Traditionally, when things were simpler, people had a primary care doctor. He looked and acted a lot like Marcus Welby or Doc Hollywod. But something huge happened that changed everything. The general field of medicine became overly complex. Atul Gawande, in his commencement speech, Cowboys and Pit Crews, addresses this complexity problem:
The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to “protocol” the MRI.
Massive complexity was introduced to primary care via two mechanisms:
#1: By an increasing body of professional knowledge that created advanced technology that led to more intricate specialized tests and procedures
#2: By payors to attempt to control costs. If we get you, the PCP, to create extremely detailed data about each and every interaction via your EMR, submit the data to us in order to get paid, we will use this data against you to attempt to control what you do in your daily practice. This backfired, as healthcare became one big cat and mouse game, which supported the age old maxim that complexity invariably increases costs and decreases value. It backfired so much that primary care is now a money-losing “department” for local hospitals. But, since hospitals need the referrals from local PCPs, they’ve been buying primary care practices knowing they’ll lose money, in order to get the referrals. They have no incentive to clean up primary care, streamline their processes, and make the “department” cash-flow positive. The more inefficient primary care is, the less time PCPs have to manage more complicated conditions, and the more they’ll refer to profitable specialty departments within the hospital networks.
Patients, who expect primary care access, have gotten the shaft. And the compromise has been the rise of the “more expensive than primary care but less expensive than the ER” urgent care centers who are now increasingly owned by local hospitals.
The accessibility of the old-fashioned primary care doctor has been decimated. Some PCPs have reacted to this scenario with nostalgia by going renegade and pulling out of “The System” and setting up a Direct Primary Care practice. A DPC doctor finds 600 to 800 local patients and convinces them to pay $70 to $120 per month for unfettered access to them, the individual doctor who checked out of the system. Systemically, this further strains primary care, as 900 primary care doctors have gone AWOL from the insurance rosters after the federal government has mandated that we all must purchase insurance.
This reaction from doctors is a bit like a whole group of taxi cab companies, who are feeling the effects of uber, announcing to the world that they’ve come up with a new solution— they’re gonna put a dude in a room, give him a phone, advertise the hell out of a phone number like 777-777-7777, say “here’s your solution” and double down on the argument that the world was better before uber.
The problem is there’s no going back. Tech has changed everything about our culture and consumers have new expectations. They want on-demand accessibility at a reasonable cost. Uber and Lyft did it to the human-powered service called taxis. Affordable “primary care” accessibility will happen with the healthcare service industry. It’s just a matter of when.
Primary care is at a crossroads. Medicine is too complex to not primarily be a data-driven, human-powered but augmented by technology, online, on-demand service. Doubling down on going back to the days of Marcus Welby is definitively not the solution today’s possibilities call for. This revolution won’t be in the form of Direct Primary Care because DPC’s focus isn’t on affordability, efficiency, and, ultimately, using data and technology to do more, better, with less. DPC is like an uber that costs 5 times as much as a cab and only has room for 1 person in the front seat of the BMW. It doesn’t maximize a higher quality, technology-driven, increased throughput.
And it won’t be in the form of TelaDoc or Doctor on Demand. While they are attempting to scale throughput for primary care, due to the design and limitations of the 10 minute oral conversation between strangers, it can only do so for 30 simple things. This is like uber getting a $1B investment and saying they can only take you to 30 different McDonalds.
It will be an on-demand online service that can handle any and all health issues. The service will advertise that you should use this service for any medical issue at any stage. But what does “handle” mean? It means 80% of the time, you can get diagnosed, treated, and have an ongoing relationship with the service until, in acute settings, the issue is resolved exclusively online, and, in chronic settings, the issue is optimally managed. “Handle” also means the service will act, in the 20% of situations that need in-person care (procedures, tests, etc.) as your healthcare financial consultant and professional concierge coordinating each and every step with local, in-person professionals and facilities to optimize your healthcare spend. No matter what, this service is the first place you reach out to at the onset of an issue and the service you reach out to throughout issues with any new updates. It is your always on, go-to “call a friend” that helps you win the healthcare game and get the highest quality treatment at the right price. And, if this service does its job effectively, everyone will know this is exactly how you use the service and, eventually, all care in America will be primarily on-demand, online communication and problem-solving between you, your doctor, and your doctor’s team of support professionals.
Phase Two of this service, to further streamline the operations and efficacy of this service, will be slick, consumer-obsessed neighborhood-based testing centers constructed to confirm your online care team’s suspicions. For example, when your doctor needs to order an x-ray or an ultrasound, or a few simple blood tests or swabs (think of this panel of tests as the most common, super inexpensive top 100 tests you’d now get at Quest), you just show up, get the test, leave, and get pinged by your online care team that your results are back and “let’s talk about a treatment plan that’s evidence-based and realistically fits in to your lifestyle.” This kind of testing center would tackle the low-hanging simple test fruit that would meet 90% of all testing needs. These testing centers would pull all the simple imaging tests from today’s imaging centers and force the imaging centers to only do more complicated things like MRIs and MRAs. They would also pull all the simple tests that Quest does and force them to do only the more complicated long tail of blood tests they currently do.
It’s my vision that this service is Sherpaa. But with healthcare being a ~$3T nationwide industry, there’s plenty of room for tons of services to compete based on price, effectiveness, and consumer experience.