Through various blog notes, many of them recent, I have been trying to sketch out the changes in the first tier of healthcare that I see occurring (see: Retail Drug Stores Emerging as Healthcare Hubs for First-Tier Primary Care; The "Proximity Advantage" Enjoyed by Retail, Walk-In Clinics Over Health Systems; Physicians Are Disappearing from the Front Line of Healthcare). This level is roughly synonymous with what we typically call primary care but now accompanied by a large dose of consumer-directed activities and responsibilities. Below are a number of statements summarizing the character and dimensions of this first layer of health care as I understand it now:
- Physicians work primarily in a supervisory role. The majority of them are, and will be in the foreseeable future, employees of health systems (see: Rapid rise in hospital-employed physicians increases costs). Direct contact with patients and triaging will be mainly the responsibility of nurses, nurse clinicians, physician assistants, and other health assistants. All of these later personnel will be increasingly guided by diagnostic and predictive algorithms that will allow them to identify the more seriously sick patients and refer them to physician specialists operating at the higher levels of care.
- Primary care clinics operated by health systems and private physician practices and clinics will be supplemented by, or compete with, walk-in retail clinics such as those of CVS and Walmart and urgent care centers (see: Retail Drug Stores Emerging as Healthcare Hubs for First-Tier Primary Care). CVS is expanding the definition of walk-in clinics with its new HealthHub model (see: CVS Health Announces Significant Expansion of HealthHUB to Deliver a Differentiated, Consumer Health Experience).
- The participation of consumers is rapidly expanding in this first tier, driven by access to health system data via EHR patient portals (see: Patients Often Lukewarm about Patient Portals; Problems with Training?), smartphone apps (see: What Are the Consequences of Big Tech Entering the Healthcare Market?), health wearables (see: Is Healthcare Ready to Embrace the Consumer "Wearable" Revolution?), and monitoring/diagnostic devices connected to smartphones (see: Smartphones Provide a Key Element in Our Personal Health Management Systems); Six-Lead, Consumer-Facing ECG Device Close to Release to Market).
- Smartphones with apps and connected to wearables and diagnostic devices will enable some engaged consumers to participate at a much higher level than previously in terms of analyzing and even diagnosing diseases. At the very least, this higher level of participation will enable some consumers to provide sophisticated diagnostic information to their physicians.
- Home pregnancy testing has been performed for decades as well as home glucose monitoring for diabetics. For about a decade, consumers have been permitted in about half the states to order a wide array of lab tests performed by a national reference lab with results sent directly back to them. One company is now enabling consumers to send a finger-prick blood sample to a reference lab(s). In a recent post I suggested that we should refer to this whole array of "home lab testing" as direct-to-consumer (DTC) testing (see: New Definition for DTC Lab Testing Prompted by EverlyWell Business Model). The breadth and sophistication of lab tests provided directly to consumers will continue to expand (see: Kroger Prescription Plans Partners with Myriad Genetics to Offer GeneSight Genetic Tests and Genetic Counseling in Kroger Pharmacies).
- I believe that wellness and health management services will increasingly be integrated into this first tier of healthcare. Support for the pursuit of wellness could theoretically be provided by health systems and physicians but most have not been enthusiastic about the idea because of reimbursement challenges and the fact that most health professionals have been trained to diagnose and treat illnesses.
- Finally, there is a need for interoperability between the health data generated in this first tier with health system EHR data (see: Integration of Patient-Generated Test Results with Those from Accredited Laboratories). At the very least, some consumer-generated data needs to be viewable by health professionals. In other words, we need an agnostic interoperable consumer health record in the cloud (see: Integration of Patient-Generated Test Results with Those from Accredited Laboratories). United Health is set to roll out an interoperable personal health records for its members (see: UnitedHealth to roll out interoperable personal health record to 20 million members). However, I would much prefer to see such a system managed by an entity that would not receive material benefits from viewing these records.
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