Recent corporate deals to acquire primary care, home care, and value-based-care companies may not have much of an impact on primary care physicians in the near term, say observers. However, these large, well-resourced corporations such as Amazon and CVS may intend to scale up their acquired operations in ways that reduce the viability of independent primary care practices.
The two most eye-catching developments in the past month have been the announcement of Amazon’s $3.9 billion deal to acquire concierge primary care company One Medical and CVS’s agreement to buy Signify Health, a provider of technology-enabled in-home services. While the Amazon acquisition of One Medical is being scrutinized by the Federal Trade Commission (FTC), there’s no indication that the FTC will challenge the buyout.
UnitedHealth recently struck a deal with Walmart to have its Optum subsidiary provide analytic and decision support that will help Walmart’s burgeoning primary care clinics serve seniors under value-based contracts with Medicare Advantage plans.
All of these agreements emphasize the role of technology in making healthcare more efficient and consumer friendly. But observers point out there’s more than that to high-quality healthcare.
“Of course, technology is important, but chronic care and especially end-of-life care require a human touch and not just someone who doesn’t know you. So we can’t forget that healthcare is not just about technology,” Jonathan Weiner, PhD, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, told Medscape Medical News.
Amazon Faces Stiff Challenge
One Medical currently has primary care clinics in 25 markets. Its business model is to give patients better access to doctors and provide more extensive services, including telehealth, in return for an annual fee that a Los Angeles Times article pegged at $199. Not surprisingly, most One Medical clinics are located in more affluent areas.
One Medical has recently lost a lot of money, and Amazon has offered to pay a high multiple of the firm’s current stock price for ownership. So why is the technology giant so interested in a concierge primary care firm with a bleak financial prognosis?
According to the announcement of the merger agreement, Amazon wants to “reinvent” healthcare and likes One Medical’s “human-centered and technology powered approach to healthcare.” Amazon adds that it is guided by a “consumer obsession,” which aligns with One Medical’s approach to the patient experience.
But why primary care? “Amazon wants to get into primary care because they want to get into healthcare, and it’s the base of the pyramid,” Weiner said. He referred to Amazon’s other investments in healthcare, including Amazon Care, a virtual and in-person primary care venture that it recently shuttered.
David Blumenthal, MD, president of the Commonwealth Fund, is less optimistic about Amazon’s ability to reinvent healthcare by using One Medical as a wedge.
“I don’t think you should assume this would happen easily or seamlessly or that ultimately they’d be successful in scaling One Medical,” he said. “They do have money, they’re risk takers, and they’re good at technology — all of which is helpful — but ultimately they have to build networks in all the areas where they are working, which is very complicated and difficult to do, as insurance companies can tell you.”
There’s also very little money in primary care, Blumenthal noted. “Primary care is critical [to good outcomes], but the payoff to [owning] primary care comes from its ability to influence hospital and specialty services.”
Therefore, he and a colleague maintained in a recent Harvard Business Review article that One Medical could become profitable only if it changed its business model to one focused on taking financial risk from health plans. While One Medical owns a primary care company called Iora that holds risk contracts with Medicare Advantage plans, Blumenthal believes it is more likely that One Medical itself would seek commercial risk contracts.
There’s Profit in the Concierge Model
Andrew Bazemore, MD, senior vice president of research and policy for the American Board of Family Medicine, views Amazon’s strategy differently. The concierge model, also known as “advance primary care,” is catching on, he said, as middle-class people with jobs and health insurance become frustrated by the difficulty of obtaining medical appointments and procuring more than a few minutes of a doctor’s time.
“If [Amazon/One Medical] can short circuit that with lesser wait times, longer visits, and better use of technology, you have a lot of inefficiencies that can be bypassed,” he said.
On the other hand, he’s concerned that if One Medical and other advance primary care operations continue to grow, they’ll reduce access to primary care for people who can’t afford their fees and will hurt traditional primary care practices.
“If you siphon off the healthier and wealthier patients and you don’t get into the places where the most vulnerable patients with the greatest need for primary care are, this deal doesn’t provide a boost, at least for that population,” Bazemore said.
From the viewpoint of primary care offices, he noted, the problem is that concierge companies — along with urgent care centers, retail clinics, and third-party telehealth services — provide more convenient care for minor acute conditions that constitute the most lucrative cases for fee-for-service primary care physicians.
“The traditional practices will continue to take care of the sicker and often poorer patients with more complex medical needs,” he said. Without the kinds of patients that One Medical caters to, however, these offices will find it increasingly difficult to stay in business, he noted.
Another reason for Amazon to purchase One Medical, Bazemore suggested, is to use its patient data — as well as those of Iora — to target consumers with ads for health-related products that they can buy on Amazon’s site. The Health Insurance Portability and Accountability Act (HIPAA) prohibits healthcare providers from sharing these data with third parties such as Amazon, and One Medical has stated that its patients’ data will remain protected. Bazemore suggested Amazon may find ways to use its ownership of One Medical in marketing products.
“There are ways to ensure that, when patients enter a healthcare setting, they can be made aware of products that are available to them, even if not directly personalized, and that can lead to data sharing,” he said.
Weiner agreed. “It’s possible Amazon may try to rejigger things by offering a discount or a gym membership if the patient agrees to get special offers on health products,” he said. “I’m sure they’re looking for synergies.”
CVS/Synergy Deal: Beyond Home Care
Although CVS also sells a variety of goods in its pharmacies, its strategy in acquiring Signify Health for $8 billion (after beating back a bid from Amazon) seems markedly different from that of Amazon.
CVS owns Aetna, one of the largest health insurers; it has a network of Minute Clinics in its drugstores; and it has built around 1000 HealthHub facilities that offer a wide range of nonemergency care. CVS has been closing some of its pharmacies, so it appears to be transforming itself into a diversified healthcare player.
Signify Health focuses on home care, mainly for Medicare Advantage plans and accountable care organizations (ACOs). It also owns Caravan, which provides infrastructure to ACOs for value-based contracting. Signify has more than 50 health plan clients, including CVS’ Aetna division, and a network of 10,000 clinicians. These clinicians not only provide home care but also assess their patients’ clinical and social needs and connect them with follow-up care and community-based resources.
Bazemore views CVS’s acquisition of Signify as another advance primary care play. “CVS would tell you that Signify clinicians spend significantly more time with patients than they get in a typical primary care office visit. You can imagine that this competes with comprehensive primary care practices, whether their doctors are independent or employed by health systems.”
It’s not clear how many of these services would be provided by primary care physicians in their offices if firms such as Signify didn’t exist. But there’s no doubt that home care is taking a larger portion of the pie as the population ages, more patients are discharged to home after hospitalizations, and some health systems start to build hospital-at-home programs.
Blumenthal and Gretchen Jacobson, director of the Medicare program at the Commonwealth Fund, see other problems with operations such as Signify’s. Said Jacobson, “One question that always comes up about home assessments is to what extent are they influencing and using care? Are they passed along to the primary care physician of the patient? Are they then used to get the resources and supports to the person that they may need? To the extent that they are actually used in that way, they can improve the quality of care.”
However, Medicare Advantage plans that use home assessments don’t necessarily pass them on to primary care doctors, she said.
Blumenthal added that this information should also be communicated to specialists who are managing chronic conditions.
“The home assessment could be very useful, but it has to flow out along the many pathways of the healthcare system and get integrated into the workflow of a fragmented system with very distorted incentives,” he said.
Ken Terry is a healthcare journalist and author. His latest book is entitled, “Physician-Led Healthcare Reform: A New Approach to Medicare for All.”