Primary care of the future: Where will consumers go and what are the industry implications?

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In the future, health status should be the main driver of where consumers go for primary care services. The sites consumers choose will be different for scheduled—or planned—care versus unscheduled, urgent care. Health systems must guide them for both cost and health reasons.

To understand how age, geography, income and care preferences impact where consumers will go for primary care in the future, use HRI's interactive tool to explore the stories of seven different consumers.
 


 

Explore which primary care sites best match the needs, demographics and preferences of these seven consumers
Select a consumer
DIY Daphne | A multi-tasker who doesn't like going to the doctor and is not sure health insurance is worth the money

An artist, Daphne balances her personal life with her professional one. She manages a private art studio, and leads a yoga class each Sunday with a group of art professionals. Daphne doesn't have health insurance or a regular doctor but uses apps on her phone to track her sleep and regularly wears a pedometer. Daphne went to see a clinician just once last year, when she had a very bad case of the flu and couldn't treat herself at home. She tries to avoid spending on prescription medications as well, and typically picks up one prescription per year. Her frugal use of the healthcare system means that she spends only about $220 annually out-of-pocket on healthcare including $20 on prescriptions.

Soccer Mom Sally | A working mother of four making healthcare decisions for the whole family

Mother of four soccer stars and organic coffee entrepreneur, Sally carefully watches her own health and manages the health of her family. Other than suffering from the occasional ear infection or sprained ankle, Sally's children are healthy. On average, her family makes two or three visits to clinicians each year and spends $160 on medical care out-of-pocket. The family's prescription drug utilization is low—on average, just one prescription at $10 each year. Increasingly, Sally also helps her ailing father make decisions about a growing number of health issues, including Type II diabetes.

Super utilizer Steve | A frequent flyer of the ER with multiple chronic diseases

Steve is a very unhealthy adult who has a hard time managing multiple health issues: congestive heart failure, chronic obstructive pulmonary disorder and Type II diabetes. As his health continues to deteriorate, Steve has been missing more and more work. He held five different jobs last year and fell behind on his car payments. He is a frequent flyer at the local emergency room because he believes the ER is the best place to have all his health issues treated quickly and in a single location. He feels he is the only one looking out for his health, which is overwhelming to him. Steve racked up over $1,200 last year in out-of-pocket healthcare costs, which he now struggles to pay. With $540 going towards prescriptions, it is difficult for Steve to adhere to taking the medications he's been prescribed.

Frail Fiona | An elderly grandmother living at home in poor health with osteoporosis and the early signs of dementia

An octogenarian, Fiona is a retired health food store owner in the Midwest. Fiona lives alone with advanced osteoporosis, which puts her at risk for falling. She has a number of other health issues that are becoming harder and harder to manage, especially now that she has been diagnosed with early stage dementia. Last year she visited a clinician more than 16 times, including by ambulance to the ER and hospital. Fiona spent $2,000 out-of-pocket last year on healthcare, including $500 on over 30 prescription fills.

Sad Sara | A working professional with a history of mental illness

A professional photographer with work cited in several fashion magazines, Sara is in good physical health but has a history of anxiety and depression. Occasionally, Sara becomes deeply depressed and her friends and family feel helpless. When this happens Sara feels isolated but seeks out care to help her connect with the simple pleasures of daily life. She sees a psychiatrist regularly, about five times per year, but dislikes the social stigma she feels is associated with going to a mental health clinic. She also dislikes having seven refilled prescriptions as a part of her mental health treatment. Because of her frequent healthcare visits, she spent $500 last year on her care out-of-pocket, including $140 on medications.

Blood Pressure Ben | An on-the-go CEO managing a chronic disease

A business executive and father dealing with a high-stress career, Ben also values a fast-paced social life with his friends in the city. When it comes to his health, he is looking for the most convenient way to manage his chronic hypertension; sometimes this means skipping doctor's appointments because of work or social conflicts. Ben is interested in finding a care team that can monitor his blood pressure outside of the doctor's office so he has more control over his health treatments. Today, he visits a clinician at least six times per year. It's costly (over $700 last year out-of-pocket), and it interferes with his busy lifestyle. Ben is also on prescription medications just for his blood pressure, which means he spends $200 on drugs to manage his health.

Healthy Hadley | A healthy adult who values exercise and preventive care

A healthy single adult and avid runner, Hadley manages a local fitness store. When it comes to health, Hadley is interested in preventive care (regular physicals and screenings) and is always seeking ways to track and improve his health. Recently, he has also been thinking about finding a wellness coach. Hadley spends about $280 out-of-pocket on medical care each year, including $35 on one or two prescription drugs.

Step 2: Select care type, age, location, income and care preference

Type of care

Age range

Geography

Income

Preference for care

The following primary care sites most closely match the information provided for Healthy Hadley's:

Retail clinics
Retail clinics
  • Consumer impact: HRI research shows that 36% of consumers visited a retail clinic in the last year. More than one-third of consumers with a primary care physician have also gone to a retail clinic such as CVS Health, Walgreens or Target for treatment of ear aches, sore throats, cuts and broken bones, and even some monitoring of chronic disease. An overwhelming 95% are satisfied with the care, and the steady flow is reducing unnecessary visits to emergency departments. Eighty-nine percent of consumers would recommend retail health..
  • Industry implications: Visits to retail and urgent care centers tripled from 2010 to 2014, according to HRI research, and the six largest retail chains have put over 1,600 such storefronts on the streets. Forty-seven percent of physicians surveyed by HRI say retail health clinics improve patient satisfaction and 69% believe they increase access to care. Yet only 17% of physicians partner with or plan to partner with a retail clinic. Leading health systems such as Cleveland Clinic, Texas Health Resources and Kaiser Permanente are partnering with retail clinics to triage patients with lower acuity problems away from more expensive mothership locations. Some are also developing joint programs to manage patients needing chronic disease management.
House calls
House calls
  • Consumer impact: According to HRI consumer research, nearly two-thirds of consumers would be interested in having a clinician treat them at home. Home care offers fresh alternatives to traditional office visits that may prove increasingly competitive, especially among the elderly but also among families with children.
  • Industry implications: New companies such as Pager and Heal and are forming to meet consumer demand, using mobile apps that dispatch clinicians to the patient's home or office. Community paramedicine is also a growing trend in which trained paramedics are dispatched to assist with chronic disease management, medication compliance and home safety. Geisinger Health System's community paramedicine program has had positive results, and participants in CMS's Independence at Home Demonstration saved over $25 million in the first year by reducing readmissions and inpatient and emergency department utilization for chronic conditions.1While on average physicians HRI surveyed do not anticipate physician house calls to make a comeback, 79% believe that non-physician house calls will increase over the next ten years.
Independent nurse-led care
Independent nurse-led care
  • Consumer impact: A growing number of consumers (75%) say they would be comfortable seeing a nurse practitioner or physician's assistant for care, according to HRI research. "There is a cadre of patients that wants to see the primary care physician every time but that group is shrinking," said Richard Kalish, MD, of the division of primary care at Lahey Health. Advanced practice nurses manage their own patient panels, without the supervision of a physician.
  • Industry implications: Nurse-led care has the potential to make a sharp ascent in the primary care market if states continue to relax restrictions on nurse practitioners' ability to practice without physician oversight. By the end of 2014, more than half of states were weighing expanding the clinical duties of nurses. Two states lead the way in nurse-led primary care: Vermont — where Appletree Bay Primary Care opened its doors in 2014 with seven primary caregivers, all of whom are faculty members of the University of Vermont College of Nursing and Health Sciences — and Indiana, where Purdue Family Health Clinics opened the same year to care for medically underserved regions. There is growing evidence to support that the quality of care delivered by advanced practice nurses is equivalent to care of primary care physicians.
DTC telehealth companies
Direct-to-consumer telehealth companies
  • Consumer impact: Gone are the days when consumers required face time with their doctors; now, 60% of HRI consumer survey respondents say they would be open to a virtual doctor's visit, whether by phone, text, email, chat or video conference.
  • Industry implications: The American Telemedicine Association estimates that 12 million Americans received telehealth services in 2014, and that number is expected to double in 2015. Companies such as PlushCare, Teladoc and Doctor-on-Demand bring a clinician into the home through a simple App download. Traditional physician practices are trying to compete: according to HRI's clinician survey, over half of all physician groups who are offering new services are using technology to improve patient access. The federal government and commercial insurers are beginning to reimburse for digital health, though uptake is greatest in value-based models. Many of Kaiser Permanente's health systems are already performing more than half of patient visits through mobile, secure messaging or video and virtual care accounts for 50-60% of Iora Health's interactions with patients, according to an HRI interview with the company's CEO. E-visits are free in One Medical's high-tech model.
New-age concierge care
At-your-service care
  • Consumer impact: Subscription-based, at-your-service care focuses on personalized, boutique- like care without the exorbitant fees long associated with traditional concierge medicine. These companies offer consumers shorter wait times and more personal attention and boast high patient satisfaction. This team-based model treats the "whole" person in one location with less bureaucracy, modern technology and access to nutritionists, diabetes specialists, integrative medicine and much more. Seventy-six percent of consumers told HRI they value high patient satisfaction ratings when selecting a provider.
  • Industry implications: Venture capitalists have given new at-your-service care companies One Medical and Iora Health a real boost in recent years, and 71% of physicians HRI surveyed believe that this model will become more dominant over the next decade. Larger health systems are contemplating whether to compete or partner with the new primary care players.
Traditional physician practice
Physician practice with team-based care
  • Consumer impact: Instead of one-dimensional, in-person visits with a primary care doctor, consumers will increasingly have multi-dimensional interactions with a broader team of caregivers at an array of convenient care sites. Consumers may log in virtually for a consult or decide to be examined in the clinician's office or at home. How these interactions occur will depend not only on the consumer's health status but on their location, income, age and what they value in care.
  • Industry implications: Traditional primary care practices are expected to look quite different in the future, relying on a broader team of caregivers, technology and consumer insights to deliver more personalized care while managing population health. About one-third of doctors told HRI they have changed their business model to adapt to non-traditional care models and new entrants in the market. Some have started providing virtual care and one-stop-shopping conveniences. To achieve desired outcomes and manage costs, primary care practices cannot be just a piece of the care puzzle; they must solve this puzzle for the patient. With a team-based model, practices can elevate the primary care physician's role to that of air traffic controller, coordinating a patient's care across various sites.
Remote monitoring companies
Remote monitoring companies
  • Consumer impact: One-third of the consumers HRI surveyed said that they were interested in a wearable device that could monitor vital signs and 85% of physicians said that the primary care doctor of the future will spend more time using mobile applications. Frail elderly patients and those with complex chronic disease need intense care management and coordination and are ideal candidates for 24/7 remote monitoring.
  • Industry implications: Remote patient monitoring can help manage chronic disease such as diabetes or hypertension. Today companies can monitor patient vital signs at rest using "smart beds" or even notify a physician if a patient's glucose level drops suddenly. Remote monitoring is expected to save the system $36 billion globally by 2018 through alerts to clinicians well before a patient's health status turns into an emergency. In January, Medicare began reimbursing clinicians $40 per patient per month for offering patients 24/7 virtual access to care, including remote monitoring.
DIY technology
DIY technology
  • Consumer impact: Empowered by innovation, some consumers are ready to abandon traditional care in exchange for remote, do-it-yourself alternatives. HRI's consumer research shows that, on average, half of consumers would prefer a DIY diagnostic option such as a strep test, a phone attachment that checks for ear infection or an app that sends a clinician a digital image of a skin rash.
  • Industry implications: In the New Health Economy, high-tech personal medical kits could help diagnose illness, flag early signs of trouble, allow recovery and rehabilitation to occur closer to home and create virtual workforce capacity. HRI estimates these DIY care tools represent more than $64 billion in traditional provider revenues. According to an HRI clinician survey, 42% of physicians are comfortable relying on the results of certain patient DIY tests to prescribe medicine.
Emergency department
Emergency department
  • Consumer impact: Today's consumer wants on-demand service and often gets it, whether purchasing airline tickets or a movie. But try calling the doctor's office and hours can pass before a human connection is made. By then, many have gone to the emergency department for 24/7 access to care at a higher cost. On average, 37% of emergency room visits are for non-urgent services.
  • Industry implications: Without a strong primary care backbone in the health system, the emergency department continues to be overused. In the future, in addition to trauma, emergency medicine physicians are expected to treat frail elderly, patients with complex chronic disease and patients with mental illness in consultation with the patients' primary care provider to reduce unnecessary admissions. Fixing only one health problem in isolation might exacerbate other health issues.
Urgent care clinic
Urgent care clinic
  • Consumer impact: Urgent care centers are a less expensive, more convenient alternative to emergency departments for unscheduled, urgent (non-life threatening) care needs for consumers who are otherwise healthy and for consumers with mental illness. They also generally offer a more extensive range of services than retail clinics. Visits to retail and urgent care centers tripled from 2010 to 2014, according to HRI research, exceeding 10 million in 2012. Studies show that the quality of care meets or exceeds standards compared to traditional care settings.
  • Industry implications: The six largest retail chains have put over 1,600 such storefronts on the streets. The federal government is pumping $11 billion into the industry to establish community health centers and expand primary care services in federally-qualified health centers, specifically.
Patient-centered medical home
Patient-centered medical home
  • Consumer impact: While the traditional model forces the sick and the healthy into the same location, the growing trend is toward segregating complex care from minor or maintenance care. By 2020, 81 million Americans will suffer from multiple chronic health conditions, further taxing the primary care system. Frail elderly patients and those with complex chronic disease need intense care management and coordination and are ideal candidates for patient-centered medical homes, which emphasize efficiency and care coordination through team-based care for distinct patient populations.
  • Industry implications: New payment models such as the National Council on Quality Assurance's (NCQA) patient-centered medical home model and Medicare accountable care organizations also focus on revving up the role of primary care. These models have been the most widely publicized attempts by traditional primary care practices to simplify healthcare for consumers, reduce emergency room visits and admissions, and lower overall costs.
Nurse-managed clinic
Nurse-managed clinic
  • Consumer impact: A growing number of consumers (75%) say they would be comfortable seeing a nurse practitioner or physician's assistant for care, according to HRI research. "There is a cadre of patients that wants to see the primary care physician every time but that group is shrinking," said Richard Kalish, MD, of the division of primary care at Lahey Health. Physician oversight is required at nurse-managed clinics, but the majority of care is provided by nurses.
  • Industry implications: Using nurse practitioners or physician assistants instead of more costly doctors has been estimated to save Massachusetts over $8 billion in the next decade and managed primary care delivered by nurse practitioners cost 23% less compared to the average costs of other primary care physicians in Tennessee. The master's-trained nursing workforce is blossoming with help from government programs. In physician practices, these nurses can lead group visits for patients with similar health conditions and needs, ranging from diabetes and heart failure clinics to newborn and prenatal groups. Nurse practitioners will represent 29% of all practicing clinicians by 2025 and, unlike studies that project major physician shortages, workforce studies for nurse practitioners foretell a surplus.


 

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Benjamin Isgur

Health Research Institute Leader, PwC US

Sarah Haflett

Director, Health Research Institute, PwC US

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