Can Amazon Deliver With 24/7 Primary Care?

Neil Skolnik, MD


February 28, 2023

This transcript has been edited for clarity.

Last night, I saw an announcement on Amazon's homepage that they are now offering a subscription service that provides 24/7 primary care. According to a letter from the CEO, this is in response to a broken healthcare system, and the service that Amazon will be providing is, in their words, "how primary care should work."

Amazon has usually been pretty good at spotting trends and opportunities. This causes me to reflect about what it is we offer with traditional in-person primary care that might be different from what Amazon will offer with 24/7 access.

Fundamentally, excellent primary care is distinguished from other types of care, particularly online care, by three things: trust, shared decision-making, and judgment, all of which are facilitated by deep relationships that develop over time.

Notice that I did not mention medical knowledge. Medical knowledge is a necessary component of any healthcare delivery system.

I want to contrast that with purely algorithm-based care. In purely algorithm-based care, a patient with no comorbidities other than hypertension, on hydrochlorothiazide, with a blood pressure of 141/91 should have their antihypertensive therapy increased so that they can reach the goal of 140/90. In fact, what usually happens is that we look back in the chart to see how many times the patient's blood pressure exceeded goal. We ask whether they've been adequately carrying out lifestyle interventions that we've talked with them about, and also whether or not they particularly want to continue with those lifestyle changes.

Then we present a choice to them, based on the risks and benefits in the context of their personal values and preferences about whether adding another medicine at this point in time makes sense for them. This all happens very quickly, and while we don't think a lot about it, what is happening is the integration of medical knowledge with shared decision-making, in a discussion with someone who trusts us, and then a judgment call about what the patient should do.

Ultimately, the way that medical care is provided will be decided in the marketplace. That marketplace is the same one that has already begun to erode some of the core features of primary care, such as the time it takes to develop trust, engage in shared decision-making, and exercise judgement. All of this takes time. But talk to any primary care physician and you'll find that time is the one thing that is in short supply.

Patients will vote with their feet. Some patients will like quick access to any provider. I don't think that any one type of care will dominate, because medicine never has been, and shouldn't be, one-size-fits-all. Some people are attracted to one doctor's personality more than to another. Some people like the way one clinician listens to them, another person likes the way a clinician explains things to them. For some, trust is built over time and facilitated by relationship. For others, trust comes from a trust in the system.

The other thing that will determine how this all plays out will be metrics of care that will be looked at by everyone from clinicians to patients to payers. Hard outcomes will be an important metric; patient satisfaction will be another. As we pay attention to metrics, though, it will be important to remember a statement that has been attributed to a number of people and which I'll twist a little bit: "Not everything that can be measured counts, and not everything that counts can be measured."

In the end, what matters is that patients receive high-quality care, in a manner that is comfortable to them, from a system and people who have their interests in mind.

Innovation presents challenges and it also presents the opportunity to reflect and refine what we have to offer. And what we have to offer always has been, and remains, profound and important.

I'm interested in your thoughts.

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