In 2021, Walgreens Boots Alliance acquired VillageMD for $5.2 billion to establish hundreds of primary care practices at Walgreens across the country. Last year, the drugstore chain added to its investment in primary care when it made the largest physician deal of the year by acquiring Summit Health for $9 billion.
Together, Walgreens will have a combined 680 provider locations in 26 different markets.
In early 2023, Amazon spent $3.9 billion to acquire One Medical, a tech-integrated, consumer-focused primary care network with 188 provider locations in 29 different markets. For $100 million, CVS Health is partnering with Carbon Health, a digital health, primary care platform, to pilot primary care practices in CVS retail stores, and most recently, CVS completed its $10.6 billion acquisition of Oak Street Health, a primary care clinic network with 169 provider locations in 21 states.
By the end of 2024, Walmart will have more than 75 primary care health centers in eight different states.
Consider this the first wave in the corporatization of the family doctor and the wave is cresting fast. By 2030, it is projected that 30% of U.S. primary care will be owned by non-traditional players like the giant companies named above.
While the roll-up of private medical practices isn’t new, the growing scale of these buyouts is likely to lead to a host of other changes in the way U.S. families interact with their doctors. What’s at stake is no less than how Americans will get their primary care—and whether they’ll have trusted healthcare teams capable of helping them with their whole health needs (e.g., physical, mental, social), including but not limited to acute, chronic, and prevention care issues.
The National Academy of Medicine (formerly the Institute of Medicine) and the National Academies of Sciences, Engineering and Medicine have both affirmed primary care’s value for decades. More than twenty years ago, the National Academy of Medicine strongly acknowledged the benefits of primary care for people and the health care system, but their recommendations were largely ignored.
In 2021, the National Academies of Sciences, Engineering and Medicine declared that the evidence still showed primary care was the only part of the health system that produced longer life and improved health equity, but that it was being starved for resources and was losing both workforce and capacity.
The private sector is banking on a disruptive opportunity that decades of neglect of primary care presents but the new corporate owners of physician practices may not understand the characteristics of primary care that make it so valuable and could mismanage this opportunity.
One of the most important figures in developing our understanding of the value of primary care was Barbara Starfield, M.D. Starfield outlined the key elements that are necessary to make these foundational interactions between patients and their primary doctor effective.
First, physicians actually need first contact with their patients—being the first to talk with and examine someone with a new symptom or concern is an obvious, if too-often-overlooked, component of good medicine. Care also has to be coordinated and properly managed. It also has to be comprehensive, taking into consideration the whole patient’s needs.
And, importantly, there has to be genuine continuity to the patient-physician relationship—meaning that a person is being cared for has a longstanding relationship when they’re healthy as well as sick.
Starfield conceptualized these elements (“contact,” “coordination,” “comprehensiveness” and “continuity”) as the Four Cs of Primary Care. We believe it’s time to add another “C” to the framework for healthy primary care: “Corporate.”
This fifth “C” doesn’t stand on its own, but rather should be thought of as an element that could either support and strengthen each of the other “Cs”—or, alternatively, undercut them and damage America’s primary care system even more. If the burgeoning corporate owners of physician practices truly engage with their new assets and shore up the first four “Cs,” the corporatization of primary care may actually turn out to be a good thing.
If they cut back on their investment and begin to cut corners, it could well erode the foundations of American healthcare.
Start with the first element: contact. Primary care, as we said, serves as the first opportunity for patients to access healthcare. When a patient experiences an acute illness or has a new symptom that may or may not need a referral to a specialist, primary care is strategically situated in the patient’s life and the health system to be the first stop to assess the patient, connect the patient with needed health services, and support the patient in navigating the broader health system.
With nearly 50% of the American public within 1 mile of a community pharmacy and nearly 90% within 5 miles of a community pharmacy, the proximity of private players like Walgreens, Walmart, and CVS would appear on its face to be advantageous for providing first contact access to primary care. Will patients and families broaden beyond traditional pharmacy and pharmacist relationships and seek to establish their primary care medical home in these settings? It depends on what the new owners do.
First contact is not just, for example, a triaging function aiming just to refer patients on to other services. Instead, it is sense-making of symptoms and developing a plan with the patient to sort through the likely and the dangerous possibilities. It requires an investment of time and real engagement with patients. Complementing these brick-and-mortar assets, these Fortune 20 companies have been pushing primary care models that are virtual-first or hybrid approaches which could significantly improve first contact both virtually and in-person. Their focus on integrating their recent acquisitions and expanding access to patients will be a good first test.
Good primary care also provides comprehensive, whole-person care for the general health needs and concerns of patients through a transdisciplinary team-based model. Unlike highly specialized healthcare, which narrows its scope to a specific part, disease, or organ of a patient’s whole health picture, primary care addresses the entirety of it, including physical, mental and oral health. Through this comprehensive approach, system-wide value is achieved through reducing overall costs and healthcare utilization.
In the context of the private sector, primary care’s comprehensiveness will be diminished if more profitable aspects lead to exclusion of less profitable but necessary services that effective primary care teams provide? Without a doubt. Regulators and patient-consumers must keep a vigilant eye on owner practices here and sound the warning if primary care coverage begins to shrink.
Primary care benefits patients and populations the most when it supports long-standing relationships that build trust and understanding within the context of family and community. Patients are increasingly frustrated that the answer to, “Will you be my doctor?” is increasingly “No”, which, among other factors, is largely due to the ongoing primary care workforce shortage.
Primary care is unique in healthcare in that it is designed for everyone to use throughout their lives—from healthy newborns and children to older adults with multiple comorbidities and people with disabilities. Consistency between patients and primary care removes the time-intensive burden of re-learning the patient’s medical history at each visit and uses understanding of the patient’s life story, social circumstances, and values—and the resulting trust—to increase the quality and patient-centeredness of care.
It is also a potent reducer of unnecessary costs and mortality. A key component of continuity is recruitment and retention of primary care talent and teams. With high staff turnover rates in the private and retail sectors, the corporatization of primary care may advance continuity of corporate relationships over the continuity of personal, productive, longstanding patient-provider relationships.
In the U.S., healthcare is a fragmented, complex system, so primary care teams play the vital role of coordinating a patient’s care within the context of their family and community. Primary care providers determine how to best approach and prioritize the patient’s specific health situation, coordinate team members and specialist referrals, and maintain the team’s sights on the overall goal: promoting patient health and wellness and achieving the patient’s personal health goals. Primary care teams often go uncompensated for their efforts to coordinate care on behalf of their patients.
Corporate America is highly sophisticated with the investments that they have made in their technology and information departments from hiring data scientists and actuaries to applying artificial intelligence algorithms for advancing behavioral change. These corporate entities manage large, diverse datasets and this could lead to better measurement, prediction, personalization, and coordination for patient-consumers.
While challenges await the new corporate owners as they adapt to a landscape reshaped by the pandemic and the economic uncertainty that followed, they will focus on how to make primary care more profitable and sustainable. That’s understandable, certainly. But while there are opportunities for efficiencies, the real business opportunity is in making primary care more effective and accessible. Over the next 5 to 10 years, these non-traditional players like Walgreens, Amazon, CVS Health, and Walmart will have an undeniable impact on primary care’s original Four Cs, and it could catalyze healthcare innovation and advance first contact, comprehensiveness, continuity, and coordination for all Americans, especially for underserved and health disparity populations.
The public and the nonprofit sectors have faced challenges in evolving policies and infrastructure to better support primary care in the U.S. Optimistically, the potential for alignment of goals and an impactful public-nonprofit-private partnership in primary care is enormous. The 2021 National Academies’ report offers a blueprint for achieving high-quality primary care and the U.S. Secretary for Health and Human Services is expected to make a related announcement in the next few months.
The 5th “C” need not be harmful to primary care and its 4 other “Cs,” but could rather lead the way in making primary care the future of a healthy and sustainable U.S. healthcare system.
Kyu Rhee, M.D., is an associate professor at Johns Hopkins Bloomberg School of Public Health. Robert Phillips, M.D., is executive director of the Center for Professionalism and Value in Health Care at the American Board of Family Medicine Foundation. Brandon Moritz, M.D., is a board member of the Association of Clinicians for the Underserved.