CareTalk Podcast – Are We Ready for Digital First Primary Care?

Should patients be required to see their doctors online first for all non-emergency care? John and David weigh in on digital-first primary care. 

David Williams:

Welcome to CareTalk, America’s home for an incisive debate about healthcare business and policy. I’m David Williams, president of Health Business Group.

John Driscoll:

And I’m John Driscoll, the CEO of CareCentrix. So David, what’s in the news today that we’re going to talk about?

David Williams:

John, the news today is about CareCentrix. Everybody I think has seen the announcement about Walgreens purchasing a majority stake. And I have a couple questions that go beyond the headlines. I want to know why is Walgreens investing in CareCentrix, how that fits with their overall announcement, and what’s going to be the impact on your customers, your employees, your suppliers, let us know.

John Driscoll:

Thanks for the shameless opportunity to talk about the CareCentrix good news, but we’ve got a longterm relationship with Walgreen stores in leadership and talking to them about how many different ways we could actually leverage their 9,000 store network to help our patients in plans, not just get a better deal in terms of prescriptions, but better coordinate drugs as a form of healing and making sure people are on the right prescriptions at the right time. And as a practical matter, post-acute, which is what we take care of at CareCentrix, our mission is to help people heal and age at home and consistently moving more care to where people want to get it, which is at home and in the community is completely consistent with what Walgreens wants to do.

But basically the Walgreen’s investment is an endorsement in CareCentrix and our success at shifting more care to the home and avoiding too many visits to the hospital and nursing home. And it’s also a down payment in expanding what local pharmacies might be able to do as they expand and get more connected to the rest of the healthcare system. There’s so much dysfunction in all of the care transitions, picking up a script, going to the doctor’s office, making sure the care that’s supposed to happen does happen when you’re post discharge. Like my 88 year old mother comes out of the hospital, who’s doing the care traffic control of making sure she’s getting the right care at the right time, is on the right drugs?

All of that currently CareCentrix coordinates, Walgreens really believes in and the opportunity to leverage the best of both to improve patient outcomes and frankly, experience like my mother’s is incredibly important.

David Williams:

So John, it sounds really excellent and makes sense at a strategic level. But I guess I’m thinking about if I’m a customer of CareCentrix, if I’m an employee, I’m a supplier, how should I be feeling about it?

John Driscoll:

Well, I think you should feel great if you’re an employee or a patient because we’ve now got a lot more, we’ve got a big capital partner, so we can continue to expand our reach. And if you are a health plan or a doctor, they tune because we’re going to come up with some really cool new products and services that are going to make your jobs easier and the impact of moving more care to the home and the community more accessible.

David Williams:

Well, good. Well, the good news, John is I have you here every week, so I can press you on these matters if we see them coming to fruition or not. So let’s talk about digital first primary care, something else that’s in the news. You hear this digital first, it sounds like America first, but I think this is meant to be a little bit more uplifting and unifying. So what is this concept? And are you a believer?

John Driscoll:

David, you’re such a skeptic. Of course, I’m a believer. What could go wrong with actually solving for more convenience for a healthcare system that no one seems to be… People are rarely available unless you get access through the emergency room to actually provide the care you want when it’s convenient for you, not the healthcare system. How can you be against leveraging digital tools? Again, you sound like such a skeptic. This is a great early stage leveraging an expansion of what telemedicine started.

And I think we’re just kind of scratching the surface of all of the different ways in which digital can be integrated into the rest of healthcare to make it more convenient and faster to get people diagnosed in health.

David Williams:

So, John, the idea here with digital first primary care is that the patients are going to see their doctor online first for anything except for an emergency. And you’re starting to see well known health plans like Harvard Pilgrim and Priority Health actually offering this as like a replacement product for their typical primary care network. Of course, that has a lot of value into it. I’m a proponent of digital health, but John, I’m more like a digital second primary care, because I think that you should have an established-

John Driscoll:

What’s all this? But-

David Williams:

What?

John Driscoll:

… you’re standing behind a flawed system here, David, a system that it takes forever to get an appointment. You aren’t even getting an appointment with the right person. You’re suggesting you start with the horse and buggy before you move to the car. Come on, David, there’s all we’re talking about here. The vast 20 to 30% of all of the patients we touch don’t even have a doctor, even though they are in managed care and allegedly have a primary care doctor. Another reasonably high percentage don’t really have a close relationship with their doctor. So digital first doesn’t mean digital exclusive. It doesn’t mean that it’s a digital barrier. It’s digital first, which means you get faster access to a doctor that can connect to you on your schedule.

David Williams:

Well, John, there’s actually a study that was published in the Journal of Medical Internet Research, okay? And they showed that the primary care workloads could increase by-

John Driscoll:

Did you write it?

David Williams:

No, it’s peer reviewed. It could be increased by 25 to 31% of the workloads of having a digital first approach. And you know why? It’s because what happens is it’s digital first and then it comes in person after that because you go and you say, “Oh yeah, I’ll do this online visit. Okay. Thank you very much. I’ll bill for that. And now come in and see me.”

John Driscoll:

Pete, you’re a skeptic of anything new. I think that you’ve hunted around to find some contrary piece of knowledge. There’s a lot of aspects in areas in healthcare where access to new services has driven demand and that dynamic does sometimes exist. But we live in a system where the healthcare system in general is torturously inconvenient. And you’ve got frail elderly people, the handicap, people with full-time jobs and sick kids. And what you’re suggesting is somehow they shouldn’t have access to a digital first alternative if they so choose. No one’s talking about replacing the system.

You’re sort of suggesting implied in your cockamamie study is that somehow providing access to services in other parts of healthcare doesn’t increase demand as well. Of course, it does. But a well curated digital first primary care really care system backed up by solid in-person doctors in a reasonable plan is certainly something we ought try. And you shouldn’t be afraid of it because it’s new.

David Williams:

Well, John, I think maybe you misheard what it was. With the way you’re such a proponent of it makes me think you heard me say Driscoll first. I said digital first. Now, listen, I’m going to give you a few of the positives. Sorry, and I’d tick off a few things. Okay. So you have a more timely intervention-

John Driscoll:

Oh, sorry. I brushed you back.

David Williams:

You did.

John Driscoll:

I brushed you back.

David Williams:

I switched 180 to being a believer. Okay. So you have more timely interventions. I don’t want to be… I’ll tell you one thing. I don’t want to be in a doctor’s waiting room, getting an infection while I’m there. Another thing that we’ve seen from way back is that if you have somebody, they have to take leave from their job, go down and the doctor tells them, “Oh, it’s nothing. Don’t worry about it.” Sometimes they feel compelled to prescribe a drug or to order a test which causes unnecessary expense and potentially harm. So there are some positives to it, John, I’m just a digital second guy, not digital first.

I want a relationship with my doctor. I don’t want to deal with some outsourced primary care hamster mill that’s out in the middle of nowhere.

John Driscoll:

I think that the thing that you’re missing, David, is that there’s an enormous hunger for more access to care with people who often find it very hard to access the system as is. Secondly, healthcare inflation’s going to crush us. And we have to try all kinds of new digital models to lower the cost while improving access. If we can actually pull those folks for whom the system is inconvenient in for more visits they should be going to and give people alternatives that allow them to connect to a healthcare system where they’re just bouncing around without a doctor, I think we’re going to be much more responsive to the market and have the possibility of actually reducing total cost of care.

I’m excited about what Oscar is doing, what Priority is doing, what Harvard Community Health Plan is trying to force you to do with your plan, but it’s based in this notion of disconnection and lack of convenience that honestly, David, you can’t solve without it.

David Williams:

Well, John, I know your big Anglo file. So you’ll be pleased to know at the National Health Service from our dear old England and the rest of-

John Driscoll:

God bless the queen.

David Williams:

… the United Kingdom. They actually published a strategy in 2019. And they said that every patient should have the right to digital first primary care by the fiscal year 2024. Now, if the NHS is doing it, it tells me one thing when they’re talking about someone having a right. It means that they get to cut down the cost-

John Driscoll:

Talking about costs.

David Williams:

… make due amend in primary care as well, John. I don’t know if you took that as you’re on your side or not.

John Driscoll:

They didn’t give you a right to a new hip. I noticed that.

David Williams:

No.

John Driscoll:

No, I think you’re just trying to muddy the water. The reality is innovation is your friend, David. Access is the friend of the patient and convenience is critical to improve healthcare.

David Williams:

All right. So let’s take it a little further. That’s digital first primary care. What about digital first specialty care?

John Driscoll:

I think digital assisted specialty care makes sense. I don’t think you need to… I think if you’re going to see the doctor about the pinch nerve in your arm, you’ve got to actually have a physical exam plus test, but the follow up meetings could easily, many of them could be done pretty comfortably virtually once you’ve actually had that initial physical assessment. I think with the way you think about specialty is it’s, how do we leverage telemedicine and virtual visits and again, make it easier to connect with patients and more convenient for those patients who have a hard time getting to see the doctor?

David Williams:

Digital second, John.

John Driscoll:

Integrated. It depends on the application. Are you suggesting that for your… We know that digital algorithms plus a derm can almost better than just walking into a doctor’s office, identify melanoma, skin cancer. A physical test isn’t always necessary. You can manage digital tools and take a picture, and probably you’re more likely to get access to the information faster. And in some cases, it’s going to be more accurate. Are going to deny access to better information about your potential skin cancer? That’s where I think digital first would make sense. There’s other areas where that connection would matter, but it entirely depends on the specific use case.

David Williams:

John, I think we’re in agreement that you want to have a combination of in person and digital and where we agree a little bit less is about whether it’s really digital first, especially on the primary care side. But I want to ask you about how this-

John Driscoll:

You’re afraid of it. Don’t be afraid.

David Williams:

I’m afraid, John.

John Driscoll:

It’s change, David, warm it up.

David Williams:

I’m afraid of going to the-

John Driscoll:

Get comfortable.

David Williams:

… dentist, and I want a digital first dental visit, but that maybe will be our next time. I want to understand how this actually fits with what we started off talking about in the-

John Driscoll:

David, that’s another example of you just throwing shade on something. The Indian Health Service found that they could not get dentists in Northern Alaska for… It’s just a brutally difficult place to live. But a lot of the tribal-

David Williams:

The whales don’t need the dentist, John.

John Driscoll:

… groups needed access to dental care. So a combination of teaching some of the folks in the community some basic skills plus a telemedicine with a dentist at a distance actually allowed certain tribes to improve the level of care. And you know what the American Dental Association did? They sued the tribes to deny them access to training and virtual tools. You stand on the side of dentists who don’t want to provide virtual care to Indians and native Americans and Eskimos who need it. How do you even look at yourself in the mirror?

David Williams:

Well, John, what I’ll say is where you’re talking about this time of year, this time zones, you have to turn a pretty bright light on to see the mirror. If you have to go all the way to Alaska to come up with a counter argument for something that’s going on in New England, I feel for you, John.

John Driscoll:

You just made something up about the dentist. Actually, it turns out that a combination of virtual care plus locally trained folks who weren’t conventionally trained in the areas of high need provided a fair amount of conventional regular dental care. It’s a perfect example of where you imagine a use case that’s a problem. It actually is one that was successfully applied in an area of high need and low access.

David Williams:

Well, John, I can always count on you for the conventional wisdom. So thank you for that. Now, getting back to where we started about people being at home where they want to be, how does a digital first approach tie in with the idea of what you do at CareCentrix in terms of the patient being able to heal and age at home? Does it reinforce it? Is it contradictory?

John Driscoll:

I think it’s complimentary. As I said, it entirely depends on the person, the situation, and what they need. We want more of our vulnerable patients connected to care. And if virtual first works for them better than conventional, that’s what we are going to be supportive of. For us it’s all about the patient. But I think more broadly my perspective is in a system that costs too much and does too little, we absolutely have to take advantage of low cost digital tools. And if we don’t test and try, we’ll never know what the opportunity is. And I think that we would naturally integrate virtual primary care, virtual telemedicine assistant specialty care into the care we deliver in the community.

But it’s a natural augment and supplement to what our nurses and PTs and OTs and personal care assistants are doing in the home to have a doctor’s oversight and support.

David Williams:

Well, John, I say we’ll do first things first and last things last and say, that’s it for another episode of CareTalk. I’m David Williams, president of Health Business Group.

John Driscoll:

And I’m John Driscoll, the CEO of CareCentrix. Thanks for listening and please subscribe on your favorite service.