‘Searching for the Family Doctor:’ An Excerpt

How 'Amazon Thinking' Is Reshaping Primary Care: An Excerpt

Timothy J. Hoff, PhD


March 01, 2022

The following excerpt is from Searching for the Family Doctor: Primary Care on the Brink by Timothy J. Hoff. Copyright 2022. Published with permission by Johns Hopkins University Press.

"Amazon Thinking," Technology, and "Pop-Up" Medical Care Create "Fast-Food" Primary Care

Timothy J. Hoff, PhD

A storm has been brewing for primary care doctors over the past two decades. Lower payments for primary care services; fewer family doctors who can make ends meet by owning practices, and so must become employees; the rise of large corporations controlling health care; paperwork demands making the job less than it could be; and fewer medical students wanting to enter the specialty because of what they see and hear about it are creating a perfect storm for disruptive innovation in primary care. Add to this a shortage of primary care doctors in many parts of the United States, and the opportunity arises for new players to enter the scene. This disruption is characterized by limiting the use of high-cost family doctors and using cheaper non-physician labor instead; overhyping technological solutions and standardization for "better" care delivery; seeing the patient as a "consumer" wanting convenience over everything else; and downplaying the importance of human-based, relational care excellence.

Primary care is first and foremost ground zero for disruption through "Amazon thinking." No doubt, this progressive fracturing and creation of "fast food" primary care service delivery through cheaper, quicker, and more episodic touch points for patients is also the result of the increased demand for primary care brought on by insurance expansion under the Affordable Care Act. In many parts of the United States, wait times to see primary care doctors are excessive, and Amazon thinking is designed in part to provide a lower-cost, accessible platform for basic primary care delivery. Family doctors are first in the crosshairs of that powerful idea because family doctors stand in the way of big organizations taking over health care, but as these doctors go, so may go many other types of doctors.

Nothing presents a greater threat to the specialty of family medicine, its doctors, and its goals of holistic, highly relational patient care than the application of efficiency-oriented business thinking and retail tactics, homed to other industries, to the delivery of primary care services. Why is this thinking such a threat? First, it diminishes the importance of the highly paid physician-expert in patient care, largely because that physician is the most expensive, least controllable input into the primary care production process. It is hard to control and reduce the cost of a given production flow when you cannot manipulate the highest-cost input in that flow. Newer primary care players such as CVS Health, Walmart, and Walgreens would rather not want to have to depend too much on high-cost family doctors. Instead, their primary staffing focus is more on cheaper and less skilled non-physician personnel such as nurse practitioners, physician assistants, registered nurses, and medical assistants.

The use of non-physician labor to deliver primary care has facilitated the increasing rise of "pop-up" offices in many communities that use nurse practitioners and physician assistants to deliver care. As the United States experiences a shortage of primary care doctors, large health care delivery systems maintain the scale and resources to create franchises that reimagine most primary care delivery as episodic visits and brief interactions. These emphasize convenience and the provision of basic services more than ongoing provider-patient relationships. These sites for primary care delivery are not based in physician-owned offices. Rather, they are owned and operated by big corporations. Retail-oriented forms of primary care delivery, like urgent care centers and minute clinics, emphasize transactional over relational excellence.

The price point for each transaction remains lower compared to the traditional family doctor's office, which means doctors as the high-cost input are less welcome in the transaction, because that raises the overall price of the service. Things like convenience and timely access are meaningful goals for many patients who want primary care medicine today. But rather than being pursued as a complement to the relational care delivery patients also want and need, they now tend to become the primary focus for these new forms of primary care delivery.

A second related threat driving primary care disruption in a direction away from family doctors is the heavy use of technology in creating "fast-food" yet accessible forms of primary care medicine, soon to be done virtually on a wide scale through phones and smart devices like Amazon's Alexa. The pop-up primary care alternatives noted above rely heavily on using an integrated electronic health record system across their franchise locations that can standardize diagnostic and treatment protocols, for example, so that the non-physician providers delivering care in these settings all practice similarly.

In this way, the management of care and actual clinical decision making gets encoded into the computerized guideline and becomes the purview of the corporation, rather than the individual care provider. Patient data is "owned" by that corporation, and not the doctor or patient. The electronic health record (EHR), implemented now in every family doctors' workplace, is a disruptive technology that can undermine clinicians' feelings of autonomy, competence, and satisfaction. As a technology designed in part to extract the knowledge of individual patients and their unique attributes from the family doctor's head and place it into a database that employers and others on the primary care team can easily access, the EHR sets the stage for other personnel to take over more of the family doctor's work and allows organizations to monitor what family doctors do and how they do it. Using artificial intelligence and lots of big data stored in electronic health records, many basic forms of primary care will likely be taken from the family doctor and given over to standardized computer algorithms for dispensing, through chat bots and other innovations.

As companies like Apple and Amazon gain control over these patient data through their cloud-based services, and various forms of primary care work are standardized in a recipe-like fashion to allow for that work to be broken into smaller pieces and apportioned to less skilled workers such as medical assistants and nurses, family doctors will lose some ability to perform the kinds of duties expected of them. In these ways, the EHR has been shown to deskill family doctors in key ways that undercut their role as comprehensive physicians and care managers for their patients. It also has increased their everyday workloads greatly, forcing them to become data depositors for patients' insurance companies, entering quality metrics into the EHR to get reimbursed and generating mounds of patient information that requires their time and attention to sift through.

This hostile environment involves the continued narrowing of the family doctor's scope of practice. Make no mistake, the scope of work for family doctors has narrowed, with the percentage of family doctors performing activities involving maternity care, pediatrics, and women's health services declining over the past twenty years. A key question is, how much of what family doctors now do will or can be replaced by this disruptive change? The smart money should be bet on the proposition that the forces pushing Amazon thinking and disruption into primary care will not stop anytime soon. The numbers of US medical students choosing family medicine remains flat, well short of what is required. While becoming salaried employees of larger health care organizations may aid family doctors in their desire to work fewer hours, have good work-life balance, and avoid the hassles of owning a business, it can undermine their feeling of autonomy and their ability to engage in a wider scope of practice, should they so wish. This may not be a problem for some family doctors, as we will see. But for others, it becomes a growing source of dissatisfaction and burnout. It may reshape their professional identities in ways that are bad for their own sense of worth and the good of advancing their specialty.

Companies like Amazon, Apple, Walgreens, and CVS Health are not going away, as they seek to make primary care delivery a core part of their health care business strategy. They are convinced there is low-hanging fruit to be had in squeezing profit out of services that can be made more standardized, lower cost, and highly transactional—chronic disease management, preventive and wellness care, and basic acute care. Some of the interest is in seeing this primary care service provision as a loss-leader, creating loyal customers who want to buy other health and non-health related services and products from these companies. Smaller health care start-ups and the venture capital that supports them also see quick money in trying to help health care organizations use the vast sums of patient information they have collected to transform how primary care is done.

The family physician–driven model of primary care delivery is more expensive than these new forms of fast-food, transactional primary care. It requires more time, more inconvenience, and more face-to-face interaction with the patient, which is another reason why these alternative forms of primary care will continue to grow. It would not be so bad if they were a complement to highly relational, physician-centric primary care, but they are not presently. They seek to transform the way all of us think about health care generally, and primary care specifically.

For patients, this new way of thinking about primary care wants us to believe that physician interaction matters less in keeping us healthy. It wants us to believe that convenience and low cost matter as much if not more than the quality of the actual care delivered. It wants us to see our consumption of primary care services and products as one part of our larger consumption needs—right alongside the need for transportation, lodging, and a host of discretionary items we buy to make us happy. If successful in convincing us of this vision, Amazon thinking and the disruptive innovation associated with it presents as a serious threat to the future of family medicine and, more importantly, to the specific vision of healthy people and communities that family medicine stands for. It is yet another hostile force that an already-weakened family physician army must meet on the health care battlefield—a force bent on fully monetizing people's health by basing the health care services and products that are bought, sold, and profited from on transactional rather than relational excellence.

How can family physicians fight back? It will require a multitude of different approaches. Embracing virtual care delivery as a ready compliment to in-person care delivery and fighting to remain the patient's chief data sentinel, even if patient data are stored elsewhere are two important parts of the response. In addition, finding new ways to expand their work relationally so that patients see first-hand the value of a family doctor, and modifying family medicine training to align better with caring for patients longitudinally and holistically, also can reinvigorate primary care. Family medicine work and careers are too fragmented currently. Ultimately, family doctors also must find new ways to advocate for themselves collectively, even as salaried employees, to create better daily work settings in which to build relationships with their patients. Other more radical change efforts may be needed as well. It will not be easy or quick. But the time for family doctors to understand better how to retain their relevance in a transformed primary care delivery system is now.

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