Healthcare as a Service

Unbundling primary care is all the hype these days but is it net good?

Hello there!

It’s been some time since I last posted here. Third year of medical school picked up and I was going through different rotations at the hospital so the hours to write were few and far between. I’ve also had a creativity block lately where I find myself wanting to create more but keep jumping in between things I’m interested in only to never do any of them (currently it’s writing and learning how to draw on Procreate, whoops). However, I’ve decided to just stop worrying about growth and what will come out of a creative pursuit and just do it (#nike) instead.

I’ve also decided to change up this newsletter. Originally, it was called Tools for Growth and I wanted to write about my interests in apps and productivity tools and share my thoughts with you. I still want to do this but I’m also interested in other topics (e.g. healthcare, tech, life) and I didn’t want to pigeon hole myself into one specific domain because then I get bored and don’t want to write anymore. I thought about putting together a new website and built something in Ghost but then just thought I should come back here and let the 200+ people who subscribe to this newsletter know that I want to write about other things too.

So knowing that not all my posts will be about productivity tools and apps, if you’re still interested to hear my thoughts I’m very grateful to have you. But if you don’t want something in your inbox about various topics from tech to healthcare to productivity tools then I definitely understand and you can unsubscribe here.

With that out of the way, today I want to talk about healthcare as a service and the rise of niche healthcare companies going after specific aspects of primary care. Let’s get into it!

Personalized Care Solutions

Everyone likes a good digital health tool. Heck, I love a good digital health tool. In a world where healthcare systems (let’s be honest) suck and systems are definitely not built with user experience in mind, it feels good when a tech company comes along and creates a solution for a specific problem that a patient might be facing and actually helps solve it.

Nikhil Krishnan aka healthcare thinkboi wrote an article a while back about a company called Thirty Madison that has four products (branded as different companies) to increase convenience for solving problems such as hair loss, migraines, acid reflux, and allergies. It was a very well written article and I think the companies definitely solve a problem and improve access and convenience for patients that may not get it at all in the first place because the current healthcare system is too difficult to interact with.

However, it also got me thinking that what Thirty Madison is doing is basically unbundling primary care. Each of the sub-companies is taking one piece of primary care and working to solve that piece in a way that creates a wonderful user experience. The user gets onboarded, is given the right medications, and gets a care team experience if they have questions and for follow-ups. I agree - this is good. But I think it is good for a specific type of patient and also only for the short run (more on that later). Here is a tweet thread with some good healthcare banter we had about this article.

Take it one step further and you have more complete services that are trying to overhaul primary care altogether. One Medical was one of the first big names in this field but others like Forward and The Lanby are popping up. They are working to recreate the whole experience of what primary care is - essentially take the current model and improve the design. Think of it like the Apple approach - take something like personal computing that is clunky and not a good user experience and make it ~just work~ and delightful.

This all sounds well and good and seems to be pushing things forward right? Yes and no. Let’s dive into what I think are some issues with these types of models.

A System-Based Approach

Before we get into it, I want to caveat that every system will have issues. There is no silver bullet that will solve every problem in healthcare for everyone. This is true in the US (duh) but I would say this is true even in other countries with single payer models that I support. So this isn’t just me saying “well policy will solve all of this!” because I don’t think it will. However, I do think that a systems-based approach (which I will explain since that is a very vague and hand-wavy term) could help.

In my mind there are two big issues with unbundling primary care services into smaller individualized companies and products. The first is all of these services typically live outside of insurance. They are subscription based products and most of them you pay for out of pocket. This means that you still have to have insurance + these other services because insurance will still be needed for things like hospital visits, labs (depending on the service you pick), and emergencies (i.e you have to go to the ED). Probably not a huge deal for the target demographic of these products (which I’m guessing is younger, healthier, wealthier populations) but overall costs will likely go up.

The larger issue is that too much unbundling can lead to further segmentation and fragmentation of healthcare. Imagine if you are a person with multiple subscription services from different companies. You have to pay for them all individually and they likely don’t talk to or share data with each other unless there are explicit partnerships. Lack of data sharing is already a huge issue in healthcare and solutions like this can eventually lead to more fragmentation for the patient.

Even if you get past the increased cost and data fragmentation issues, a big issue with companies like this is that patients may forgo primary care altogether because they were able to take care of the one thing that bothered them through this specific product. Now the argument definitely stands that many patients don’t have primary care to begin with and so this is at least some kind of touch point for these patients. However, I still think the way to fix this is to inherently fix primary care itself rather than pick off parts of it.

For example, if you purchase an Evens subscription to help you with your acid reflux, you may never follow up on your hypertension that also needs management or your A1c levels that could help prevent diabetes and its complications. The reason primary care is important is because it works to help you not only with acute issues that are causing symptoms today but also works to make sure that preventative care is in place so you are less likely to develop chronic conditions down the line. The model doesn’t work perfectly yet but unbundling will only make this process harder.

How do you fix it?

The ultimate question: how do you fix it? Well of course there is the policy route. Give everyone access to a primary care physician via a single payer system so that they can get the care they need for a PCP and then any follow-ups or referrals as well and don’t have to be burdened by extreme costs or dealing with insurance that makes the system difficult to navigate. This is probably most helpful for the patient but also the most difficult option because it requires a government solution that could take years to become a reality.

My friend Nikita actually suggested that an ideal solution (that some companies are working to employ) is to have these services be the acquisition channel for new users (many of whom may not be interacting with the healthcare system currently because it is so complex) and then transitioning those users to partner organizations who can manage things like complex care or comorbidities that the company itself can’t take on.

That is to say if Evens has a ton of users who are there for acid reflux but also have hypertension or diabetes it could partner with a healthcare system and essentially refer those patients to practices that can help manage them. This is a great solution and if you partner with organizations that accept insurance it would even help cover cost because you wouldn’t add another subscription service for the patient to subscribe to but just refer them to a doctor that takes their insurance (of course you’d have to deal with insurance routing which is a beast itself and hence single payer would again solve for this).

I actually think that is a great idea and if companies like Thirty Madison are going into these ventures with that mindset then more power to them. However, my hunch is that all of that coordination costs a lot of additional money to manage with not as great of a return for the company (Evens doesn’t profit from you having your diabetes managed by a partner org unless there is some kickback fee or maybe increased word of mouth marketing because patients and providers like Evens). It’s not impossible but lots of things would have to go right for a deal like to be valuable to a company like Evens.

Overall, I think that that rise of new healthcare as service companies should be looked at with some caution. It is easy to see a pretty landing page and attractive Instagram ads bundled with an easy onboarding and user experience and think that there will be a net benefit to the healthcare system. There are definitely a lot of positives that come from these services but it is also up to the companies behind them to take it upon themself and make sure that they are not only focusing on one specific aspect of a patient’s health but have ways where patients can get holistic and complete healthcare that primary care provides them with. It’s a fine line and one that should be walked carefully.

Wow thanks for making it to the end and checking out this post. It’s the first time I’ve written something at length about healthcare and it’s fun to sit down and think about issues like this that I read about but don’t really always take time to critically think about and process.

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