As recently as 40 years ago, Americans turned to their primary care clinicians to treat most of their ailments — from checking sore throats to delivering babies.
"Primary care was this idea from birth to death, that the primary care doctor would be the main provider," says Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School. "We have seen a slow but steady erosion of that in many ways."
Today, Dr. Mehrotra says, many of the things primary care clinicians used to do are covered by other specialties. Delivering babies, for instance, is now often obstetrics.
The result, in some cases, is that seeing a clinician has become more difficult. It can take months to get a first appointment, and specialists can be costly.
Enter technology companies and big retailers, who are eyeing primary care as a space that's ripe for disruption. Walmart, CVS and Amazon have all announced plans to expand primary care services for their customers. A big part of that expansion includes more virtual care.
Proponents argue virtual care has the potential to reduce costs and improve health for patients by providing more services in-house, such as basic mental health care.
"We're able to provide that depression care without needing to refer out," says Dr. Nisha Basu, medical director at Firefly Health, a Watertown-based health care startup. "That is better for the patient. That'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 coaches, sees patients almost exclusively via video and text messaging. The idea is that quick 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 cubicles and a giant basket of snacks in the kitchen. Instead of dimly lit exam rooms, there are glass-windowed offices filled with natural light where clinicians conduct virtual appointments.
The one exam room at Firefly has been used only a handful of times in the last 18 months, and the company says its providers no longer use it.
"You can still do an exam through a virtual visit," Dr. Basu says. "We use our eyes. We use our ears. We're able to have patients run through certain maneuvers at home."
If patients need to measure blood pressure, for example, Firefly will mail them a cuff to use at home. As technologies for at-home diagnostics improve and become more ubiquitous, patients will be able to do even more from home, such as collect their own blood samples.
For more complicated procedures, such as biopsies or X-rays, Firefly refers patients to in-person visits with specialists.
Dr. Basu says patients' needs are changing. More people want to ask questions about their diets or over-the-counter medications. More patients want mental health care as part of their routine care. And they want to connect with the doctor's office as easily and quickly as they communicate with friends and colleagues, such as via text messages.
She says primary care — and medicine in general — has gotten too focused on treating people after they get sick.
"Everyone should be able to contact their PCP when they have a question," Dr. Basu says. "Everyone should be able to have access to high quality preventative care, and we don't have that in this country today."
Dr. Basu believes technology provides a unique opportunity to improve health care. And investors seem to agree with her. The health tech space has surged during the pandemic. In 2021, investment dollars in Massachusetts digital health companies more than tripled when compared to 2019, topping $3 billion, according to the venture fund Rock Health.
"If you can put the word 'tele' in front of anything, there seems to be a startup out there for it," says Harvard's Dr. Mehrotra.
He attributes a significant part of the growing enthusiasm for health tech to cost. Firefly, for example, has an ambitious goal to cut total medical costs — that’s everything from buying medicine to emergency room visits — in half.
A number of other medical tech startups are also making big promises to slash health care spending. However, data to prove these claims is still scarce, health policy experts say. Firefly is currently in the process of running its own cost analyses.
"I get it. I understand why these new care options are very both exciting, [and] potentially can have a substantial impact on the U.S. health care system," said Dr. Mehrotra. "On the other hand, I wish I had the evidence to actually support that. And I do fear that, at least some of them, are probably not helping people and actually may be providing inferior care."
All of the clinicians WBUR spoke to say virtual care has been a great tool, especially during COVID, and it's likely that patients and doctors are getting 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 how much clinicians should rely on telehealth in the future.
"I think that the patient needs to be seen face to face — hands on," said Dr. Sterling Ransone, the president of the American Academy of Family Physicians. As a practicing primary care physician 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.
Still, 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’m looking at someone’s skin, I’m touching it. I’m feeling it. I'm seeing it. There’s a lot we can get from a face-to-face interaction that we can’t get via 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 been waning 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.
This article was originally published on March 04, 2022.
This segment aired on March 4, 2022.