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The American Journal of Managed Care January 2020
Using Applied Machine Learning to Predict Healthcare Utilization Based on Socioeconomic Determinants of Care
Soy Chen, MS; Danielle Bergman, BSN, RN; Kelly Miller, DNP, MPH, APRN, FNP-BC; Allison Kavanagh, MS; John Frownfelter, MD, MSIS; and John Showalter, MD
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The Challenges of Consumerism for Primary Care Physicians
Timothy Hoff, PhD
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The Challenges of Consumerism for Primary Care Physicians

Timothy Hoff, PhD
Implementation of retail health consumer tactics in primary care poses challenges for primary care doctors that must be recognized and addressed.
Am J Manag Care. 2020;26(1):e1-e3.
Takeaway Points

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.1 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.2-5 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.

The retail-oriented meaning of the term healthcare consumer reflects its ongoing adoption by existing organizations and high-tech innovators seeking to promote retail tactics in the healthcare space.6 Examples include large, well-branded nonhealthcare companies just entering healthcare, like Apple, Google, and Amazon7-9; existing healthcare entities, such as information technology companies that make electronic health record (EHR) software,10 medical device and pharmaceutical firms,11 integrated delivery systems (eg, Kaiser Permanente, Geisinger), insurance companies, and national pharmacy chains; and start-ups eager to gain acceptance in the healthcare marketplace.12-16

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.17 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.15

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—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.18 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.19 Physicians question the merit of many performance measures used to assess their work.20 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.21

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