A recent JAMA viewpoint by Hamilton Moses caught my attention: Serving individuals and populations within integrated health systems: A bridge too far? The essay examines the growth of the integrated health systems and their impact on the doctor patient relationship.  The formation of integrated health systems accelerated in response to the Affordable Care Act. Hospitals buy clinics creating hospital—clinic systems. Independent physician practices have come together under an umbrella to contract jointly for payment. And large multi-specialty group practices better manage primary care and specialty referrals. They all have electronic health records to document interactions with the patient. In addition, the relaxation of antitrust laws has allowed for vertical mergers like insurer Aetna and pharmacy-chain CVS. And other non-health ventures are jumping into healthcare. Most recently Amazon, Berkshire Hathaway and JP Morgan created HAVEN and hired Atul Gawande as the CEO. Their hope is to provide "better outcomes and lower health care costs" for their employees. Clearly money is to be made and saved!

As an aside, Amazon hires many employees covered by Medicareto work in their warehouses.  I just readJessica Bruder’s Nomadland—andI just gave you the link on Amazon! The book reminded me of BarbaraEhrenreich’s Nickel and Dimed (I didn’t use Amazon that time) whichexamined the realities of the working poor after Welfare reform in the mid-1990s.Today seniors who don’t have enough money in their retirement pensions, or losthomes in the 2008 crises, are the workers Amazon is pursuing and they live inAmazon’s worker camper parksin their mobile homes, vans or even cars.

All these disruptive changes point out that healthcare isclearly broken and put pressure on the precious doctor—patient relationship. For example, the effort to getthe patient in ASAP (because you get quality points for open access) oftenbypasses a visit with the doctor who knows the patient the best, or the primarycare physician/clinician. The classic relationship allows for familiarity witha patient’s health issues, worries, living situation, habits and values nurturedover a handful of visits year after year and more intensely during a healthcrisis. Trust is built and there is knowledge not captured in the electronichealth record. Let me say that again—continuity and trust are key.

While the doctor--patient relationship continues to exist,the current model of care, what is reimbursed, and the outcomes measured are pressuring its survival. As we have discussed before on these pages: The EHR is cumbersome. The fee-for-service payment model which has largely not yet been replaced, makes it hard to capture and pay for the work of the doctor and his/her team members. Billable activities often still rest on what that physician does. Finally, the administrative work of pre-authorization for medications, tests, devices, and referrals is time consuming for both physicians and their staff and takes time away from patient care.

Some of these disrupter models appear to be replacing the doctor--patient relationship with a health plan--patient dyad. Can the relationship with the health plan really replace the relationship with a clinician? That means that the electronic health record has to capture much more than past medical and surgical diagnoses, test results, immunization list and medications. Perhaps our “I want it,need it now culture” of convenience and immediacy takes priority. One can go to the ED or urgent care 24/7. One can get his/her immunizations—flu shot,tetanus, travel immunizations, or a sore throat checked at the local pharmacy or food store. Now CVS is piloting stores that manage chronic illness like diabetes and asthma.

These health plan—patient relationships are being cultivated. Reed enrolled in a Medicare Advantage plan when he turned 65 this past year. He receives calls weekly from the health plan. The representative has information for him about cheaper options for medications, preventive checks, etc. My own work with home visits for a health plan has shown me that the primary care doctor/office is missing patient’s care issues. Either the patient has missed enough visits that no one from the office tries to reach out. Or the patient has a hard time navigating the complicated network of who he/she can and cannot see or what drug is or isn’t covered and the doctor/office staff are unable to help, or have lost patience with the patient. As the health plan representative going into the home, I see what is missed or neglected and can bridge the gap by helping the patient phone the health plan’s member services or send a message to the health plan’s case manager or social worker or behavioral health specialist to phone the patient. These staff have had customer service training and are gracious and make the patient feel important.

As a primary care physician for more than thirty years, I’d like to think the health plan and the CVS model can’t replace me and what I know and the trust my team and I build with patients. And more importantly, critical elements are missing. The health plan’s continuity with the patient is dependent on what is captured in the electronic health record—their database. The staff of the day in CVS won’t be able to help that patient be more adherent to their diabetes medications or motivate them to follow a food plan, like I could because there are things they don’t know about the patient. The health plan and CVS’s data bases have data, but the electronic health records don’t talk to each other, elements are missing, and much, much more cannot be captured.

The trusted doctor-patient relationship grows richer when the physician and patient have negotiated several health challenges together. I know what is important to them, whom is important to them. It is a relationship that also nurtures me, the physician, as well as the patient. There is a point where it becomes more than a job. It is a calling.

Whether or not the doctor—patient relationship can weather these changes remains to be seen. My own hope is that rather than undermining it, new models of care will find ways to support it and help it thrive.