VIDEO: How can different primary care models make healthcare more affordable?
There are many flavors of primary care – direct care, concierge models, subscriptions – but how can they actually make healthcare more affordable and what headwinds do they face in the U.S.?
Lown Institute president Vikas Saini gives his perspective in the latest episode of “Office Hours with Dr. Saini.”
“I’m of the view that if we want to do this right, we kind of need a Manhattan project for primary care.”
Dr. Vikas Saini
Welcome to office hours with Dr. Saini. I’m Vikas Saini, president of the Lown Institute. In this series, I give you my honest take on the U.S. health care system, one question at a time.
This week’s question is how can primary care models or movements make healthcare more affordable?
Q 1: What’s the role of primary care in an affordable healthcare system?
Thing about affordability in primary care is that almost everywhere in the world what’s been shown is that a robust comprehensive primary care system is really the bedrock of an affordable health care system. That means primary care needs to be in the center as the lynch pin of a good delivery system. The real challenge of course in the United States is that primary care situation in the country is really pretty weak and deteriorating in many ways.
There’s a model of primary care as being one module inside a large hospital system along with all the specialists and all the ancillaries and all the other dimensions of of modern care. I think that actually recreates the problem. It recreates the power imbalances, recreates the money imbalances, and doesn’t really alter the trajectory of how both the funds flow, how care is managed, even if people doing this have the best of intentions and want to quote-unquote empower primary care. I think that’s actually one of the the dilemmas and that’s why at least in our upcoming conference you know we’ll hear from a primary care doc who who sitting inside a large delivery system has decided there’s no way no path forward without unionizing doctors.
Q2: What are some of the alternative primary care models and do they work?
There are broadly speaking two flavors if you will. There’s the old model of concierge care which conjures up images of you know the old carriage trade and and you’re sort of you’re the plastic surgeon to the stars in Hollywood or or you’re taking care of a very elite group and that and you charge those those kinds of concierge fees like $5,000, $10,000, $20,000 a year just for the privilege of of being able to talk to you. I have trouble with that.
The newer model is more like a subscription, and everybody’s into subscriptions. Who’s who doesn’t like that? Amazon loves it. Apple loves it. Everybody gets a a reliable revenue stream through subscriptions. Even the subscription model is on top of whatever somebody’s paying for their health care, insurance coverage, assuming it’s a bolted on primary care. I think it’s absolutely not a solution unless it’s scalable and the workforce is scalable and it fits into the rest of the system. My own view is that we have to figure out how to have primary care in a functioning delivery system that provides all the professional satisfaction and ease of use and all the other pieces of the puzzle that direct primary care you aims to solve and does solve for a small group of people. We need to think about and design and engineer for that for the entire delivery system.
Q3: What are the unique challenges primary care faces in the U.S.?
What’s really difficult about the United States is when you look at other countries that are doing primary care or a greater portion of the premium dollar is going to primary care and you can see you know the robustness of the primary care, and you can see the the lower spending overall. The hard part is that much of this depends on initial conditions:how you set things up and in what ways it evolves really is a strong determinant. That means to start where we are in which we’re very specialist dominated where primary care is under siege or maybe even withering – I don’t know if that’s not too strong a word – but to imagine revival, renaissance and even a transformation makes it that much harder than in other countries because they’re starting at their starting point they already had that perspective. I don’t think we can sugarcoat that. I think the challenges are enormous.
Q4: “What is the product of healthcare?”
At the heart of this of course is the question of what is the product of healthcare? Is it health or is it a procedure, a vaccination, an event? Quite clearly most people for themselves their families, you don’t want it to be transactional. They want to be understood. They want to be known and then they want good advice.
I’m of the view that if we want to do this right, we need a Manhattan project for primary care. And the numbers, last time I did a back of the envelope, the numbers seem big like you know $100,$200 billion, but relative to the kind of money we’re spending for all sorts of things, it’s actually not that big. And the payoff, the ROI is pretty damn significant.
Well, that’s all we have for today. So, we’ll see you next time.
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Q1: How can AI be useful in medicine?
The one area where AI might be useful I think generically is, since a lot of human intelligence is pattern recognition and since a lot of kind of diagnostic acumen is pattern recognition – it’s not all – some of it has to do with a more methodical way of looking at at you know the odds, what AI is going to do is allow many people to operate at a higher level in terms of some of the prompts for for diagnoses they might not have thought of and the like. If you have something that isn’t quite a fit, if you had a new disease, for example, or a new virus, I wonder, you know, could that ever happen? A new virus? That’s an area where you might actually run astray. And so I think one has to be cautious there as well.
Q2: What does AI mean for the art of healing?
What does AI mean for the art of healing? What an interesting question. I think the short answer is it could be liberating. When you know when a physician is working with a patient, especially if it’s a new patient or if it’s a new symptom and you’re trying to sort it out, you go to work. There’s a lot you have to cover and things you don’t know. You got to check the literature. You got to do this, you got to do that. And even then, it’s tough. Similarly, figuring out treatment options or even a plan of treatment takes up time. And I think the biggest complaint that patients have is they don’t get enough time. And the reality is, and this is one of the paradoxes of healthcare is that you’re actually as a clinician, you’re more efficient, not the less time you take, the more time you take. Because the more holistic your understanding of the situation, the easier it is to find that through-shot that actually addresses multiple things at once. But the deployment of AI could – and not current AI, but an AI of the future could easily make that seamless and painless in a way that it frees up space for the being together that I think is an important part of the healing process.
So then let’s think about what the future might hold. And, because I’m a doctor, I like to think about “What is the role of a doctor in that world?” And I actually think it could be incredibly liberating. And by that I don’t just mean liberating from coding and billing and the burden of commerce. I’m actually talking about liberating in terms of some of the anxiety about you forgot to think of a certain diagnosis or even the understanding that you have to spend a lot of your time figuring out this or that when instead you can now really be present with the patient. Really, be in a relational conversation with the patient in which the imparting of information – both from the patient to you and from you to the patient – is faster and automated, freeing up both of you to explore the implications of it, to explore the emotional tenor of it. And I will submit that that’s really one of the highest callings of physicians is to be present with the person together facing an illness.
Q3: Will AI lead to fewer specialists?
I don’t think we’re anywhere near the point where AI will lead to fewer specialists. In a hundred years, I could see robots that are highly highly intelligent that can do robotic surgery. They probably be able to do a bunch of robotic procedures and be able to talk to you. So I can imagine that world and I don’t think it’s anywhere near happening. I think where it might matter, again, if we’re trying to bend the cost curve, where it might matter is in places in which the same work can be done by fewer people. But I have to re-emphasize that in healthcare one of the problems we have is there is no policeman. It has to be done in a way that not just improves patient care or some metric of outcome. It improves the experience. And so if we can do that, that’s a win. Otherwise, if you have the same reimbursement system and the same chasing for dollars, then what you’re going to do is you’re going to have a lower nurse patient ratio and you’ll have a robot walking into your room and you know, dystopia.
Q4: What scares me most about AI in healthcare
What scares me most about AI in healthcare is what scares me about AI in general, which is that so far we seem to be dependent on a very small handful of companies that are duking it out looking to become near monopolies. In that kind of world, the opportunities and the possibilities to realize not just the savings but some of the efficiencies and some of the less commercial aspects of the benefits of AI, the opportunities to realize those are going to be foreshortened, curtailed, constrained by business considerations, by monopolies and by the inability of smaller operators to really deploy their tools and reach a market.
Well, that’s all the time we have for today. So, tune in next time. If you’re interested in our work, in our events, publications, go to lowninstitute.org and check us out.