By MATTHEW HOLT

If health policy wonks believe anything it’s that primary care is a good thing. In theory we should all have strong relationships with our primary care doctors. They should navigate us around the health system and be arriving on our doorsteps like Marcus Welby MD when needed. Wonks like me believe that if you introduce such a relationship patients will receive preventative care, will get on the right meds and take them, will avoid the emergency room, and have fewer hospital admissions—as well as costing a whole lot less. That’s in large the theory behind HMOs and their latter-day descendants, value-based care and ACOs

Of course there are decent examples of primary care-based systems like the UK NHS or even Kaiser Permanente or the Alaskan Artic Slope Native Health Association. But for most Americans that is fantasy land. Instead, we have a system where primary care is the ugly stepchild. It’s being slowly throttled and picked apart. Even the wealth of Walmart couldn’t make it work.

There are at least 3 types of primary care that have emerged over recent decades. And none of them are really successful in making that “primary care as the lynchpin of population health” idea work.

The first is the primary care doctor purchased by and/or working for the big system. The point of these practices is to make sure that referrals for the expensive stuff go into the correct hospital system. For a long time those primary care doctors have been losing their employers money—Bob Kocher said $150-250k a  year per doctor in the late 2000s. So why are they kept around by the bigger systems? Because the patients that they do admit to the hospital are insanely profitable. Consider this NC system which ended up suing the big hospital system Atrium because they only wanted the referrals. As you might expect the “cost saving” benefits of primary care are tough to find among those systems. (If you have time watch Eric Bricker’s video on Atrium & Troyon/Mecklenberg)

The second is urgent care. Urgent care has replaced primary care in much of America. The number of urgent care centers doubled in the last decade or so. While it has taken some pressure off emergency rooms, Urgent care has replaced primary care because it’s convenient and you can easily get appointments. But it’s not doing population health and care management. And often the urgent care centers are owned either by hospital systems that are using them to generate referrals, or private equity pirates that are trying to boost costs not control them.

Thirdly telehealth, especially attached to pharmacies, has enabled lots of people to get access to medications in a cheaper and more convenient fashion. Of course, this isn’t really complete primary care but HIMS & HERS and their many, many competitors are enabling access to common antibiotics for UTIs, contraceptive pills, and also mental health medications, as well as those boner and baldness pills.

That’s not to say that there haven’t been attempts to build new types of primary care