Embracing a Diversified Future for US Primary Care

The American Journal of Managed CareJanuary 2013
Volume 19
Issue 1

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.

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.

(Am J Manag Care. 2013;19(1):e9-e13)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.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

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.18

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.27,28 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.29

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

Funding Source: None.

Author Disclosures: 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.

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

Address correspondence to: 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.

9. Pollack CE, Gidengil C, Mehrotra A. The growth of retail clinics and the medical home: two trends in concert or in conflict? Health Aff (Millwood). 2010;29(5):998-1003.

10. Mehrotra A, Liu H, Adams JL, et al. Comparing costs and quality of care at retail clinics with that of other medical settings for three common illnesses. Ann Intern Med. 2009;151(5):321-338.

11. Goroll AH. Reforming physician payment. N Engl J Med. 2008;359(20): 2087, 2090.

12. The Physicians’ Foundation. The Physicians’ Perspective: Medical Practice in 2008. http://www.physiciansfoundation.org/uploadedFile/PF_Survey_Report_Nov08.pdf. Published 2008. Accessed December 15, 2011.

13. Kaiser Health News. The Walmart opportunity: can retailers revamp primary care? http://www.kaiserhealthnews.org/stories/2011/november/17/walmart-opportunity-can-retailers-revamp-primary-care.aspx. Published 2011. Accessed January 7, 2012.

14. Ashwood JS, Reid RO, Setodji CM, Weber E, Gaynor M, Mehrotra A. Trends in retail clinic use among the commercially insured. Am J Manag Care. 2011;17(11):e443-e448.

15. RAND. Health care on aisle 7: the growing phenomenon of retail clinics. http://www.rand.org/pubs/research_briefs/RB9491-1.html. Accessed December 8, 2011.

16. Kocher R, Sahni NR. Hospitals’ race to employ physicians—the logic behind a money-losing proposition. N Engl J Med. 2011;364: 1790-1793.

17. Merritt-Hawkins. 2010 Physician inpatient/outpatient revenue survey. http://www.merritthawkins.com/pdf/2010_revenuesurvey.pdf. Published 2010. Accessed January 10, 2010.

18. Freudenheim M. Hospitals begin to move into supermarkets. New York Times, May 11, 2009. http://www.nytimes.com/2009/05/12/business/12clinic.html. Accessed December 29, 2010.

19. American Association of Medical Colleges. Physician shortages to worsen without increases in residency training. https://www.aamc.org/download/150584/data/physician_shortages_factsheet.pdf. Accessed December 22, 2011.

20. National Resident Matching Program. Results and data: 2011 main residency match. http://www.nrmp.org/data/resultsanddata2011.pdf. Published 2011. Accessed January 3, 2012.

21. Fairman JA, Rowe JW, Hassmiller S, Shalala DE. Broadening the scope of nursing practice. N Engl J Med. 2011;364(3):193-196.

22. Sox HC. Quality of patient care by nurse practitioners and physicians’ assistants: a ten-year perspective. Ann Intern Med. 1979;91(3): 459-468.

23. Laurent M, Reeves D, Hermens R, et al. Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews 2005. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001271.pub2/abstract;jsessionid=1A31B1353904A88486F31D84A80C29BF.d02t03. Published 2005. Accessed December 1, 2011.

24. Hoff T. Practice under pressure: primary care physicians and their medicine in the twenty-first century. Piscataway, NJ: Rutgers University Press; 2010.

25. Starr P. The social transformation of American medicine. New York: Basic Books; 1982.

26. American Academy of Family Physicians. Nurse practitioners. http://www.aafp.org/online/en/home/policy/policies/n/nursepractitioners. html. Accessed December 16, 2011.

27. Gray B. Conditions facilitating interorganizational collaboration. Human Relations. 1985;38(10):911-936.

28. Pfeffer J, Salancik GR. The external control of organizations: a resource dependence perspective. New York, NY: Harper and Row.

29. Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies of Science; 2010.

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