Why Reinventing Primary Care Starts with Patient Education

Everyone from healthcare incumbents to entrepreneurs to vertical integrators to new market entrants is trying to reinvent primary care. The reason is simple. In a risk-based payment world, you can make a lot of money by keeping healthy people healthy and people with chronic illness as healthy as possible. After all, primary care is a business just like any other business in any other industry, including healthcare.

The only people who don’t seem to be onboard with this plan are patients — the customers. Specifically, we’re talking about Medicare beneficiaries, at least according to a new study.

The new study, published in the Annals of Internal Medicine, suggests that most seniors still prefer to go to specialists, not primary-care physicians (PCPs), when they’re sick. You can download the study here.

That’s consistent with virtually every conversation I’ve ever had with a senior citizen about their medical care. Perhaps channeling their great disappointment that their son or daughter didn’t become a famous surgeon, most seniors will mention that they’re seeing “the best” specialist in their area of expertise for their medical care. “He’s the best in the city,” or, “She’s one of the top doctors at the hospital,” they say. They never say, “I saw someone who I think was a doctor who upped my blood pressure medication.”

But I digress. Four researchers from Harvard, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center, all in Boston, compared Medicare beneficiaries’ use of PCPs and medical specialists over a 20-year period, from 2000 through 2019. They did that by looking at the Medicare claims of six million to seven million beneficiaries each year for 20 years.

Here’s what they found regarding beneficiaries’ use of PCPs:

• The average number of primary-care visits per beneficiary per year changed little from 2.99 in 2000 to 3.00 in 2019 (give them credit for not rounding up here, which would be no change).
• The average number of unique, or different, PCPs whom the beneficiaries saw at those visits rose from 0.89 in 2000 to 1.21 in 2019.
• The average number of unique, or different, PCP practices that beneficiaries went to for those visits rose from 0.79 in 2000 to 0.94 in 2019.

(Before you say, “How can a patient see less than one doctor or less than one practice,” the answer is, the researchers included patients who had zero primary-care visits during a study year. The zeros bring the numbers down below one.)

Here’s what the researchers found regarding beneficiaries’ use of specialists:

• The average number of specialist visits per beneficiary per year increased from 4.05 in 2000 to 4.87 in 2019.
• The average number of unique, or different, specialists whom the beneficiaries saw at those visits rose from 1.63 in 2000 to 2.18 in 2019.
• And the average number of unique, or different, specialty practices that beneficiaries went to for those visits rose from 1.56 in 2000 to 1.77 in 2019.

Despite 20 years of promoting primary care to patients, steering beneficiaries to PCPs via value-based payment programs and making primary care more lucrative for PCPs, seniors still like their specialists.

“Medicare beneficiaries are receiving more specialist care from greater numbers of physicians with little change in contact with primary care,” the researchers sighed.

What’s the lesson for all the healthcare incumbents, entrepreneurs, vertical integrators and new market entrants trying to reinvent primary care? It means that just because you have an innovative care model that delivers better care at less cost, people, especially seniors, will give a damn and log in to your online scheduling system.

A foundational piece of your primary-care business model must be patient education that’s custom to your patient population. In its most-distilled form, primary care good, specialist care bad. Stay healthy and stay away from expensive medical specialists. There’s nothing special about seeing a specialist.

You need to convince seniors that it’s just as cool to brag about not going to the hospital as it is to brag about the best orthopedic guy in town doing your hip replacement surgery.

Thanks for reading.