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Although they are generally overshadowed by more newsworthy items, massive changes have been occurring in how, where, and by whom primary is delivered in the U.S.

Traditional primary care physician (PCP) practices have been on a gradual decline for decades, but the extraordinary challenges and revenue losses experienced by these practices during the pandemic only exacerbated the problem. Given that nearly 60% of all American adults have at least one – and approximately 40% have multiple chronic conditions - this comes at the very time we most need high-quality, accessible primary care services. Sadly, even if their numbers were to increase, most traditional office-based primary care practices are not adequately equipped to provide optimal medical management for this patient population.

What has changed in the primary care landscape and what does it look like today? Allow me to introduce some leading "disruptors".

Integrated Primary Care Delivery

Integrated primary care delivery models - many of which include chronic care management in the home setting - have proliferated across the country since the start of the pandemic. Theoretically, (HBPC) enables patient-centric, continuous care (primary, urgent, and palliative), allays stress for patients, and helps avoid unnecessary emergency room visits and hospital admissions. Successful models customize care to address the unique needs of specific populations. The focus is on reducing the cost of care without compromising quality. For example:

• Landmark Health has experienced a 33% increase in demand for its 24/7 home-based medical care management for patients with multiple chronic conditions. In partnership with health plans, the organization's services include medical and behavioral health care, palliative care, and social services. Mobile providers conduct in-person "house calls" and/or telemedicine visits (video or phone).
• Iora Health's clinic-based, interdisciplinary team model offers medical care to a broad population of clinically complex patients. Now owned by Amazon (see later in this column), Iora partners with health plans, unions, and employers, assuming full financial risk and benefiting only through clinical quality improvement and cost containment. Physicians and non-physician health coaches connect with patients to identify and address unhealthy behaviors, manage chronic conditions, and advocate on their behalf as necessary.
• Care Management Plus (Intermountain Healthcare) takes a clinic-based coaching approach by embedding a "care manager" in the PCP office to enhance care for patients with complex needs. Supported by information technology tools, care managers develop care plans and provide self-care guidance for patients and caregivers.
• The Center for Medicare & Medicaid Innovation's Independence at Home is a test program wherein HBPC practices conduct in-home visits using interdisciplinary teams directed by physicians and nurse practitioners. Practices that meet quality standards and financial targets receive incentive payments from the Centers for Medicare & Medicaid Services. In the first 5 years of the program, a relatively small number of HBPC practices with a total of 10,000 Medicare beneficiaries per year showed savings of $100 million.

Integrated, holistic approaches to managing care are particularly useful in meeting the needs of senior and Medicare Advantage populations. With the anticipated rise in the number of seniors suffering from chronic conditions, the prospects for continued growth in this area are favorable, and payers have shown willingness to support PCP care management for these patients.

'Big Retail' Presence in the Healthcare Sector

Another notable change is occurring within the nations' largest businesses and employers – i.e., . Recent high-profile partnerships and acquisitions extend the reach of these retail giants into primary care delivery by increasing patient access to care at their clinics and retail locations.

Walmart Health recently partnered with Oak Street Health (a value-based primary care service provider for adults -- particularly Medicare Advantage participants -- in medically-underserved communities) and acquired the multispecialty telehealth provider MeMD. Renamed Walmart Health Virtual Care, the latter offers primary care, urgent care, men's and women's healthcare, and behavioral health services through contracts with commercial payers and employers.

Walmart's 10-year partnership with UnitedHealth enables collaboration on value-based care strategies, and Walmart Health clinicians benefit from analytics and support tools provided by UnitedHealth's clinical data subsidiary, Optum. This partnership may give Walmart broad clinical advantages without its needing to purchase a payer and/or pharmacy benefit manager (PBM).

CVS's foray into primary care is well established, having offered walk-in medical services at its retail pharmacy locations since the early 2000s. CVS's MinuteClinics offer routine physicals, screenings, immunizations, minor injury care, and illness treatment, as well as mental health counseling provided by advance practice providers and therapists (in-person or virtually). The organization acquired a major health plan (Aetna) in 2018, and its CVS Caremark is one of three large PBMs that collectively control 80% of the prescription drug market.

in May 2022, the organization launched CVS Health Virtual Primary Care, a comprehensive, physician-led primary care service whereby patients can combine the virtual service with in-person visits to providers (including MinuteClinics) using a virtual care app for electronic health record interoperability and care coordination across providers. It's easy to envision the organization's likely next steps - perhaps full-service primary care, chronic care management, and laboratory services.

Amazon began to provide hybrid (in-person and virtual) primary care to its own employees in 2019. With its purchase of One Medical in July 2022, the organization acquired a highly recognizable brand in concierge primary care, a network of more than 200 brick-and-mortar locations, and (crucially) One Medical's payer contracts. The purchase also included Iora Health, the senior/Medicare Advantage primary care provider described above.

Is Amazon is interested in providing value-based care for One Medical's commercially insured patients? What are its intentions regarding Iora Health? Only time will tell.

Is what I've described above the right road for primary care's future? The long-term impact of these alternate approaches on the healthcare system – and on us as consumers – remains an open question.

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