Navigating the Future of Healthcare

Examining the evolving landscape of primary care amidst rising chronic diseases and technological advancements.

By Nolan Shah

Our country’s population health data isn’t adding up. By 2050, 1.5 billion people will be over the age of 65. Nearly 95 percent of that group suffer from at least one chronic condition, but just 3 percent of healthcare spending goes toward preventive services. On the heels of the pandemic, people want to be more proactive about their health than ever before. Preventive medicine is the key to reversing chronic disease rates — but primary care, the branch of medicine intended to keep patients out of the hospital is shrinking. There will be a projected shortage of 18,000 to 48,000 primary care physicians by 2034, exacerbating the unmet needs of an aging population.  

Primary care involves basic medical care that addresses a wide variety of symptoms and diseases. It is often a patient’s first entry point into the larger healthcare ecosystem. A primary care physician can treat everything from depressive disorders to the common cold and they offer preventive services like annual checkups, blood tests, and patient education. Primary care physicians also help manage chronic conditions such as high blood pressure and insulin resistance, usually referring patients with more complex and severe issues to specialists.  

The traditional primary care model is this: A primary care physician sees patients ranging from infants to the elderly. They work in office settings and are responsible for about 2,500 patients. Primary care services are meant to be routine, but a quarter of all adults consult their doctor less than once a year, citing underinsurance and inadequate physician supply as reasons. 

“The primary care labor model is very challenging, as there are not enough primary care physicians and an increased prevalence of chronic conditions”, says Dr. Patrick Carroll, former Chief Medical Officer of Wallgreens and current Chief Medical Officer of Hims & Hers. “You have limited resources, which is providers to manage a growing need in terms of chronic conditions, like diabetes, COPD, and cardiovascular disease”.  

Even though there are still amazing primary care doctors out there, Americans are declining to see them — and only sometimes by choice.  

Telehealth and retail clinics: a new frontier in accessibility

Those with a choice — specifically Gen Z and millennials — prefer telehealth over in-person care because of convenience. However, with telehealth, it is difficult to receive care from the same primary care doctor. Americans are the least likely to have a consistent physician and place of care compared to other high-income countries.  

Those without a choice, in low-income communities, face many barriers to accessing primary care including lack of transportation, rigid appointment hours, and inaccessibility. The biggest barrier, however, is cost, with over 40 percent of all Americans delaying or forgoing care because of financial burden. Even if low-income communities were able to use healthcare in the same way populations without barriers do, the U.S. would be short an additional 102,000 primary care physicians.  

High-quality primary care services are needed to combat rising chronic disease rates. However, the current care model is unsustainable, as both costs and primary care physician shortages increase. These barriers have brought about novel models of care, improving affordability, convenience, and access. However, these new methods of primary care delivery should evolve to treat more complex conditions if traditional 9-5 family doctors are to be completely replaced.  

Doctors are leaving family medicine faster than any other specialty and aren’t being replaced by new medical school graduates. Instead, med-school grads are opting for careers in specialties such as cardiology, ophthalmology, and dermatology, all of which pay better than primary care. The average U.S. doctor earns about $350,000 per year but primary care physicians at their peak earning potential earn just $201,000. Burnout also stands to be a big reason for primary care doctors leaving their field or not joining to begin with. With such large patient panels, they see up to 20 patients per day and are tasked with administrative burdens taking up to 25% of their time.  

What’s more, every state has seen a reduction in primary care doctors per capita. This is forcing nurses and physician assistants to assume the roles of primary care. A study published earlier this year found that over a quarter of all Americans only interacted with nurses and physician assistants during their health visits.  

A typical family medicine doctor completes 15,000 hours of training over 5 years of training including residency. In contrast, physician assistants are required 2 years and 2,000 hours of training while nurse practitioners must complete 1,000 hours. Select research shows receiving care from nurse practitioners or physician assistants leads to worse health outcomes, though the data remains unclear. Still, the Biden Administration is doubling down on the power of nurses and PAs by changing existing policies that would allow them to play a larger role in primary care. Biden even set up a $100m grant to train more nurses to open their primary care practices.  

Dwindling supply, and dramatically increased demand have pushed the government to tackle the issue. This past September, the Senate outlined plans to create a primary care system that can serve the “average” person. Senator Bernie Sanders (I-Vt.), Chairman of the Senate Health, Education, Labor, and Pensions Committee recently announced a deal on potential legislation addressing the “primary care crisis” in America as well as the shortage of nurses and doctors. The legislation would invest $5.8b toward building community health centers which would provide high-quality primary care to more than 30 million Americans. These health centers, according to Sanders, are the next iteration of primary care and a stark contrast to traditional primary care. Community health centers are easier to access and have shorter wait times for appointments than the normal care model. Yet, just like in telemedicine, continuity of care and building a relationship with a provider remain challenges for these health centers.   

The challenges of primary care shortages

The pandemic has also expedited the emergence of a new type of provider: retailers. Throughout COVID-19, pharmacy chains including Walgreens and CVS Pharmacy provided on-site testing and vaccinations. Now, those pharmacies, along with other retail stores like Walmart and Albertsons, are expanding healthcare services by meeting people where they are. Customers are increasingly choosing to sacrifice the physician-patient rapport, which was at one point so central to coordinated care, for convenience. Large retailers are leveraging their existing relationships with millions of customers by providing them healthcare and making them patients.  

But with increased convenience comes a limit on the types of care retailers are capable of providing. Chronic diseases, for example, are best treated when a provider is informed about a patient’s medical history and the types of care they’ve received before. Retail clinics are best suited for treating simple illnesses, not complex diseases. 

“There is always going to be a role for in-person brick and mortar care with the primary care provider, particularly for the more chronic and complex patients”, says Dr. Carroll. 

Retail health collaborations are growing. Costco recently partnered with Sesame, an independent primary care marketplace that allows patients to compare out-of-pocket prices for virtual doctor visits. Costco members are now charged discounted prices for using Sesame’s virtual health services which include primary and mental healthcare. Similarly, Walmart plans to open 75 health clinics across the US by 2024, and Kroger announced a collaboration with Performance Kitchen to curate medically tailored meals for customers living with chronic diseases.  

Retailers will play a huge role moving forward in providing primary care. 90% of Americans live within 10 miles of a Walmart, for example, illustrating the potential for retail clinics to serve underserved and rural communities that wouldn’t otherwise receive care.  

Even Amazon, the world’s largest online retailer is rolling up brick-and-mortar primary care solutions. The e-commerce giant acquired One Medical back in July 2022 and just recently began offering primary care services to Prime members. The One Medical announcement bolsters Amazon’s healthcare services which now include primary care, telehealth, and generic drugs through RxPass. For $9/month, Prime members gain access to 24/7 virtual health services in addition to same-day online scheduling at any of the 200+ One Medical clinics operating in most metro areas.  

Costco’s partnership with Sesame is especially significant because it illustrates a drastic change in how people pay for primary care. Unlike One Medical, Sesame does not accept any insurance and instead directly charges Costco customers a monthly subscription fee. Taking away payers from how healthcare is paid for is an example of a larger theme already going on —the consumerization of healthcare.  

“Healthcare consumerism has really evolved in my 20 years in practice”, says Dr. Tara Bishop, Clinical Associate Professor of Population Health at Weill Cornell Graduate School of Medical Sciences. “When I first started practicing, the concept of a patient being a consumer was not something we were talking about. Now we talk about that all the time, that patients are the ultimate consumer of healthcare services.”

Considering consumerism in healthcare

Whether or not in retail clinics, patients are now active customers. They want to drive their own health decisions and demand price transparency, which is usually quite difficult in healthcare. You don’t necessarily know how much a doctor visit or treatment is gonna cost, and that’s because of insurance.  

Consumerism as a concept works well in free markets, which all of healthcare is not. However, the role of health insurance is to prevent financial catastrophe when you become severely sick or injured. Economists argue that the predictable and routine nature of primary care does not lend itself well to being covered by payers. Deductibles are also rising, making out-of-pocket costs for patients large anyway.  

Removing health insurers from the equation for simple health issues may seem like a no-brainer. However direct-to-consumer primary care poses certain systemic challenges. Direct primary care panels are small, with just 200 to 600 patients. Doctors who leave traditional primary care and start their direct care model exacerbate the physician shortage because they leave patients without a provider. Though direct-to-consumer care does not include insurance, a monthly membership fee does resemble that of a premium. Direct primary care only benefits patients with high-deductible plans, patients without insurance, and medically “simple” patients who would rather pay for a subscription to their health rather than for insurance. For more complex cases, receiving care through the traditional primary care model is still the best available option.  

Nonetheless, direct-to-consumer primary care has grown substantially, especially within the private sector. The pandemic accelerated the adoption of virtual health, paving the way for digital health giants like Hims & Hers to serve a younger demographic that is accessing care very differently from previous generations. People are used to shopping online for clothes and shoes. Now they can shop online for their health. Hims offers virtual care for conditions like acne, hair loss, and sexual health. It also launched chronic disease care platforms including weight management and heart health, in an attempt to provide more comprehensive care. The success and popularity of Hims & Hers is highlighted by the company becoming one of the fastest digital health startups to reach unicorn status, reaching a $1.6b valuation after just 3 years of operation. Hims specifically treats stigmatized conditions such as sexual dysfunction and mental health in a discrete manner that appeals to patients.  

Direct-to-consumer primary care is the latest iteration of a failing traditional model. Hims & Hers builds on the consumer focus of retail clinics to retain customers through an unmatched customer experience. Similar to retail health, access, and affordability are at the core of direct-to-consumer primary care. The latter goes one step further by integrating virtual care, making convenience even easier.  

The evolution of the primary care model is certainly underway. Under the current model, almost a third of all Americans lack access to primary care services. What started with community doctors providing services door-to-door has since transformed into robust telehealth platforms used for primary care by millions of people across the country. There are still care gaps in retail and consumer health, namely the types of conditions they can treat. But until primary care doctors are paid more, the shortage will only get worse and the need for alternative care models shall remain.