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Kyna Fong: What Primary Care’s “Barnes & Noble Moment” Means for the Future of Digital Health

A version of this article was recently published by Kyna Fong, CEO and co-founder of Elation Health, in the publication MedCity News. 

Primary care is essential to living healthier lives, and we need all forms of it, from small local practices to big health systems and retail chains. Ultimately, it’s going to be all primary care hands on deck, working together to make a lasting change for the health of Americans.

Impossibly, it’s already been 25 years since Meg Ryan and Tom Hanks fell in love to the soundtrack of dial-up internet in the movie You’ve Got Mail. At the time, independent bookstores (“Shop Around the Corner” in the film) were under threat of extinction from the rise of the big national chains (“Fox Books” in the film and Barnes & Noble in real life). The movie ends with the bookstore owner getting the guy and closing her business. Big chains forever killed off small bookshops nationwide … the end, right?

Not exactly. Amazon entered the market, creating a whole new category of online sales. Barnes & Noble held on strong with 600 stores today. Independent bookstores started to rebound in 2010 and saw a boom of new openings in 2022 — which the New York Times called a “surprising and welcome revival.” The David vs. Goliath story may have made for a great rom-com, yet the economic reality two decades later is showing that there’s room for many different and new kinds of delivery models for the book market.

Primary care appears to be moving through a comparable cycle today. Like independent bookstores, local independent primary care practices are written about almost daily as “going extinct.” All the while, national chains such as One Medical (now Amazon’s) and Carbon Health are opening glossy storefronts in major metro areas. Online delivery and technology are changing the scene too with rapid virtual care from Teladoc, CVS and more just a few clicks away. Large payers and hospital systems, fueled by new value-based care programs, are also trying to build their primary care offerings.

What’s actually happening? Which “winners” and “losers” could emerge? How do we make sense of who is adding value? Based on my background as a health economist and my experience leading a health tech startup, there are five takeaways I see regarding the dynamic growth across primary care in all settings.

The national chains are innovating primary care access, but they can’t be everywhere. Like Barnes & Noble, chains like One Medical, are reinventing the landscape for primary care in metro areas. Their slick retail-like experience with modern technology and a focus on convenience is pushing the rest of the healthcare market to do better. Yet with 200 clinic sites and 800,000 members, One Medical is reaching less than .25% of the American population today. There are still plenty of people who need primary care in Lodi and Topeka who don’t have access to a national chain.

  • Specialty-driven care models aren’t going to change so easily. Big health systems such as Sutter Health, Providence St. Joseph, and Yale New Haven have expanded and consolidated territories significantly over the recent decades. While fresh investment in value-based care programs have made it more lucrative for these organizations to provide primary care in-network, their business models remain largely driven by fee-for-service systems that reward the highest-cost surgeries, specialists, and hospital procedures. They’re undergoing a seismic shift, while adding a new domain for primary care growth, but it’s going to take a long time for their business models to truly transform.
  • Don’t be fooled by primary care that is not primary care-led. There are vast differences between primary care-led delivery models that adhere to core tenets—comprehensive, continuous, first contact (accessible), and coordinated—and those that have consolidated America’s primary care infrastructure in order to feed high-cost downstream revenue generators: hospital beds, expensive subspecialty care, and surgery centers, to name a few. One health system bucking the trend is Kaiser. Kaiser’s primary care-led delivery model has embraced the benefits of primary care while also coordinating resources when specialty or higher acuity care is needed.
  • There will always be a need for local, relationship-driven primary care practices. At the end of the day, local primary care practices survive the same way that small bookstores survive. They’re local, they know your name, they speak your language, and you trust them to make recommendations relating to your health. While you can get a flu shot at CVS any day, you are going to need a primary care doctor in your home community to help keep you healthy and well, manage chronic conditions, and navigate tough healthcare decisions. Today, a third of family doctors work in private physician practices. In New York City alone, 40% of primary care providers are working in small independent practices that “provide access to care for many of the city’s poorest communities, including large numbers of minority and immigrant populations,” according to Health Affairs. Local primary care practices are an essential component of the healthcare system, and unfortunately, U.S. policies and fee-for-service reimbursement models often make it incredibly hard for them to thrive.
  • Primary care has a major impact, and we need more of it. Ultimately, even if we could vastly expand the number of primary care practices in the U.S. overnight through any of these channels, we’d still be far behind other countries. America spends 50% less on primary care than any developed country. Patients in the U.S. visit the doctor just four times a year, compared to nine times a year in Germany and 13 times a year in Japan with an average 20 day wait time for a U.S. primary care appointment. We know that having access to primary care helps increase life spans, results in higher quality care, and reduces healthcare costs — delivering $13 in savings for every $1 spent on primary care. There is plenty of market value for major expansion as long as it is led by primary care to deliver high value that facilitates relationships between physicians and their patients.

While there is a lot of movement in the market, the truth remains that primary care is essential to living healthier lives, and we need all forms of it. Small local practices are a crucial community safety net, big health systems are grappling with putting primary care in the driver’s seat, and retail chains are showing us a bold new way in select markets. Ultimately, it’s going to be all primary care hands on deck, working together to make a lasting change for the health of Americans. We need policy leaders and investors to put primary care in the position to lead, and we need innovation in care delivery models and technology to accelerate that success.