The Challenges of Consumerism for Primary Care Physicians
Timothy Hoff, PhD
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
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.22-24 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.21 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.25,26 Many primary care doctors have experienced the heavy documentation burden that the EHR thrusts upon them.27 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.17 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—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).28 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.29,30 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.