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Insights From Harvard’s Primary Care Innovators Round Table

In 2005, I was invited to participate in an innovators’ workshop by the Harvard Interfaculty Group, funded through a grant from the Robert Wood Johnson Foundation. The question at the meeting was this:

“If primary care is critical to a vibrant and cost effective healthcare system, and
If primary care is going extinct, which most now predict;
Who is out there innovating new primary care systems and what is their vision?”

During the four years since this conference, I’ve found that this question is first and foremost when it comes to changing primary care.

I felt honored and surprised to be invited to the meeting. After all, our practice and its innovations are simple and are based on the following:

  1. Communication-centered practice where doctors and the medical team are continually available to their patients through phones and emails thereby eliminating up to 60% of office visits.
  2. Robust Information management and retrieval systems so that doctors can immediately pull up the answer they need to any medical question when their memory falls short.
  3. Transparent pricing based on time that gives patients control of their time and subsequently how much care they want or need. All time is priced the same, be it on the phone, in the office, or in a patient’s home, so our incentive is to do the right thing for the right reason with the patient “policing” the transaction.

At the start of the conference, the discussion leader greeted us as we entered the room, “Take a look around you,” he said to the ten who attended the innovators workshop. “After three months of searching, you represent the majority of the movement of innovators in primary care in the U.S.”

I could not believe my ears or my eyes. “This is all you can find?” I murmured to myself, distressed. “These are the only docs? Even if the number was 10 or 100 times larger, you’re telling me that a profession in crises and that is predictably being pushed to the brink of extinction, a profession where most of my colleagues are talking about “getting out” or advising their children not to enter, a profession considered critical to the healthcare infrastructure of this nation, that only had a handful of innovators willing to take on the challenge of change.

I was dumfounded that there were fewer than 1% in our profession who were innovating, willing to take risk, who were standing up and saying: ”Let’s change this. Let’s stop waiting for others to tell us how to do our job. Let’s stop worrying about getting rich. Let’s restore the integrity of our work and do the right thing for the right reason. Let’s stop letting others interfere with the sacred and professional obligation of truly being in relationship with the people we serve one person at a time.”

One by one, we shared our stories and business models with each other. We all had similar philosophies and therefore similar problems. What we shared was the old fashioned knowledge of the need to remove the conflicts of interest inherently brought into the therapeutic environment of a doctor-patient relationship by third party payers, coders, data miners, drug reps or conflicts of interests brought in by the doctor’s business practices.

These round table attendees in fact understood that restoring the integrity and soul of primary care was nothing more than being committed to their patients in ways that are violated by outside parties as well as outdated assumptions about the current business practice of care. The roadblock to success that the innovators truly focused on was this: what did it take to win back the loyalty and allegiance of the patient.

I thought the conference could be seen centered on this one notion, winning back the hearts and souls of the patient, by differentiating on quality, science, control, access and convenience, price, not to mention trust. I’ve found that medical practices and primary care physicians today believe in these values but are completely hamstrung.

What has brought primary care to its knees to the point where we are talking about our own extinction is that we have lost the loyalty of the patient who fundamentally ask the single question with its kiss of death “Doctor, are you a preferred provider, do you accept my $20 co-pay?” This means the patient is “owned” by the insurance company who thereby dictates policy and preferences to the patient and rules, regulations, reporting requirements, and acceptable innovations, to the doctor. Right now, differentiation on quality, trust, access, and any other value is meritless to the consumer over the power of the $20 co-pay. Despite our innovations, none of us had found a way to grow rapidly or sustainably or crack the power that the lure of the $20 co-pay held over the consumer.

We left the meeting two days later understanding that nothing we had done so far … not better care, not more efficient care, not more cost-effective care, not trusting environment, not gaining better control over health decisions … nothing had innovated its way into the hearts and minds yet of the American consumer.

The road ahead would be, and continues to be, long and hard, but the journey is underway.

Until next week I remain yours in primary care,

Alan Dappen, MD

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