quality measures. 

. 2016;35(3):401-406. doi: 10.1377/hlthaff.2015.1258.

20. Wachter R, Goldsmith J. To combat physician burnout and improve care, fix the electronic health record. Harvard Business Review website. hbr.org/2018/03/to-combat-physician-burnout-and-improve-care-fix-the-electronic-health-record. Published March 30, 2018. Accessed February 25, 2019.

21. 2018 survey of America’s physicians: practice patterns and perspectives. The Physicians Foundation website. physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf. Published September 2018.

Practice Under Pressure: Primary Care Physicians and Their Medicine in the 21st Century

. New Brunswick, NJ: Rutgers University Press; 2010.

Primary Care: Balancing Health Needs, Services, and Technology

. New York, NY: Oxford University Press; 1998.

24. Stewart MA. Effective physician-patient communication and health outcomes: a review. 

25. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. 

. 2017;15(5):419-426. doi: 10.1370/afm.2121.

26. InCrowd survey: physicians say burnout remains high, and hospitals aren’t doing enough [news release]. Boston, MA: InCrowd; June 20, 2016. incrowdnow.com/press-release/physician-burnout-remains-high-and-doctors-say-their-hospitals-arent-addressing-it-according-to-new-data-from-incrowd. Accessed February 25, 2019.

27. Tai-Seale M, Olson CW, Li J, et al. Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine. 

. 2017;36(4):655-662. doi: 10.1377/hlthaff.2016.0811.

28. What is customer segmentation? Amazon Web Services website. aws.amazon.com/pinpoint/customer-engagement/customer-segmentation. Accessed February 25, 2019.

Articles

Implementation of retail health consumer tactics in primary care poses challenges for primary care doctors that must be recognized and addressed.

The Challenges of Consumerism for Primary Care Physicians

Although less focused upon given the current emphasis on the patient-centered medical home innovation, the future for US primary care is arguably one that will be characterized by diversity in service delivery structures and personnel. The drivers of this diversity include increased patient demand requiring a larger number of primary care access points; the need for lower-cost delivery structures that can flourish in a low-margin business model; greater interest in primary care delivery by retailers and hospitals that 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 PCPs whose career and job preferences leave them open to working in a variety of different settings and structures. A key issue to ask of a more diversified primary care system is whether or not it will be characterized by competition or cooperation. While a competitive system would not be unexpected given historical and current trends, such a system would likely stunt the prospects for a full revitalization of US primary care. However, there is reason to believe that a cooperative system is possible and would be advantageous, given the mutual dependencies that already exist among primary care stakeholders, and additional steps that could be taken to enhance such dependencies even more into the future.

The information in this article can be used in everyday practice and policy decisions in the following ways:

		Understanding the sources of primary care system diversity helps policy makers target scarce resources in an evidence-based way to foster cooperation and interdependency among primary care deliverers.

		Understanding primary care system diversity supports the growth of practice structures and innovations that move beyond medical home models which may not be adequate to meet future demand.

		 Primary care growth and enhancement should be more clearly linked to the specific strategic interests of different industry stakeholders, with an eye toward building a multidimensional brand image for the field as a whole.

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 (

). 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.

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,

 and the model’s strict reliance on a physician-centric approach

 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.

 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.

 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.

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.

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.

 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.

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.

 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 hospital

; and the strategic benefits offered through affiliation with different types of primary care service delivery.

 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.

Primary care system diversity is also being propelled by shifts in the primary care labor force. A continued shortage of PCPs is expected.

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.

 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.

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.

 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.

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.

 Even while the field of primary care remains less appealing to medical students,

 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.

One problem is that organized medicine views these alternative delivery structures and personnel as potential substitutes for rather than complements to traditional physician-centric primary care. As a result, it also continues to support a patient-centered medical home definition that has few co-equal roles in it for these other deliverers. Meanwhile, retail clinics and urgent care centers grow in ways that bypass strong affiliations with traditional primary care practices, linking up with hospitals, for example, while also remaining entrenched within their larger retail sponsors.

If competition and balkanization define the diversity in a future primary care system, each type of delivery structure and occupational group will make self-interested strategic decisions with less focus on how such decisions might enable primary care as a field to compete effectively against other forms of medicine (eg, specialty care) for political and societal legitimacy. Without this legitimacy, primary care services will remain undervalued, meaning lower reimbursements for everyone delivering primary care. In a balkanized delivery system, primary care delivery can still expand, but the expansion could be fragmented, inefficient, and less concerned with quality improvement, while still leaving significant pockets of need scattered across the geographic and demographic landscapes. It would also leave the question of primary care system value largely up to third-party payers rather than the practitioners who produce the care.

Alternatively, a future of diversity defined by greater cooperation, collaboration, and trust among primary care system participants has potential. For this to happen, mutual dependence among primary care providers and delivery structures must become the norm. Generally, when a system possesses high levels of mutual dependence, cooperation and collaboration come to typify its inhabitants.

 In this regard, the US primary care delivery system is further along than it realizes. For example, nurses and PAs need to have greater practice autonomy, and PCPs must employ them in greater numbers, if the medical home model is to become widespread and work financially for traditional, physician-centric primary care. Nurses and PAs can ally with PCPs to gain continued legitimacy in the public’s eyes and make it easier for them to expand their scope of practice. Strategic alliances between these personnel groups would strengthen the primary care system’s infrastructure, and in the process enable each group to advance its own interests.

Similarly, retail clinics will require a large supply of nurses and PAs to maintain their cost-leadership edge. But they will also benefit from greater physician involvement to gain the expertise for providing complex primary care services, and to enhance their credibility with the general public, especially if the physician-centric medical home model is recognized as primary care in its most valued form. In addition, hospitals have something to offer traditional primary care practices, ie, financial stability and access to a vast array of clinical and quality- improvement resources. At the same time, PCPs can use hospitals to shift some of the financial risk of doing business off themselves, while gaining access to the kinds of flexible job structures they may increasingly desire.

Higher levels of mutual dependence within primary care can also be furthered through policies that tie the fates of primary care delivery structures and personnel closer together. One example could be economic incentives used in a targeted way to promote formal collaborations among structures such as traditional physician-centric practices, retail clinics, and urgent care centers in coordinating overall primary care delivery within a given geographic area. In this sense, one could imagine a sort of accountable care organization that exists solely for primary care delivery within an area. A second example is workforce recruitment policies that provide major financial rewards to training institutions that partner to produce more and different primary care personnel simultaneously, and that seek to train professionals such as nurses, PAs, and PCPs in an integrative manner that reduces the barriers to working together as co-equal partners.

That a future US primary care delivery system will be structurally and occupationally diverse makes sense. What must be debated extensively is how to move that diversity forward in ways that can elevate rather than continue to erode primary care as a viable, valued, and comprehensive form of medicine in the United States.

 From Northeastern University, D’Amore-McKim School of Business and School of Public Policy and Urban Affairs, Boston, MA..

Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content; administrative, technical, or logistic support.

 Timothy Hoff, PhD, Associate Professor of Management, Healthcare Systems, and Health Policy, Northeastern University, D’Amore-McKim School of Business, 137 Richards Hall, 360 Huntington Ave, Boston, MA 02115. E-mail: t.hoff@neu.edu.1. Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Early evaluations of the medical home: building on a promising start. Am J Manag Care. 2012;18(2):105-116.

2. Hoff T, Weller W, DePuccio M. The patient-centered medical home: a review of recent research. Med Care Res Rev. 2012;69(6):619-644.

3. Closing the Quality Gap: Revisiting the State of the Science Series: The Patient-Centered Medical Home. Structured Abstract, July 2012. http://www.ahrq.gov/clinic/tp/gappcmhtp.htm. Rockville, MD: Agency for Healthcare Research and Quality.

4. Carrier E, Gourevitch MN, Shah NR. Medical homes: challenges in translating theory into practice. Med Care. 2009;47(7):714-722.

5. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Steward EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7(3):254-260.

6. Patient-centered primary care collaborative: joint principles of the patient-centered medical home. http://www.pcpcc.net/content/jointprinciples-patient-centered-medical-home). Published February 2007. Accessed January 3, 2012.

7. Bohmer R. The rise of in-store clinics—threat or opportunity? N Engl J Med. 2007;356(8):765-768.

8. Deloitte Center for Health Solutions. Retail clinics: update and implications. http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_chs_RetailClinics_111209.pdf. Accessed December 19, 2011.

The future US primary care system will be one characterized by diversity in both delivery structures and personnel. This diversity will benefit from a collaborative approach in which stakeholders realize high degrees of interdependency.

Embracing a Diversified Future for US Primary Care

	The patient-centered medical home (PCMH) is viewed as an idea whose time has come. In theory, the PCMH enables better primary care centered on a more defined relationship between primary care physicians (PCPs) and patients, team-based primary care service delivery, enhanced care coordination and access to primary care, and improved quality through the use of disease registries and health information technology.

 Integral to the PCMH model is added payment for PCPs to help compensate them for enhanced care coordination, as well as to fund the personnel and technology-related investments needed in the practice to do medical home—type care.

	Proponents assert that the PCMH makes sense for a healthcare system that is fragmented, impersonal, and overly focused on high-cost specialty care. With demonstration projects under way nationally, they hope that implementation of the model can show enough quality improvement and cost savings to ensure its long-term survival. But something important is missing in the current medical home debate. Little serious attention is being paid to whether implementation of the medical home model can help solve several key problems already transforming our current primary care system, or if the model will succumb to these problems despite evidence that it works.

	One key problem involves the retention and growth of the primary care workforce. Primary care careers remain grossly unappealing to the vast majority of US medical students. For example, over the past 5 years, existing family medicine residency slots have been filled annually with US medical school graduates 45% of the time or less, despite declines in the total number of positions available.

 In addition, a recent survey showed that only 24 of 1177 fourth-year medical students intended to pursue careers in general internal medicine.

 These realities on the front end of PCP supply are bad enough. But we also see an increasingly large older cohort of PCPs who, even if they enthusiastically embrace medical home—type care as proponents suggest, will exit active practice in the next decade in numbers that cannot be matched by those coming into the field.

	If we are to believe common wisdom, insufficient compensation and undervaluing of primary care services in the healthcare marketplace are significant causes of the primary care recruitment problem. Yet these reasons oversimplify the reality. For example, it is hard to imagine how an extra $30,000 or $40,000 per year—optimistic estimates of what enhanced PCMH reimbursement can deliver to individual PCPs&mdash;will suddenly spur vast numbers of medical students to enter a generalist specialty such as internal medicine, family medicine, or pediatrics, which remain lower paying than almost all other medical specialties. Add to this the reality that primary care careers have a serious image problem among the medical student cohort, and it gets easier to suggest that the recruitment issue could undermine rather than be positively impacted by the medical home model.

	A second hypothesis to explain the recruitment problem is that profound value shifts have occurred in the medical student cohort. As much as money, they want the choice of a career that gives them flexibility and the ability to have a life outside of work.

 Many want a job with defined work boundaries. The cultures of many medical schools and residency programs do not promote primary care as a viable career choice for young medical students or residents. Within a training system geared to turning out specialists, a primary care career is increasingly perceived by many medical students as a “consolation prize” that involves a diffuse knowledge base, less intellectual rigor, and more everyday hassles than other careers like emergency and hospital medicine, or specialties like dermatology or radiology, all of which pay more than primary care and provide a “nine-to-five”—like workday.

	In fact, such perceptions may not be valid in the real world of primary care practice. However, the negative perceptions also are fueled by the fact that PCPs no longer have complex work like procedural medicine and hospital medicine within their occupational grasp and struggle with incorporating new types of complex work like behavioral healthcare into crowded workdays. The decreasing presence of PCPs in the hospital also lessens the exposure of medical students to everyday primary care, further promoting the negative stereotypes noted above.

	Proponents of the PCMH argue that the medical home ideal will give medical students more of what they desire in their careers, including sufficient compensation and greater worklife balance. But what if the opposite ends up to be true? What if effective medical home implementation in the average primary care practice exacerbates practice pressures and generates a negative image of primary care? It is possible, at least in the beginning, that some of the medical home principles put into practice could force PCPs to work longer and harder, without significant new compensation, particularly if they still have to pay the bills by continuing the existing business model of large numbers of face-to-face office visits. Within such a model, where assembly-line medicine is the norm, there will be fewer opportunities to build in the extended, patient-centric care offered by the PCMH. Innovations such as the use of integrated care teams that make maximum use of all the practice’s human resources may help alleviate the workload. But adopting a team-based clinical approach in a busy practice is not easy, does not always work in intended ways, and may require additional financial investment that practices operating under a razor-thin profit margin might be reluctant to make.

	Will young physicians with a different value set than their older cohorts see a more complicated primary care job (even if it involves roles for the PCP such as “team leader” and “care manager”) as something that (1) still doesn’t pay enough for the work required and (2) remains more life wrecking than other specialties that are “neat and clean” in their job and task structures? And can PCPs, especially younger ones, fulfill the varied demands of a clinical care consultant, clinical team leader, or clinical care manager without ongoing exposure to a diverse array of work such as hospital medicine, the absence of which could potentially undermine the level of mutual trust in existing patient relationships and self-confidence in clinical skills, and limit access to new clinical knowledge?

	A second problem involves shifting consumer preferences. The notion that patients want a traditional primary care delivery system with PCPs and their practices managing their care is a bedrock assumption on which support for the PCMH rests. But it could also be posited that many patients, particularly younger, healthier ones, do not necessarily think that a physician-centric primary care system is the only one that can work for them. Many of us have now come of age in a health system where fragmented, specialty care is the norm for many of our ailments. It also is a system where medical home—type primary care has not been seen for a long time, if at all, replaced by 15- to 20-minute office visits for discrete illness episodes that provide a fast-food experience for both doctor and patient.

	New, alternative forms of primary care delivery such as retail clinics are growing rapidly. These places are patronized disproportionately by younger adults.

 Some early evidence points to a general public with less apprehension than might be expected in receiving care in retail clinics that often are staffed by nonphysician care providers.

 The idea that such places might compete effectively with traditional primary care practices on the basis of more than a few low-level clinical diagnoses is anathema to many PCPs. But what if new delivery forms like retail clinics suit a wider range of consumer needs with respect to primary care, including greater convenience and speed, as well as lower cost?

	What if younger patients especially are not willing to learn about and commit themselves to the personal responsibilities required in being part of a PCMH, when many of their primary care service needs might be met cheaply and quickly while they also shop or pick up their prescriptions? What if competing forms of care like retail clinics end up poaching younger, healthier patients away from traditional primary care practices, leaving higher percentages of older, sicker patients for whom medical home—type care must be provided? Will this make implementation of the medical home model harder? Will it end up costing a lot more? If fewer younger, healthier patients actively participate in PCMHs, will that undermine some of what the model is supposed to do (ie, teach already-healthy individuals how to stay healthy) while at the same time leaving PCPs with a sicker cohort of clients in their practices who are less compliant and who require higher levels of basic acute care on a constant basis?

	I do not mean to disparage the medical home concept. In an ideal primary care practice environment, it might work well. But greater attention must be paid to building a solid foundation on which to implement it. Focusing more on the primary care workforce and consumer preferences would help attend to this necessity. For instance, although many PCPs have adapted to the current business model in ways that allow them to do their work efficiently, they likely have less familiarity with true care coordination, case management, and accessible care delivery because of fewer opportunities to engage in them over the past decade or more. Many practicing PCPs will require retraining to serve as case managers, care consultants, or clinical team leaders. Young students and residents interested in primary care will need better socialization to the realities of doing primary care work that is both medical home oriented and assembly line oriented, and must know ahead of time how much is expected of them in such a bifurcated practice model. And some consumers may need extended convincing that this more intrusive model of care is worth it for them, enough so that they are willing to bypass newer, cheaper, and more convenient forms of alternative primary care delivery and place their faith once again in the traditional primary care practice.

	If foundational elements like these are ignored, it strains credibility to think that the PCMH idea, which initially will complicate primary care delivery and impose stricter accountability on both doctors and patients, can provide a reliable, long-lasting hinge to swing a major component of the US health system in a more patient-centric direction.

 From the Department of Health Policy, Management, and Behavior, University at Albany, Rensselaer, NY.

Dr Hoff reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content; and administrative, technical, or logistic support.

Timothy Hoff, PhD, Department of Health Policy and Management, University at Albany, 1 University Pl, Rm 181, GEC Bldg, Rensselaer, NY 12144. E-mail: 

1. Patient-Centered Primary Care Collaborative. 

Joint principles of the patient centered medical home. http://pcpcc.net/content/jointprinciples- patient-centered-medical-home. Accessed October 16, 2009.

2. American Academy of Family Physicians. 

National Resident Matching Program. 2010 Match Summary and Analysis. http://www.aafp.org/ online/en/home/residents/match.html. Accessed May 25, 2010.

3. Hauer KE, Durning SJ, Kernan WN, et al. 

Factors associated with medical students’ career choices regarding internal medicine. 

Practice Under Pressure: Primary Care Physicians and Their Medicine in the Twenty-First Century. Piscataway, NJ: Rutgers University Press; 2009.

Influence of controllable lifestyle on recent trends in specialty choice by US medical students. 

6. Block SD, Clark-Charelli N, Peters AS, Singer JD. 

Academia’s chilly climate for primary care. 

7. Mehrotra A, Wang MC, Lave JR, Adams JL, McGlynn EA. 

Retail clinics, primary care physicians, and emergency departments: a comparison of patients’ visits. 

8. Deloitte Center for Health Solutions. 

Retail Clinics: Facts, Trends and Implications. http://www.deloitte.com/assets/Dcom-UnitedStates/ Local%20Assets/Documents/us_chs_RetailClinics_230708%281%29.pdf. Accessed October 18, 2009.

For the medical home concept to work, greater attention must be focused on primary care workforce needs and consumer preferences.

Timothy Hoff, PhD

Articles

The Challenges of Consumerism for Primary Care Physicians

Embracing a Diversified Future for US Primary Care

The Shaky Foundation of the Patient-Centered Medical Home