Just 40 years ago, Americans turned to their primary care clinicians to treat most of their ailments, from controlling sore throats to childbirth.
“Primary care was this idea from birth to death, that the primary care physician would be the primary provider,” says Ateev Mehrotra, associate professor of health care policy and medicine at Harvard Medical School. “We’ve seen a slow but steady erosion of that in many ways.”
Today, According to Dr. Mehrotra, many of the activities that primary care clinicians used to do are covered by other specialties. Delivering babies, for example, is now often a matter of obstetrics.
The result, in some cases, is that seeing a clinician has become more difficult. Getting a first appointment can take months and specialists can be expensive.
Enter tech companies and big retailers, who view primary care as a space ripe for disruption. Walmart, CVS and Amazon have all announced plans to expand primary care services to their customers. Much of this expansion includes more virtual care.
Proponents argue that virtual care has the potential to reduce costs and improve patient health by providing more services in-house, such as basic mental health care.
“We are able to provide this depression care without the need for a consultation,” says Dr. Nisha Basu, medical director of Firefly Health, a Watertown-based healthcare start-up. “It’s better for the patient. It’s better for their care, better for access, literally better for everyone.”
Firefly’s clinical team, which includes doctors, nurses, social workers, nutritionists and fitness trainers, sees patients almost exclusively via video and text messaging. The idea is that faster but more frequent check-ins are better for overall health, even if they are virtual.
The Firefly office looks more like a tech startup than a doctor’s office. There are bright green cabins and a giant basket of snacks in the galley. Instead of dimly lit exam rooms, there are glass-encased offices filled with natural light where clinicians hold virtual appointments.
Firefly’s only exam room has only been used a handful of times in the past 18 months, and the company says its vendors no longer use it.
“You can still do a checkup through a virtual visit,” says Dr. Basu. “We use our eyes. We use our ears. We can have patients perform certain maneuvers at home.”
If patients need their blood pressure measured, for example, Firefly will mail them a cuff to use at home. As home diagnostic technologies improve and become more ubiquitous, patients will be able to do even more from home, such as draw their own blood samples.
For more complicated procedures, such as biopsies or X-rays, Firefly directs patients to in-person visits with specialists.
Dr. Basu says patient needs are changing. More and more people want to ask questions about their diet or over-the-counter medications. More and more patients want mental health care as part of their routine care. And they want to connect to the doctor’s office as easily and quickly as they communicate with friends and colleagues, for example via SMS.
She says primary care — and medicine in general — has focused too much on treating people after they’ve gotten sick.
“Everyone should be able to contact their PCP when they have a question,” says Dr. Basu. “Everyone should be able to access high-quality preventive care, and we don’t have that in this country today.”
Dr. Basu believes that technology offers a unique opportunity to improve healthcare. And investors seem to agree with her. The health technology space has exploded during the pandemic. In 2021, investment in digital health companies in Massachusetts more than tripled from 2019, topping $3 billion, according to venture capital fund Rock Health.
“If you can put the word ‘television’ in front of anything, there seems to be a startup for that,“ says Harvard’s Dr. Mehrotra.
He attributes a large part of the growing enthusiasm for health technologies to cost. Firefly, for example, has an ambitious goal of halving total medical costs, from purchasing drugs to emergency room visits.
A number of other medtech startups are also making big promises to cut healthcare costs. However, the data to prove these claims is still scarce, according to health policy experts. Firefly is currently performing its own cost analyses.
“I get it. I understand why these new skincare options are both exciting, [and] can potentially have a substantial impact on the US healthcare system,” Dr. Mehrotra said. “On the other hand, I wish I had the evidence to back this up. And I’m afraid that at least some of them are probably helping people and actually providing substandard care.”
All WBUR clinicians said virtual care has been a great tool, especially during COVID, and patients and physicians are likely to feel more comfortable with telehealth visits. According to Blue Cross and Blue Shield of Massachusetts, there were 130 times more telehealth claims in 2021 compared to 2019.
However, not everyone agrees on the extent to which clinicians should rely on telehealth in the future.
“I think the patient needs to be seen face-to-face,” said Dr. Sterling Ransone, president of the American Academy of Family Physicians. As a primary care physician practicing in rural Virginia, he’s been doing more telehealth visits during the pandemic. It’s also a useful practice for patients who live far from his office, he says.
Yet he worries about what gets lost through a screen.
“Just because someone has a rash doesn’t mean there isn’t a tactile quality to it,” Ransone explained. “When I look at someone’s skin, I touch it. I feel it. I see it. There are a lot of things we can get from face-to-face interaction that we can’t get through telemedicine. .”
Dr. Ransone says patients want a connection with their providers that virtual care can’t give them. But it’s that connection that Dr. Basu says has faded over time in primary care. Now, she argues, we have more digital tools to bring it back.
Correction: This post has been updated to reflect that delivering babies is often – but not always – obstetrics.