Defining the “New Normal” in Primary Care

Abstract

Health care organizations in the United States have transformed at an unprecedented rate since March 2020 due to COVID-19, most notably with a shift to telemedicine. Despite rapidly adapting health care delivery in light of new safety considerations and a shifting insurance landscape, primary care offices across the country are facing drastic decreases in revenue and potential bankruptcy. To survive, primary care’s adaptations will need to go beyond virtual versions of traditional office visits. Primary care is faced with a chance to redefine what it means to care for and support patients wherever they are. This opportunity to shape the “new normal” is a critical step for primary care to meet its full potential to lead a paradigm shift to patient-centered health care reform in America during this time when we need it most.

Just a few years ago, Starbucks described its coffee shops as a third place¹—distinct from people’s homes or workplaces—where the company was committed to providing “a warm and welcoming environment where customers can gather and connect.”² In 2020, the COVID-19 pandemic pushed Starbucks to accelerate reframing of the third place from a physical space to a theoretical one that begins “from the moment [customers] think of Starbucks.”³ Starbucks and other business chains have been exploring more drive-thru and walk-up pickup locations, mobile ordering, delivery, and other innovative ways to continue to provide value to their customers and survive in our new reality.

COVID-19 has shaken the United States health care system to its core, but we are now in a unique position to consider: What is primary care’s opportunity to meet with patients in a redefined third place? Even before the pandemic, visits to primary care clinics were declining.⁴ For too many patients, the “old normal” was not working. Patients were waiting a month or more to get a first appointment with their primary care physician,⁵ taking time off work for appointments, and spending time and money traveling to clinics.⁶ Additionally, these barriers disproportionately affected Black people and other historically disadvantaged groups.⁷ The “old normal” was synonymous with disparities in health outcomes and deeply entrenched health inequities.⁸

PRIMARY CARE’S VIRTUAL THIRD PLACE

Primary care clinics across the country have made drastic changes in their workflows, office visit volumes, and outreach to patients since March 2020.⁹ The defining structural change in health care delivery thus far has been the rapid deployment of telemedicine, which allowed clinics to transform the physical space of an office visit to a virtual space. The dramatic uptake of telemedicine¹⁰ from both the patient and clinician standpoint is a central feature of health care delivery since March 2020. Patients coming into the office for care is no longer the default. Suddenly, care can be delivered anywhere there is a telephone or computer: at work, from home, and with caregivers conferenced in from multiple locations.

For some patients, virtual visits already represent greater convenience and access. But for older adults, disadvantaged racial and ethnic groups, and low-income individuals who may be more likely to have limited access to technology or telecommunication services,¹¹ telemedicine represents another structural barrier to equitable care. The virtual office visit will do little to address the health disparities entrenched in the “old normal.” Similarly, if we adhere to an office visit structure in a virtual space, we will miss an important opportunity to define new ways to address preventable disease in the expensive and inefficient US health care system.¹²

Doing away with primary care’s reliance on the office visit is not a new concept. For decades, leaders in health care have called for shifting the focus from measuring the production of health via procedures and office visits.¹³ The uptake of telemedicine in response to COVID-19 has created an opportunity to rethink how health care systems and patients connect. This opportunity comes with new urgency as primary care practices across the United States have continued to report pandemic-related furloughs and layoffs.¹⁴

BEYOND THE VIRTUAL THIRD PLACE

Delivery of health care has already begun to go beyond just taking what we had done in person and doing it on a video meeting platform. For example, Michigan Medicine has dramatically reduced the number of in-person appointments recommended for low-risk pregnant patients in order to “right-size” prenatal care.¹⁵ Their aim is to use virtual visits when high-quality care can be provided by telephone or video and only require in-person visits when examinations or testing is necessary. This strategy was designed to decrease the risk of COVID-19 transmission, but also to eliminate unnecessary visits and health care costs, reducing travel time and burden for patients. Health care organizations in the United States have transformed at an unprecedented rate over the last few months due to COVID-19. Primary care’s rapid adaptations to the virtual third place of telemedicine visits begs the question: Can primary care take the lead in providing what patients need in ANY space, just as businesses like Starbucks have—from the moment someone thinks of their health or wellness?

Now is the time to take bold action to connect patients with health in innovative ways that no longer rely on the outdated structure of the office visit. Care can be delivered where patients live, learn, work, and play. Some clinics are already mailing sexually transmitted infection (STI) testing to patient’s homes¹⁶ or connecting them with prescriptions for birth control via smartphone apps.¹⁷ Patient access to important point-of-care testing and vaccine administration can be extended using mobile health clinics, drive-thru sites, and school-based health centers.¹⁸ Wearable sensors and smartphones can guide health recommendations informed by EKGs, blood glucose, pulse oximetry, and more without interrupting the workday.¹⁹ And community health workers can connect with patients outside of traditional clinic hours to help them overcome barriers to health and to support their long-term health goals.²⁰

The potential of primary care’s third place is not just virtual office visits—it is a paradigm shift in what it means to care for and support patients wherever they are. These are just a few examples of what the future may hold if primary care were to truly meet patients where they are. There will be many others. For this level of transformation to occur, we will need to conduct research into effective and innovative care delivery. And medical education will need to provide adequate training in telemedicine and other new frontiers of health care.²¹

Inevitably, in this “new normal,” we will get what we pay for. If we approach telemedicine encounters simply as virtual versions of traditional office visits and reimburse them with the same transactional fee-for-service models, we can expect to see very little change in terms of health outcomes and health inequities. Instead, we need payment systems that encourage us to embrace innovations that maximize the capacity to care for patients beyond the traditional office visit.²² Incentive systems in primary care should be aligned with patients getting the right care, from the right team member, at the right time, no matter where they are. Capitated payments are one such example of a reimbursement model that could promote patient-centered advances making it possible for patients to connect with primary care on demand.²³

COVID-19 has forced primary care to connect with patients in a new virtual third place, but we are just beginning to explore how to make health care and health promotion available in any space. Beyond the chaos of a global pandemic is an opportunity for bold action that our health care system has needed for decades. We are well poised to embrace innovative strategies that provide the support and care all patients need where and when they need it. This opportunity to shape the “new normal” is a critical step for primary care to not just survive this crisis but to achieve the full potential to transform health and health care in America during a time we need it most.