A recent, longish article in the New York Times discussed the "disappearing doctor" from the front line of healthcare by which is meant walk-in retail clinics in drug stores and urgent care centers (see: The Disappearing Doctor: How Mega-Mergers Are Changing the Business of Medical Care). People are flocking to these facilities because they are readily accessible, user-friendly, and efficient. Patients with the most serious injuries and diseases are triaged to hospital ERs so the patient mix at these walk-in centers is more homogeneous. Below is an excerpt from the article:
...[The] reason big players like CVS Health, the drugstore chain, and most recently Walmart, the giant retailer, are eyeing deals with Aetna and Humana, respectively, to use their stores to deliver medical care. People are flocking to retail clinics and urgent care centers in strip malls or shopping centers, where simple health needs can usually be tended to by health professionals like nurse practitioners or physician assistants much more cheaply than in a doctor’s office. Some 12,000 are already scattered across the country....On the other side, office visits to primary care doctors declined 18 percent from 2012 to 2016, even as visits to specialists increased....There’s little doubt that the front line of medicine — the traditional family or primary care doctor — has been under siege for years. Long hours and low pay have transformed pediatric or family practices into unattractive options for many aspiring physicians....
Apart from true emergency situations, patients’ expectations now reflect the larger 24/7 insta-culture of wanting everything now.....[N]ew deals involving major corporations loom over doctors’ livelihoods, intensifying pressure on small practices and pushing them closer to extinction. The latest involves Walmart and Humana, a large insurer with a sizable business offering private Medicare plans. While their talks are in the early stages, one potential partnership being discussed would center on using the retailer’s stores and expanding its existing 19 clinics for one-stop medical care. Walmart stores already offer pharmacy services and attract older people. In addition, the proposed $69 billion merger between CVS Health, which operates 1,100 MinuteClinics, and Aetna, the giant insurer, would expand the customer bases of both. The deal is viewed as a direct response to moves by a rival insurer, UnitedHealth Group, which employs more than 30,000 physicians and operates one of the country’s largest urgent-care groups, MedExpress, as well as a big chain of free-standing surgery centers.
It's very clear that the former front-line of healthcare, the primary care physician office, is under siege. As noted above, "office visits to primary care doctors declined 18 percent from 2012 to 2016 even as visits to specialists increased." I have previously blogged about how some consumers who visit hospital ERs can be presented with "surprise" bills due to out-of-network services and ER facility fees. Publicity about such bills is causing further erosion of visits to ERs in favor of the alternative first-tier services. Hospitals may be partly to blame for this by trying to generate more revenue from ER visits.
There is another problem for primary care physicians on the horizon. More sophisticated computerized algorithms are being developed for deployment in walk-in clinics and urgent care centers to help diagnose and triage serous disease that might otherwise be missed by the NPs and PAs that staff such facilities. Such algorithms are referred to as CAST tools (see: Computer-aided simple triage). I suspect that CAST software in the hands of skilled PAs or NPs could theoretically rival the skill set of a primary care physician working without such a tool. Here is a list of emergency problems where CAST might be used that I copied from the Wikipedia article just cited:
- Pulmonary embolism (PE)
- Aortic dissection
- Coronary artery disease
- Bone fractures
- Internal bleeding
- Idiopathic intracranial hypertension
Addendum on 6/1/2018
One good marker for this trend is the year-over-year change in hospital admissions. Data given to Congress in the latest MedPac (Medicare Payment Advisory Commission) report on Medicare payment policy show that, between the years 2006 and 2016, the cumulative percent change in the number Medicare inpatient discharges per beneficiary declined by 21.8%. During these same years, the cumulative percent change in the number of outpatient visits per Medicare beneficiary increased by 49%!