While large hospitals and health systems launch many of the pilots and implementations of digital health in their specialist care wings, primary care is still the first step on most patients' healthcare journeys. And the same move to value based care that is creating opportunities for so many health tech companies, can place an undue burden on independent primary care providers.

“If you want to go down the risk contract road you need upfront capital. You need a large enough panel to be able to distribute risk. And often what you’re going to have to do is, you’re going to have to sell yourself off or get into some arrangement with the health system down the street. So you’re seeing a lot of consolidation in the market,” Ankit Patel, vice president of provider alignment at Clover Health said at HxR 2016 yesterday. “A lot of those don’t go really well.”

At the conference, held in Boston this week, representatives from a number of different organizations with new takes on primary care spoke about the role they’re stepping up to fill in an emerging healthcare system. The roster included Clover, a health insurer that works closely with providers; direct primary care providers Iora Health and MedLion; hospitals Massachusetts General and Dartmouth-Hitchcock; and Walmart, which recently launched expanded clinic services that offer many primary care services.

Patel explained Clover’s presence as the sole payer on the panel by arguing that from his perspective, insurers are in the best position to make sure primary care providers have access to all the data about their patients.

“Part of the reason we’re an insurance company, is it’s one of the few institutions that quickly and rapidly has the capacity to give you a 360 degree view of a patient’s healthcare,” he said. “Because everyone wants to get paid and we’re getting charts and bills from the entire health system. Our goal is to partner with primary care physicians and give them a full view into the patient’s clinical background: all the prescription history [and] a problem list. So every time a patient shows up the doctor has a sense of all the other things that are happening behind the scenes that they might not be aware of... the patient just happens to be in there for a 15-minute visit because they have the flu.”

Many of these new models spring out of the trend towards high deductible health plans that make consumers more responsible for their own healthcare costs. For instance, Walmart Chief Medical Officer Daniel Stein said that the retail giant added its Walmart Care Clinic because some of their customers, not to mention employees, didn’t really have access to healthcare.

“The reason we expanded our scope of service is because that’s where the need was,” he said. “When we talked to our customers, our associates, that’s where their access and affordability problems are. … We’re particularly interested in three groups: the uninsured, the underinsured — Americans in high deductible health plans who don’t have the savings to pay that deductible, so they’re acting like they’re uninsured, and Medicaid members, who have insurance but they don’t have access. … A typical story for us is the patient who comes in with a bag of medications, all of which are empty, and says ‘I know I have hypothyroidism. It used to be managed. I can afford the medications, but I can’t afford the doctor’s visit.’”

Iora Health and MedLion were both founded, in part, on the theory that eliminating fee for service on the primary care level can save money, and the best way to do that is to eschew insurance entirely at the primary care level and charge a flat fee, either to patients or to their employers.

“Today we need insurance for everything, for primary care and for catastrophic care,” MedLion CEO Samir Qamar said. “But that’s not what insurance was designed for. By definition, insurance is risk management for rare and expensive events, period. You don’t need insurance for a $5 sinus event, you don’t need insurance for your aspirin. But it’s become practice to claim insurance for those things.”

Both MedLion and Iora use technology to enable cost savings: Qamar spoke about telemedicine, while Iora VP Clinical Development Andrew Schutzbank described their inhouse EHR and patient management software, named Chirp.

“The idea is it’s a passive record to guide you to do the right things without pushing or prompting you while you’re taking care of patients,” Schutzbank said. 

Later in the session he described the difficulties of creating a software that gives doctors exactly the information they need when they need it. 

“Medicine’s a messy business,” Schutzbank said. “If you ever talk to any doctor and ask them what they want to see, they want to see everything at once. They don’t really, they just don’t know what they want to see. It’s little things. It’s a million data points that are hard for a machine to capture today. The reason we still use notes is that medicine is still an incredibly story-driven business.”

Dartmouth-Hitchcock’s Director of Remote Medical Sensing Nate Larson and Director of Clinical Integration for Remote Medical Sensing Justin Montgomery talked about the hospital’s ImagineCare program which uses wearables like the Microsoft Band and analytic software to track and manage patients’ health. ImagineCare combines wellness-driven behavior change programs with triage programs that help people get quick access to healthcare.

“ImagineCare builds off of the idea that it’s not just technology that will solve these problems, but it’s actually the human touch,” Montgomery said. “So we think of technology as a way to get the barriers out of place so people can interact with their health coaches, consumers of their health.”

Perhaps the most poignant comment on the relationship between technology and delivery models came from MedLion’s Qamar, who said that technology is valuable in making new care models work, but wasn’t a replacement for new models of care.

“I look at the system and I look at the technology companies trying to create solutions for our broken system,” he said. “To me it’s akin to, if you have a car and the axle is broken, changing the oil and adding a new coat of paint isn’t going to help. You need a new vehicle for delivery.”