Virtual Primary Care - The Time Has Come to Bring Continuity of Care and the Physician Relationship back into Primary Care

Original Article By Kurt Tamaru, MD

The Archetypical Family Doctor

As a family physician, I was always in awe of the “Marcus Welby'' approach to care that my family doctor took in his care of patients.  For those too young to remember, Marcus Welby was a television character that portrayed a family doctor who cared for a wide variety of conditions and patients including the social/personal aspects of caring.  I can remember as a young child seeing my family doctor who treated my parents and siblings and who’s care helped my father during his diagnosis of coronary disease, or my mothers care following Colon Cancer as well as every scrape, broken bone, and fever that evolve in our family of four boys with our doctor just a phone call away! 

Changing Face of the Primary Care Landscape

However, the health care system I remember seemed to quickly change in just my lifetime whereby the care provided by my childhood family physician seems so foreign by today’s standards.  Over 70% of physicians today are now employed by hospital or corporate entities.    As such, the practice of medicine has moved to more large system based care which arguably has fragmented the continuity and relationship patients traditionally had with their doctors.   Furthermore, the specialization of medicine over the many decades has also resulted in a dramatic increase in early specialty care or unguided care in a complex system of multiple specialists.   As such, family practice providers today have a high variability in referral rate patterns and some speculate that such referrals could be driven by patient expectations. With  multiple patient concerns and limited time and reimbursement, physicians may be more prone to refer out to more specialty providers to sort through the complexity.  High referral rate may also reflect the need for  better training and internal consultative capability in primary care that may also be missing.

Issues of Limited Time and Resources

Often physician colleagues have commented that the volume of patients required to be seen in an office, limits the ability to manage complex issues and traditional fee for service reimbursement from payers doesn’t provide adequate compensation for the complexity and follow up required.   As such, patients may get frustrated by delays or physicians may find it better to refer a patient out.   Compounding the issue is a dwindling physician base and the growing expansion of use of other clinical licensed providers such as nurse practitioners and physician assistants as independent providers of care to bridge the gap in physician workload. Unfortunately, patients with complex issues are left at the back of the line or having to actively voice their needs.

Impact of these Changes

Ultimately, as a result of these many changes that have occurred over the decades, our global ranking in the health of our citizens ranks last amongst the top 11 high wealth countries despite the United States spending the highest proportion of GDP on healthcare. Arguably, more care has not necessarily improved the overall quality of life of the population as demonstrated by recent news of a declining life expectancy in the United States despite the obvious impact of the COVID pandemic.  So then, what needs to change?

Reconnecting Patient to Primary Care

Greater focus needs to be spent on redesigning the primary care model taking into account the needs of the populations served and unique and personalized solutions that re-engages the patient in a trusted patient-physician relationship again.  This trust is facilitated by greater connectivity and touch points as many studies have shown the relationship between frequency of visits and engagement, improved access to care, specialty knowledge through primary care services, and concentration on more proactive and predictive care. 

Recent global adoption of telemedicine due to the pandemic has challenged the thinking of how we deliver care and more innovative “hybrid” models of combined in-person and digital interactions are being developed beyond the brief video urgent care visit during the pandemic.   Use of seamless multi-channel communication along with new data points in care at the home and regarding lifestyle and behavior are being monitored and tracked along with biometric data that can be easily transmitted to a clinician or interpreted through advancing AI capabilities.  These new hybrid models have the potential to improve the engagement and interaction across a population of patients under a single provider that is lacking in care today. 

Building the Model with Digital and Virtual

Building on this model is the ability to offer other virtual capabilities like diet, nutrition, physical therapy, counseling,  behavioral health, and early specialty consultations  - essentially a virtual medical group which can sit on top of a fee-for-service network of a payer.  This front end coordination and early clinical guidance from a general practitioner is where the value of a primary care relationship is best realized.  As such, more proactive care and interaction at the primary care level is required which begs the need for a better approach to engaging patients seen in the typical medical office today. 

Improving Engagement and Continuity of Care

I am amazed at how the concept of Accountable Care Organizations , Patient Centered Medical Homes or Advance Primary Care have been highlighted as new and innovative ways to move toward more quality outcomes and effective care.  These are not new concepts but rather a commitment to returning to those foundational elements that have underpinned family medicine and general primary care practice before specialty fragmentation.    The ability to engage our patients beyond the in person office visit through digital means is the key to bringing continuity of care back to the future of primary care.   Re-establishing a relationship with your medical care provider and an advocate who has the time and ability to address the complete needs of a patient and with an eye toward anticipating future issues and needs.  Added is the ability to facilitate a digital consultation or expert opinion to improve the diagnostic and treatment sensitivity at the primary care level as opposed to the growing urge to “unbundle” primary care into more consumer direct sub specialized offerings.  Virtual and Digital health capabilities need to be designed and organized to support a more personalized approach to care focused on the relationship with access to technology and rapid knowledge at the point of care - such a modern healthcare world would make  “Marcus Welby” proud!