Alternatives to Traditional Medical Care

Elizabeth Maciel grew frustrated that she couldn’t get a same-day appointment with her daughter’s pediatrician when, smack in the middle of flu season, the 3-year-old woke up with a high fever and bad cough.

So the 39-year-old from Hayward, Calif., turned to an app-based service called Heal, which connected her with a physician within 2 hours. Better yet, the doctor came to her house. “I never had to get my daughter dressed or deal with taking my other kids to the doctor’s office,” Maciel says.

Ilya Ginzburg, 34, had a different experience. After moving to San Francisco for a new job, Ginzburg, who has high blood pressure, struggled to find a primary care doctor despite having a list of physicians from his insurer. Some no longer accepted his plan. Others weren’t taking new patients. A few had simply closed up shop.

His solution: One Medical, a network of primary care clinics that guarantees same- or next-day appointments and offers virtual visits. “I found a doctor who I can trust who knows me,” he says.

For Gary Blankenship, a 70-year-old retired truck driver in Lynchburg, Va., one big problem was long waits in his doctor’s office, made worse by stiff chairs that were hard on his bad back.

So Blankenship was thrilled when his doctor went solo, opening a new type of practice known as direct primary care, which offers a variety of perks, including no long waits and 24/7 availability. “It’s almost like having a private doctor, like wealthy people and movie stars have,” Blankenship says.

As those examples illustrate, finding a primary care provider—someone who helps oversee all your healthcare needs and doesn’t just treat common issues, such as the flu and sprains—can be hard. At the same time, out-of-pocket costs for doctor visits are rising, leaving some consumers more hesitant to make those appointments. (Read about 8 places to get your primary care and how to choose the one that is right for you.)

Partly as a result, Americans are turning to alternative models of primary care. Options include full-service walk-in health clinics in big-box stores, such as Walmart, or at drugstores, like CVS; apps that offer real-time video chats with a healthcare provider; and high-end concierge practices at large university medical centers.

The big question: Can these options provide convenient, affordable ways for you to get the quality of care you need?

Why Primary Care Is Key

It used to be that people typically relied on a go-to doctor who took care of all their general medical needs, knew their health histories well, recommended specialists, and checked on them if they were hospitalized.

And that kind of care remains essential, says Margot Savoy, M.D., a family physician in Philadelphia and a member of the American Academy of Family Physicians’ board of directors. These providers can not only give physical exams and vaccines, administer or order screening tests, and deal with problems such as infections and minor injuries but also help manage chronic conditions like diabetes and high blood pressure.

Importantly, they also coordinate the care you receive from other healthcare providers, such as, say, a cardiologist if you have heart problems. “A primary care doctor should be the quarterback for your health team,” Savoy says.

That care usually comes from a doctor trained in internal medicine, family practice, pediatrics, or geriatrics. (These physicians can be M.D.s or D.O.s—doctors of osteopathic medicine, whose medical education includes special training in muscle and skeletal issues.) Some people regularly see a specialist, such as an OB-GYN, but they typically can’t offer the same breadth of care as a primary care provider.

Fewer M.D.s, Broader Needs

And yet getting time with a primary care provider is becoming harder, for several reasons.

A smaller percentage of medical school graduates are choosing primary care, opting for more lucrative specialties. Those who remain carry ever-larger patient loads—each typically has 1,200 to 1,900 patients and sees an average of 20 each day. That, combined with growing administrative tasks and ever-changing regulatory requirements, is causing many primary care doctors to report burnout. In one study, doctors reported devoting almost half their day to administrative chores and only one-quarter to seeing patients.

Thanks also to the growing number of older people in the U.S.—who are especially likely to require regular, comprehensive care—the need for primary care providers is growing. The Association of American Medical Colleges predicts a shortage of up to 55,200 primary care physicians (PDF) nationwide by 2032.

Worryingly, there has already been a steep decline in the number of people getting regular primary care. Among people with private health insurance, appointments with primary care providers dropped 24 percent between 2008 and 2016, while appointments with specialists remained the same, according to a recent study in the journal Annals of Internal Medicine.

Two big reasons Americans don’t get the care they need: cost and convenience, as shown on the chart above. But some of that decline may also be generational. Gen Zers, millennials, and Gen Xers are less likely to have a primary care doctor than older generations, according to a 2019 Consumer Reports nationally representative survey of 3,030 adults.

The Search for Alternatives

Many experts welcome the new avenues for primary care.

“Innovation in primary care is a good thing,” says Ishani Ganguli, M.D., at Brigham and Women’s Hospital in Boston, lead author of the recent Annals of Internal Medicine study on the decline in appointments with primary care doctors. “We need to make primary care more convenient and accessible because it’s clear that people who get regular primary care have better health,” she adds.

Consumers are also embracing these newer options, says Kaveh Safavi, M.D., a senior managing director for consulting firm Accenture’s global healthcare business.

For instance, almost half the respondents in a 2019 Accenture survey on consumer digital health trends (PDF) say they have used a walk-in or retail clinic, and 29 percent have tried some form of virtual care. And 18 percent have used on-demand healthcare services, such as the one Elizabeth Maciel used.

But sorting through the old and the new to find the one that’s right for you may feel overwhelming.

Take cost. Because many of the new services accept health insurance similar to the way a traditional medical practice does, if you have coverage your out-of-pocket expenses could be about the same. Some don’t accept insurance and charge flat fees instead. That cuts the provider’s administrative costs and could be more affordable for some people with high deductibles or no insurance.

But in some cases, these alternatives come at a premium. Ilya Ginzburg, for example, spends $199 per year for his One Medical membership, on top of paying for his regular health insurance. Gary Blankenship pays an $80 monthly fee to his doctor, along with the cost of his Medicare premiums.

Both consider the added convenience valuable enough to justify the extra cost. “If I have a problem, my doctor will either see me right away or call in a prescription if I need one,” Blankenship says. “It’s well worth it.”

Ultimately, the right choice is going to vary from person to person. “What’s best for you is going to depend on your financial situation, insurance coverage, and healthcare needs,” says Ganguli at Brigham and Women’s Hospital.

8 Places to Get Your Primary Care: How to Choose the One That Is Right for You

To help you find the option, or combination, that’s best for you, we took a close look at how primary care practices are changing and the growing number of alternatives, we reviewed the research, and we spoke with experts and patients about traditional primary care, urgent care clinics, retail walk-in clinics, direct primary care, concierge care, high-tech hybrids, workplace health clinics, and the new house call.

Traditional Primary Care

About a third of the 700,000 practicing doctors in the U.S. are primary care providers. They often work in group practices or are affiliated with a larger healthcare system. The practices tend to be open during normal office hours, but with a doctor on call at other times.

Some are trying to reinvent themselves by offering extended hours, weekend appointments, online booking, email access to a doctor, and follow-up care via computer or smartphone, says Kaveh Safavi, M.D., a senior managing director for consulting firm Accenture’s global healthcare business.

Practices are also hiring nondoctor providers, such as physician assistants (P.A.s) and nurse practitioners (N.P.s), to take on some of the workload.

Physician assistants work under a supervising physician and can often do many of the same things as M.D.s and D.O.s, such as physical exams, ordering X-rays, and prescribing medication. Nurse practitioners must be registered nurses before they go on to get advanced training. In some cases, they can practice on their own and, like P.A.s, prescribe drugs and diagnose and treat common health problems.

Still, even if doctors have the technology and desire to provide more convenient services, administrative burdens remain, Safavi says. “Doctors only have so much time in a day,” he says.

While private insurers, Medicare, and Medicaid may now cover the cost of e-visits, doctors aren’t always reimbursed at the same rate for those visits, giving doctors less incentive to provide them. Just 17 percent of primary care doctors say they practice some form of telemedicine, a 2018 survey by the nonprofit Physicians Foundation found.

How you pay: Most accept insurance, but depending on your plan, you may owe deductibles (what you pay out of pocket before insurance kicks in), copays (a flat fee with each appointment, typically about $25), and coinsurance (a percentage, typically 18 percent for people insured through work, of the cost of the medical services you get).

Consider for: Routine and preventive care, problems that need attention but aren’t emergencies, managing chronic health problems, and coordinating with your other providers.

Watch out for: Long waits for appointments and limited time with your doctor.

Urgent Care Clinics

These stand-alone facilities, often part of privately owned chains or run by hospitals, are staffed by doctors, P.A.s, and N.P.s, and handle problems from colds and the flu to sprains and asthma.

The nearly 10,000 urgent care clinics in the U.S.—up from 6,100 in 2013—also usually offer on-site lab tests and diagnostic imaging, such as X-rays. And some are open seven days a week.

How you pay: Many take insurance, so you may have deductibles, copays, and coinsurance. The average out-of-pocket cost of an urgent care visit for someone with insurance ranges from $155 to $190, according to the Urgent Care Association.

Consider for: Problems that need to be treated right away but aren’t severe enough to require the emergency room.

That’s how Sue Krikorian, a 64-year-old retiree in Tampa, Fla., uses these services. “Although I go to my primary care for yearly physicals, I prefer our local urgent care center when I am ill,” Krikorian says. “I can make an appointment at urgent care and get in there the same day.”

Recently, unsure of the cause of a cough, a headache, and fatigue, Krikorian booked an appointment on a nearby clinic’s website. Within 2 hours she had seen a doctor and received an upper respiratory infection diagnosis. “They even looked up where it was least expensive to fill my prescription and printed out a coupon for me,” she says.

Watch out for: Possible lack of coordination with a primary care doctor and unnecessary prescriptions, particularly antibiotics. A September 2018 study in the journal JAMA Internal Medicine found that inappropriate prescribing of those drugs for viral respiratory infections—at 46 percent of visits—was higher in urgent care clinics than at doctor’s offices or walk-in clinics.

Retail Walk-In Clinics

The roughly 2,700 health clinics located in chain pharmacies, supermarkets, and retail stores—up from 1,200 in 2010, according to the Convenient Care Association—offer no-appointment-needed treatment. Staffed mainly by P.A.s and N.P.s, they’re typically open every day and have become a common source of care for nearly a quarter of Americans with no primary care doctor, CR’s survey found.

Some of these clinics, such as the MinuteClinics in more than 1,000 Target locations and CVS drugstores, have been around since the early 2000s. What’s new is that CVS and several other retailers are expanding the services they offer. CVS recently launched more than 50 of a planned 1,500 HealthHubs, where consumers can get nutrition counseling, attend wellness classes, and receive help managing chronic conditions, such as type 2 diabetes and high blood pressure, as well as vaccines and treatment for problems like colds and the flu.

Anthony G. Green, 51, considers himself a regular at the CVS HealthHub in Marietta, Ga., consulting with the store’s “care concierge” on everything from diabetes screenings to product recommendations. The pastor says he appreciates knowing he can drop in and have his blood pressure checked between appointments with his usual doctor.

Several other retailers are also offering a more robust roster of services. Walmart runs two stand-alone Walmart Health clinics in Georgia, with more expected later this year. The company says you can choose to see the same physician at each visit, so you can develop a relationship with a provider.

Walgreens is ramping up its options, too. In partnership with the VillageMD chain of primary care practices, the company recently opened a clinic near Houston with plans to open more in the future.

How you pay: These accept insurance, so you may still have deductibles, copays, and coinsurance. For people without insurance, some offer a menu of services for a flat fee. At Walmart Health centers, you can get checkups for $30, office visits for $40, cholesterol tests for $10, and stitches for about $115, as well as dental exams for $50.

Consider for: Routine or simple but nonurgent medical needs, such as vaccines; treatment for colds, strep throat, cuts, and rashes; and simple screenings such as blood pressure and cholesterol tests.

Watch out for: Limited services and in some cases lack of coordination with your regular providers.

Direct Primary Care

Instead of accepting health insurance, the estimated 1,200 direct primary care, or DPC, practices across the nation charge patients a flat fee for the promise of easy access to care. Usually solo or small group practices, they can offer unlimited office visits; preventive screenings and wellness exams; diagnostic tests; minor urgent services, such as stitches; and wellness programs, like weight management and nutritional counseling.

Doctors, not just patients, appreciate the extra time they can spend with patients in this kind of practice. Andrew J. Anderson, D.O., the doctor Gary Blankenship sees in Lynchburg, Va., says in his former practice he had 2,400 patients, seeing 20 a day and spending less than 10 minutes with each. Now he has 400, sees seven to eight a day, and can spend more than 30 minutes with each.

“I can catch things that might have not come up before,” he says. For example, he recently found a mass on the neck of a patient who’d followed him from his former practice. “She told me she had the lump for a while but didn’t bring it up . . . because it was on her B list of things to talk about and there wasn’t time,” he says.

How you pay: DPCs charge a flat fee—$80 per month, on average—that covers primary care services, including screenings, physicals, office visits, and urgent care needs. But you’ll still need health insurance to cover medical needs that go beyond primary care, such as specialist treatments, hospitalizations, and emergency services.

Consider for: People with a chronic medical condition that requires frequent primary care doctor visits or who have a high-deductible health plan and would have to pay thousands of dollars out of pocket before their coverage kicks in.

Watch out for: In addition to the cost of insurance, the money you spend on DPC fees typically won’t count toward your deductible.

Concierge Care

These practices are similar to direct primary care but are aimed at those willing to spend more for luxury care. That includes same-day appointments, quick answers to calls or texts, and sometimes access to top doctors at prestigious medical centers, or perks such as body composition analysis and coaching by personal trainers.

High-end concierge practices have been around for a few decades, but only about 20,000 physicians practice in them, according to Concierge Medicine Today, a trade publication.

Several major medical centers—including Cleveland Clinic Florida in Weston; Duke Health in Durham, N.C.; and Stanford Health Care in California—have added concierge services. Cleveland Clinic Florida’s program even offers use of the clinic’s private fleet of land and air ambulances in an emergency for an additional fee.

How you pay: The annual fee, which is not covered by insurance, averages about $2,000 but can be 10 times that amount in practices with very few patients, says Thomas LaGrelius, M.D., president of the American College of Private Physicians, which represents concierge physicians. Many will also bill your insurer for the care they provide. And you still need insurance to cover hospitalizations, emergency care, and services that the concierge practice doesn’t provide.

Consider for: People willing to pay for very personalized care, extensive time with their doctor, and a host of wellness amenities.

Watch out for: Possibly offering screening tests that most generally healthy people don’t need. For example, the Food and Drug Administration cautions against full-body screening CT scans, which some concierge practices offer, because they can expose people to significant radiation and often cause false positives.

High-Tech Hybrids

These are companies that have both virtual and in-person care, with a traditional office visit, a video chat, or an app that performs an initial diagnosis, and a phone or in-person follow-up as needed. These hybrids are primarily in major metropolitan areas and are often housed in modern spaces that look more like a spa than a doctor’s office.

Some have venture capital backing and celebrity investors. For example, investors in Forward, founded in 2016 and based in San Francisco, include former Google CEO Eric Schmidt, actor Ashton Kutcher, and NBA star Kevin Durant.

Like direct primary care, Forward accepts no insurance. Instead, it charges $149 per month for unlimited doctor visits and 24/7 remote access to its physicians. It emphasizes preventive care, including genetic testing and immediate blood test results. Forward is still small, with five locations around Los Angeles and San Francisco, two in New York City, and one in Washington, D.C.

Some hybrids, such as Carbon Health, based in California, accept many insurance plans, in which case you pay for each visit as you would at a traditional provider—with out-of-pocket costs for copays, coinsurance, and deductibles.

If your insurance isn’t accepted or you don’t have insurance, Carbon has flat-fee services. A new patient physical, for example, costs $199. And sick visits cost $195 plus additional charges, depending on what’s ordered, such as $50 for a strep test and $150 for an X-ray. Carbon has 14 locations, all in California and Nevada.

One Medical, the provider that Ilya Ginzburg uses in San Francisco, has 70 clinics in nine cities. It accepts insurance and charges its nearly 400,000 members an annual fee of $199 for its services, which include women’s health, nutrition counseling, and sports medicine, as well as routine medical care. Some 6,000 employers cover the membership fee for workers.

How you pay: It varies, with some accepting insurance and others offering flat-fee or membership options.

Consider for: People who want the option of seeing a doctor in person but are also comfortable getting care remotely and managing their care with an app or online.

Watch out for: You’ll still need separate coverage for hospital, emergency, and other care.

Workplace Health Clinics

Located in or near workplaces, employer-sponsored medical clinics offer care from doctors, N.P.s, and P.A.s. They often also have pharmacy services, physical therapy, and programs to help you stop smoking, lose weight, or eat better. Open to employees who are covered by company insurance, and sometimes their dependents, most are managed by private vendors or local health systems. About a third of companies with 5,000 or more employees have opened such a facility, according to the National Association of Worksite Health Centers.

Some big-name companies are getting into it, too. Apple has opened Wellness Centers for workers in the San Francisco Bay Area. And last year, Amazon launched Amazon Care, with health services via video or chat, and office or in-home follow-ups for employees in Washington state.

How you pay: These clinics accept employer-sponsored insurance, so deductibles, copays, and coinsurance apply. Some employers offer lower copays or premiums to people who use these facilities.

Consider for: Routine and preventive care. Janine McClung, 49, an account executive at an insurance broker firm in Kansas City, Mo., has used her workplace clinic since 2018 and says she has lost 36 pounds and been able to drop her medications for high blood pressure, cholesterol, and blood sugar. She credits the easy access to her healthcare providers there for motivating her to exercise regularly, deal with lingering problems such as her plantar fasciitis, and plan healthy meals. McClung texts her blood pressure, weight, and heart rate weekly to a P.A. at the clinic and gets feedback quickly.

Watch out for: Privacy concerns because colleagues may see when you visit a doctor.

The New House Call

Home-based primary care, which was once the norm, is making a comeback. That resurgence is fueled in part by advances such as portable X-ray machines and apps that can make a smartphone function like an ultrasound machine, and by a realization that treating people at home can be cost-effective, especially if it means catching problems early, says Brent Feorene, executive director of the American Academy of Home Care Medicine.

While home visits are still primarily for people with health problems that make it hard to travel to a doctor’s office, convenience may also be a factor. Take Debbie Carini, 60, of San Francisco, who uses Heal, an app-based service that provides house calls on demand, for her regular care. “It was a big hassle to go to the doctor and wait up to an hour in a room full of sick people,” she says.

And through Remedy, an on-demand medical service based in Texas, users can choose between video visits and in-person care at home. If you request the latter, the company says it will send a healthcare provider to your home in about 2 hours.

How you pay: Some insurers cover this kind of home medical care, but you may still have to pay a copay, coinsurance, or a deductible, depending on your plan. Some services may also have a one-time fee, such as the $49 “dispatch” charge from Remedy for sending a doctor to your home. If you don’t have insurance, some also offer a flat fee for services. Remedy, for example, charges $199 for a house call if you don’t have insurance, and Heal charges $159 for a home visit.

Consider for: People with health problems that make it difficult to get to a doctor for regular care or who simply want to be seen at home.

Watch out for: Limits on range of care available at home.

Editor’s Note: This article also appeared in the May 2020 issue of Consumer Reports magazine.

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