Toward a New Definition of Primary Care: Primary care 3.0

For the last couple thousand years, doctors have used the same tool to treat their patients— an appointment, a physical room, a conversation, and a payment for the time. Communication and problem-solving has happened exclusively in the exam room. The average person age 18–65 visits the doctor 2.7 times a year and the average visit is ~10 minutes for a total of 27 minutes of doctor communication and problem-solving per year. Because it’s an oral conversation, full of anxiety and jargon, patients forget ~85% of the conversation. That’s ~4 minutes of memorable education/conversation per year. This is Primary Care 1.0. Primary Care 2.0 is today’s “innovative” versions of value-based primary care 1.0 designed to fit a square peg into a round hole. It’s the same office-based primary care 1.0 trying to fit itself into an insurance payment model that transfers risks away from insurance companies and onto primary care doctor groups. Primary Care 2.0 also includes the Direct Primary Care model which can best be described as concierge medicine-lite. It deifies the old-fashioned doctor-patient relationship and offers consumers that one-on-one relationship for a fixed cost. It’s not trying to solve the “how do we scale primary care?” problem. It’s saying the old-fashioned doctor patient relationship is the best tool out there and we’re just gonna double down on it and sell that same couple thousand year old tool at a premium.

Tools solve problems. Primary care 1.0 and 2.0 are tools to solve a problem. Are these the best tools we can imagine to deliver care?

Primary Care 3.0 leapfrogs today’s old-fashioned primary care out of necessity and pressure placed on the industry to meet today’s consumers’ expectations. It also exists simply because it can. Technology like machine learning and mobile-first services exist in other industries and there are a few in healthcare who can’t stand sitting by idly and ignoring what these tools can do for our nation’s health. We’re seeing this kernel in services like TelaDoc, Lemonaid, Sherpaa, Nurx, SteadyMD, and a few others. But what is Primary Care 3.0 and why should it exist?

Consumers don’t want Primary Care 1.0

In this 18–65 year demographic, 50% of people say they don’t have a primary care doctor. And, of that cohort, 50% say they don’t want a primary care doctor. Two conclusions can be drawn from this:

• Half of working age Americans do not value the tool given to them enough to establish a meaningful connection/relationship.

• Twenty five percent of working age Americans want a transaction, not a relationship. They just want their problem solved as quickly, as easily, and as affordably as possible.

Consumers Expect Easy Convenience

Consumers now expect tech-enabled services to be beautiful, easy to use, and centered around them. In an age where you can summon an uber in 3 minutes, people are logically expecting the same for healthcare. They’re also expecting services to be economical, especially as a new high deductible, out-of-pocket market is coming on board as deductibles have dramatically risen and will continue to rise.

Our Society is Mobile

Compounding this is a marked increase in mobility in our culture. Working age people are changing jobs, traveling regularly, moving neighborhoods, and changing insurance companies on an every few year basis. And primary care doctors are moving around as well as they become increasingly employed by local healthcare systems, urgent care centers, etc..

Primary Care 1.0 is Outdated

Today’s neighborhood-based primary care that depends exclusively on exam room communication and problem-solving has not been updated for thousands of years. It’s about time we start thinking of primary care, not as a one-on-one individual local relationship, but as a cloud-based service that quickly, accurately, and cost-effectively diagnoses, treats, and connects patients with the right care, at the right time, every time. Primary care must transition from unscalable one-on-one, local, in-person expensive transactions to scalable, mobile-first, inexpensive data-driven diagnosis and treatment services. Online asynchronous communication (email-like messaging) will be, by far, the main communication mode and in-person (office visits) or virtual/real-time (phone/video) will be reserved for more in-depth/urgent situations.

Primary Care 1.0 is Unstructured and Artsy

Today’s diagnoses come from physical visits, unstructured oral conversations, physical exams (a very blunt tool for most situations), and broad-testing (the more you test for, the more you can bill and the more diagnoses you can make). Future diagnoses will come from online, structured, analyzable conversations, and targeted testing to confirm data-driven suspicions. Due to machine learning/AI, it will cost nothing, except for the cost of a targeted test, to arrive at an accurate diagnosis 95% of the time. No humans will be involved in this stage of the process.

Primary Care 1.0 doesn’t manage conditions cost-effectively

Once a diagnosis is made, today’s ongoing management of a condition involves more increasingly expensive physical visits, more unstructured oral conversations, hopefully more targeted testing to follow progress, and no standardized, structured way to mark an issue as officially resolved. Tomorrow’s primary care management will involve few physical visits, structured oral conversations designed to elicit updates on progress, and targeted testing to objectively measure resolution. Over time, this entire process will be mostly automated via machine learning. Because outcomes are best when humans are augmented by machines, the machines will flag a situation and solicit a doctor’s help when necessary.

Primary Care 1.0 Thinks They Own Patients

Even more importantly, Primary Care 3.0 will function as a super-connector. We’ve all met people who are super-connectors. Their network is huge and they view their role in life as altruistic problem-solvers. Through engaging conversation, they identify someone who can help you. They do this for free, because they don’t feel like they own your problem and they don’t feel like they have the best solution to your problem. They always know someone who could truly help you. Today’s primary care claims too much ownership of their patients. They make patients come into the office to get a feel for the situation, and then refer relatively blindly to a specialist, without data to support the most appropriate referral. This is an expensive, time-consuming, error-prone, and inefficient process. By asking the right questions online, when assessing complicated situations, it’s nearly always immediately clear that a patient needs specialty care, not general care. And as our society gets more and more technical and specialized, consumers will demand cost-effective specialists. Primary Care 3.0 is agnostic and does not claim ownership. The whole goal of Primary Care 3.0 is to get problems solved as quickly as possible, with the fewest steps possible, from the most appropriate service. We won’t own people, we’ll own problems.

Primary Care 1.0 is Designed for Complex Problems

Primary Care 3.0 will meet the needs of the vast majority of the population because most people are simply not that sick and in need of high touch, expensive, ongoing routine care. Remember, 20% of people are responsible for 80% of total healthcare costs. And 5% of people spend ~50% of costs. Most people in this category are in their last stages of life or they temporarily need expensive care for a reversible condition (example: hip fracture due to a car crash). But 50% of people spend ~3% of costs. Low-touch, data-driven, online communication and management will diagnose and treat health problems for 80 to 90% of the US population.

Primary Care 3.0 isn’t humans, it’s humans augmented by machines

As you can see, Primary Care 3.0 is not a one-on-one relationship with a human in your neighborhood, it’s a relationship with a technology-enabled service designed to automate a diagnosis, recommend the least expensive treatment plan with the highest chance of success, and effectively flag a situation where real human doctors need to be involved. This scales primary care.

Primary Care 3.0 Will Exist Outside Insurance Payment Models

Insurance companies move too slowly to incorporate healthcare service innovations. Meanwhile, real people’s out of pocket healthcare costs are skyrocketing. If health insurance companies do not meet consumer expectations, they’ll quickly catch on that insurance will only be used for high cost, old-fashioned services only when you absolutely need that type of service. Lower cost catastrophic insurance + Primary Care 3.0 will be the most cost-effective way to solve health problems.

Primary Care 3.0 will be a Tech Platform

Primary Care 3.0 will be powered by a secure, network-driven, artificially intelligent communication and problem-solving platform. Here’s an example of what it should look like.

This is not a matter of if this is going to happen, it’s a matter of when.

Technology will disrupt the traditional old-fashioned exam room-based doctor and make the online practice of medicine markedly more efficient and higher quality. And the massive forces of economic pressure placed on individuals faced with skyrocketing healthcare costs will drive the growth of these new models of online healthcare delivery.

Politically, this is a challenge as primary care doctors want so badly to believe in the traditional primary care model and say good primary care is dependent upon a meaningful in-person doctor-patient relationship. But 50% of working age Americans don’t care enough about that to invest in a relationship and 25% of Americans don’t even want a relationship. We, as doctors, can’t deliver what we want. We have to deliver a service that people want. And we also have to admit that the tool we invented thousands of years ago is too expensive, too inconsistent, too unstructured, too much of an art, and lacks accountability. If a computer can drive a car in a chaotic physical world, a computer can easily leverage the right data to ask the right questions to accurately arrive at a diagnosis, treatment plan, and cadence for ongoing management of 90% of people’s problems.

I’m proposing a new definition of primary care, or, rather a new tool to solve problems updated for today’s changing economics and culture. The tool should accomplish the following. It should:

• Solve the problem of our culture’s mobility. Primary care 3.0 should be accessible anytime and anywhere.

• Solve today’s on-demand expectation. Primary care 3.0 should be available within minutes- not hours, days, or weeks.

• Determine a patient’s immediate needs at no cost to the patient. Prior to spending any money, a person must understand their needs. This will be done through a combination of human and machine learning.

• Be an agnostic, intelligent, super-connector at no cost to the patient.

• Be data-driven (“if a person answered a series of 25 questions in the following way, there’s a 98% chance they have this diagnosis” and “if they have this diagnosis, “there’s a 99% chance they’ll respond to the following treatment strategy.”)

• Be cost-conscious. Care is getting wildly expensive. Primary Care 3.0 should use data to recommend the least expensive way to diagnose and treat, and manage over time 95% of general health issues.

• Know its limitations. When Primary Care 3.0 needs a human to make a decision, it will solicit help from a professional.

• Work for 90% of the population.

• Be an open-source, secure tech platform