EP504: A Back-to-Basics Roadmap Through the Perverse Incentives to Advanced Primary Care, With Ryan Jacobs

It's been a while since we started from the beginning, so let's just take stock of the basics in this show, refresh ourselves if you're a longtime listener, or welcome if you're new around here. Today we are digging on and about what I would call the poster child for proven healthcare strategies: advanced primary care, otherwise known as APC. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. If you look at the data, APC, well done and with the right segmentation—neither of which should be underestimated—but done well, APC should be a slam dunk. It improves patient outcomes. It reduces costs. Listen to the episode with Kenny Cole, MD (EP431) for more on what good advanced primary care looks like and the show with Beau Raymond, MD (EP455) on pulling it off in a community. Now I wanna make one thing really clear. When I say advanced primary care (APC), please note I do not mean some kind of seven-minute patient visit during which the clinician tells the patient he or she is limited to but one concern only and if they wanna talk about anything else, they gotta make another appointment and pay another co-pay. I'm also not talking about any kind of model where a doctor takes a capitated payment and then doesn't even see the patient. They just process a referral, which I saw a post about by Stacy Mays the other day. So, nothing of that ilk. We're talking about real advanced primary care, which is managing risk, not symptoms. So anyway, here is the probably multibillion-dollar question: If the evidence for APC is so robust, why isn't APC everywhere? Why aren't we tripping over high-value primary care clinics on every street corner? And if you're a clinician trying to do APC, why isn't it super easy to stand up a practice and get paid? The answer, as usual, lies in the pachinko machine that is the U.S. healthcare industry. You throw a great idea—even when with lots of evidence—into our industry, into our sector; and the results that bounce out the other side are rarely what anybody may have expected, intended, or wanted. So, on the show today first, we are exploring the pit traps, I'll call them—the blockades that keep APC from really scaling, starting with two root causes, the first one being conflicting fiduciary duties. Because look, when we talk about your average—let's just say hospital board, let's just start there—health system board's fiduciary responsibility, we aren't just talking about mission. There's a reason for the epidemic of burnout and moral injury amongst clinicians in this country. There's a reason why fewer than half (45%) of frontline clinicians trust their organization's leadership to do what's right by patients. At the board or C-suite level, it's all about heads in beds, as they say. A health system drives revenue by driving volume, profitable surgeries, infusions that are tens of thousands of dollars more than you can find at an indie practice, and, again, filling those beds. Meanwhile, the entire goal of advanced primary care is to keep patients out of the hospital and out of the ER. As my guest, Ryan Jacobs, today points out, there is a very steep uphill battle when your innovation actually threatens the revenue of some of the largest players in the nonmarket that we have here. Listen to the episode with Scott Conard, MD (EP391) talking about his, he calls it his Pelican Brief moment when he was dealing with a local health system. It is a really stunning, just stop you in your tracks perfect example of this whole conflicting fiduciary duties thing playing out in real life. So then, after that, we get to a second reason why APC is not available on every corner. Ryan Jacobs, again, my guest today, he calls this second reason the black box of complacency. In our healthcare nonmarket, innovators and those looking to improve quality or lower costs often don't lose to better competitors. They lose to the status quo. I mean, you think about this—it is often a rational move for "lazy networks" and consolidated health systems to do nothing because they get the volume anyway, especially when self-insured employers buy on discounts and not much else. Listen to the episode with Jonathan Baran (EP483) on the healthcare flywheel for a really, really deep dive into this point. All right … now let's make all this actionable. Ryan lays out a three-step roadmap for founders, clinicians, plan sponsors, anybody who is tired of waiting for the invisible hand to fix things because … yeah, exactly. There's no functioning market in most of the healthcare industry, so there is no invisible hand that's gonna level up quality or keep prices down. It does not work that way. Here's the roadmap that Ryan Jacobs lays out today: Step 1: Perform a reality-based assessment. Think about all the things that we just talked about. No magical thinking allowed. You have to follow the...