Primary Care: Rebuilding the Gateway to Our Healthcare System

The healthcare ecosystem has been experiencing a seismic shift. From companies like Boulder Care who are facilitating innovative treatment strategies for those affected by the opioid crisis, to startups like Robin Care who are changing the face of cancer patient advocacy, it seems that every healthcare institution is being transformed by “disruptive innovation.” The challenge is in bringing change to parts of the care continuum that are trapped in a cycle of misaligned incentives. Our nation’s primary care model is antiquated and broken. Doctors are incentivized to see the maximum number of patients possible, which translates into less quality per patient interaction. A volume-based system leads to fewer questions, more standardization, and less depth of care, which in turn leads to worse outcomes for patients, and helps fuel a bloated and costly system. As the gateway to our healthcare system, we are missing a tremendous opportunity for impact with primary care.

A few years back, I experienced firsthand how our broken primary care model can lead to a dramatic negative outcome, and how as the patient – however “informed” we may be – we often base the quality of our experience on the wrong things. In 2013, my sleep health began to decline dramatically. I was getting a couple of hours each night, if that – not quite full-blown insomnia, but pretty damn close. It went on for close to two years. To this day, I don’t know the root cause.
There was plenty going on in my life at the time, so stress is a likely factor, though it’s possible there were others. To me, the best way to describe it was feeling like my body was out of balance.

I did all of the things they tell you to do when you can’t sleep: I stopped watching TV in bed, kept the phone away from my face before sleep, didn’t eat too close to bed time, cut back on the booze. I took the basic over-the-counter stuff – CVS Sleep Aid, Nyquil, Melatonin – sometimes it worked, most of the time it didn’t. Soon my lack of sleep began to impact my work. I was groggy, out of it, not firing on all cylinders. I didn’t want to over-caffeinate or else I’d be up all night, so I started to feel utterly helpless. I was trapped.

One day at the end of 2013, I visited my primary care doctor for an annual physical. He ran a standard EKG test and did some routine blood work. There was no talk of sleep, since this was just before the value of sleep really permeated the public consciousness. No one was talking about sleep back then, so my doctor just asked basic questions about my diet and exercise. He didn’t delve into any detail regarding my lifestyle – how could he? We had about 7 minutes together.
7 minutes doesn’t leave you much time for a deep-dive Q&A. Thing is, if you asked me if I liked my PCP, my answer would have been a resounding yes. He scheduled appointments on short notice, rarely kept me waiting, would communicate with me via email, wrote a script without requiring a visit, and was pleasant to meet with. Cool stuff? Sure. Right criteria to judge him on solely? Probably not.

In my mind, the only real by-product of my lack of sleep was being tired and not as sharp. My blood work came back, and a bunch of stuff that was green the year before had turned yellow or red, so I could tell I was trending in the wrong direction. I was on a path to pre-diabetes. My doctor’s advice was to eat better and lay off the booze, which is exactly what I did. My plan was to tough it out. After all, I was young, energetic (sorta), in otherwise excellent physical (sorta) and mental condition – so I decided to white knuckle my way through the problem until it subsided and I was back to getting 6-8 hours a night.

Little did I know that if I didn’t change something drastically – and soon – I was about to be in serious trouble.

A few months later, I had lunch with a friend of mine who was the CEO of a population health management company, specifically focused on sleep disorders. He began talking about lack of sleep, and what a problem that is for society. He explained how a lack of sleep has a cascading effect on people’s health and leads to all sorts of co-morbidities, some very serious – even fatal. My jaw hit the floor. I could almost feel the light bulb go off: he was talking about me! That cascading effect, all of those co-morbidities he was describing… that was reflected in my blood work. Finally the dots connected.

During that same time, I had a friend – Alex – who was battling cancer (you can read Alex’s story here). Alex happened to mention an acupuncturist whom he was seeing to alleviate some of the effects of his chemo. After my conversation with the guy running that sleep health company, I knew I had to do something, so I visited Alex’s doc. That decision saved my life. Within a month of weekly acupuncture treatments, I was sleeping through the night 5 nights a week. Within 3 months, my sleep patterns returned to normal. My annual physical was right around the corner, and when my blood work came back, everything was back to normal. And no other variable changed during that time frame – I was eating, drinking, working, exercising and socializing the exact same amount.

When I think back on my ‘years of no sleep,’ I reflect on how fortunate I am. As an educated adult in the healthcare industry, I was entirely ignorant about the effect of sleep on my overall health, yet I had access to people like Alex and others who through their wisdom and expertise could alter my perspective in a single conversation. Imagine if I hadn’t been so lucky. Imagine if I didn’t have access to the same network. Would I have made the necessary changes? What if I couldn’t have afforded those acupuncture treatments? I would have likely ended up with Type-2 Diabetes, which not only affects me personally, but impacts all of society by instantly converting me from a profitable member of a health plan into a costly one. Who knows how many millions of chronic conditions can be averted through enhanced primary care interactions? Is it unreasonable to think that if I had had 30 or 45 minutes with my primary doc, we might have gotten to the bottom of things sooner? Nevermind this doozy from CNN recently…

The problem is, our primary care model is not designed to solve these kinds of problems in its current form. The structure is built for revenue generation, not disease prevention. We need to figure out how to incentivize doctors away from a higher volume of patients, and towards a higher quality of care. There are already a number of companies looking to do just that by coupling standard primary care with intensive preventative care solutions aimed at halting or even reversing the effects of chronic disease. Companies like CareMore, Iora Health and Aledade are utilizing technology and data analytics to organize their practices around patient populations requiring similar types of care. That helps reduce ER visits and unplanned hospitalizations while improving the overall quality of care.

Startups like Eden Health are taking that model one step further by unifying private doctor visits, 24/7 telemedicine, and insurance navigation into a single mobile platform. The result is that undiagnosed conditions are suddenly being discovered and treated. “One patient was bounced around for almost a decade with seasonal effective disorder,” says Matt McCambridge, Eden’s CEO. “It was absolutely a deficiency related to their vitamins. They [the patient’s primary care providers] were saying it’s not really anything, but we spent the time to figure it out. If you have 40 minutes, you can move past the simple stuff to the things that people don’t really feel comfortable talking about.” McCambridge highlights his firm’s infusion of technology as a key differentiator between Eden Health and the standard primary care model. “When a patient signs up with us, we see their medication history immediately. We have a back-end that pulls all of that info, so we have more data on patients than other providers do. The stuff you talk about with a PCMH, it can be put into practice in a more reasonable way when you have access to data. A lot of things aren’t purpose-built for primary care providers.”

And therein lies the rub. The primary care model in its current form just isn’t cut out to handle the complex systemic and operational flow of the doctor-patient relationship. The model is built for speed, not depth. What good is blood work done after the primary care visit with no follow up? Thankfully, companies like Eden Health are taking the wheel and steering a new course, aiming to solve for these variables with innovative technology and aligned incentives.
Unfortunately, the deficiencies embedded in our primary care structure are far too sweeping and entrenched for a silver bullet to fix them. It’s going to take significant cross-industry collaboration and empowering primary care providers to truly provide preventative care.

Primary care is the gateway to our entire healthcare system. Optimize the gateway, and you optimize the entire funnel beyond. That gateway represents an opportunity to legitimately alter someone’s lifetime health trajectory – for the good or the bad – but it’s unrealistic to expect any kind of impact in an appointment that lasts a matter of minutes. Real change is out there, it’s only a matter of time.