Crisis in Care: Solving the Primary Care Puzzle for Employers

The U.S. healthcare system is facing a mounting primary care crisis—marked by physician shortages, limited access, and rising costs. In this timely episode, we examine how the decline in effective primary care is not just a health issue, but a serious business concern for employers grappling with escalating healthcare expenses and workforce wellbeing challenges.

Our expert guests unpack the systemic issues behind the crisis and explore what employers can do to strengthen access to quality primary care. You’ll hear practical insights into benefits design, provider partnerships, and policies that prioritize prevention, continuity, and cost control.

In This Episode, You'll Learn:

• Why primary care is foundational to employee health and healthcare affordability
• The downstream impact of poor access on absenteeism, chronic disease, and claims
• What forward-thinking employers are doing to restore value to primary care
• Strategies to align health benefits with long-term business and employee health goal

This is a must-listen for HR leaders, benefits professionals, and executives seeking sustainable healthcare strategies that work for both their people and their bottom line.

Transcript

Welcome to The Pulse, produced by Vital Incite, where we keep pace with what's trending and employee benefits. This series was developed to bring together nationally recognized subject matter experts from the health and pharmacy industry, as well as top academic and research institutions. Our goal is to provide unbiased information and offer scalable strategies that give you clarity amid the chaos and provide answers to your most burning questions. I'm your host, Mary Delaney, managing partner of Vital Incite, an Alera Group Company.

I have to say, this might be the most critical topic in health care that we've ever covered. For years now, we've been hearing the alarm bells. The US health care system is facing a serious shortage of primary care providers. But what does that really mean, and why should employers be paying closer attention? Let's start off with this. The ideal ratio of primary care providers to specialists is 1 to 1, but according to the Kaiser Family Foundation, only 24%, one quarter, of the US health care providers practice primary care. That imbalance alone should give us pause. And the challenges are growing. Fewer medical students are choosing primary care due to the lower reimbursement, overwhelming patient loads, and the increasing difficulty of delivering quality care in that environment.

It's a vicious cycle. The fewer providers we have, the more strain we place on the ones who remain, and the harder it becomes to fill those roles. Let me hit you with a few more numbers that bring this crisis into sharp focus. The ideal provider to patient ratio is 1 to 1000. In the United States, primary care providers are often managing 2500 to 3500 patients, more than double even triple of what is ideal.

About one-third of our population doesn't have a primary care provider at all, and in rural communities the shortage is even more severe. Nearly 8% of all U.S. counties don't have a single primary care provider. And while the demand continues to grow, we're seeing new vendors and models of care popping up everywhere. But innovation alone won't fix this.

We need structure. We need strategy. And we need to ensure that these solutions are designed for long-term success, not short term gains. To help us unpack this crisis and explore what can actually be done, I'm joined by two national experts who bring powerful insight from a provider's perspective and practical ideas to the table. So with that, let me introduce you to these incredible panelists.

So let me start with Anne Griner. We are so fortunate to have her join us and serves as President and Chief Executive Officer of the Primary Care Collaborative, a multi-stakeholder membership organization focused on improving the nation's health by strengthening primary care. I bet you can see why we've asked her to join us today. PCC's Better Health Now campaign is focused on federal policy changes to increase investment in primary care through advanced payment models to support more robust, comprehensive and team based primary care.

PCC’s achievements include successfully advocating for the CMS Innovation Center's launch and implementation of the ACO Primary Care Flex model and the Medicare Shared Savings Program. The introduction of bipartisan legislation aimed at establishing hybrid primary care payment and the wide scale implementation of the patient centered medical home. And you are doing so much in this area. We are so thrilled to have you join us today.

Thank you so much, Mary. Delighted to be here.

We're delighted to have you. And last but not least, we have Christopher Habig to provide a perspective from the DPC model. Christopher Habig is the Co-Founder and CEO of Freedom Healthworks, a company dedicated to scaling the direct primary care practice model, putting doctors back in control of patient care. Amazing thought there, Christopher. Christopher envisioned a system where health care could be accessible, high quality, and affordable.

Imagine that this vision led to the inception of Freedom Healthworks, which provides the tools, technology and support for doctors to run successful DPC programs and practices. Christopher dedicates his time to educating both consumers and health care providers about the benefits of the DPC model. His goal is to create a future for Americans where health care is synonymous with caring, individualized attention. That was its original hallmark. Christopher, thank you for bringing your expertise to the conversation today.

Thank you, Mary. Thrilled to be here. This conversation is long overdue, so thank you for pushing it to the forefront.

Yeah, I'm really looking forward to that. Let's dig in. And I would love for you to kick us off. I provided some quick, scary statistics to introduce this topic. Please feel free to add anything that you think our audience needs to hear. And as you do that, can you start us off by providing some feedback on the value of a strong primary care relationship and the impact when it's not available?

Thanks so much, Mary, and thanks for focusing on this critical conversation. Like I'm sure many of our listeners, we don't feel like we're getting much value out of our healthcare system. We're paying more and more, and yet, the American public and those that are in the workforce are not getting healthier. We seem to be spending more and more money on expensive health services, but we don't seem to be getting health.

So clearly, we've got some changes that need to be made. And primary care is a is such an important vehicle for improving health. And I'm delighted to be here because I think that employers have such an important role to lift up primary care in their relationships with health plans. Other employers, in your geographic market and nationally, policymakers and primary care clinicians.

The organization that I lead was founded in 2006, by employers, principally IBM, Paul Grundy, and physicians, specialty societies. In 2006, they didn't feel like they could either purchase or provide the kind of primary care that we know leads to better health outcomes, addressing the disparities in care that exists between rural and urban populations and across socioeconomic, characterizations, and also can bend the cost curve because you're going upstream to give people well, so that they don't end up in the hospital with exacerbated chronic conditions.

You can prevent chronic conditions in many cases. So primary care is really essential. And yet we're under investing in primary care. We spend as a country less than $0.05 on the dollar on primary care. Let me repeat that because people are stunned when I tell them that. And in fact, there was a recent survey done of, Joe and Jane on the street.

So a consumer survey and consumers, suggested that our health care system spent 50% on primary care. 501 is less than 5%. At the same time, we're asking primary care to do more, and, wrap here addressing mental health crises, deal with multiple chronic conditions, help employees get back to work supervising, absenteeism, manage conversations at the end of life, etc. the list goes on.

All for less than $0.05 on the dollar.

So and you started this organization because you saw something going wrong. What what are the what's the providers view of why this is so critical?

Well I do I I'm, I'm actually standing on the shoulders of others who started the organization. Been there about eight years. And they came from the quality field. And, I think when I talked to primary care doctors and, nurse practitioners and PAs and those in the behavioral health space, as we consider them, primary care, they're up to their eyeballs with aggravation of all the administrative work they have to do.

I feel badly because I was in the quality movement for a very long time, and a lot of the measures that are, you know, very time intensive to report all of the billing, all of the, billing and coding, that takes a lot of time. So Primary Care was asked to do a lot of administrative work, while at the same time they're not paid to terribly well relative to specialists.

I think the other, discontent, if you will, is that we have fewer primary care practices that are independent, only about 20% at this point. And primary care often joins a hospital or a, health insurance company or, private equity backed firm because they they don't have any negotiating power in a increasingly consolidated market. But when they get into those arrangements, they're often not very happy because their, ability to make decisions about what kind of care they want and deliver is constrained.

And oftentimes they need to meet certain quotas, like a production line. You know, they have quotas, for the number of patients in any given day. That really is problematic. What we need to be doing in this country is spending more time with patients on primary care and doing the hard work of partnering with them to help change lifestyle, behaviors, which are a huge contributor to our poor health.

And that is not a five minute visit. That is not a 15 minute visit. That is a relationship with someone who trusts you and who you feel has your best interests at heart, who knows your family situation. Your economic situation is grounded in the community. Understand you know, the kinds of, obstacles you're up against, but is there for you as you try to change these behaviors that may be leading to obesity and diabetes and asthma and congestive heart failure?

That's what we need to work on as a country. It is delightful that we have these high end services. When you get really sick. But many of those, high end services would not be needed if we were doing better in managing, the health of the population.

Well said. Now, Christopher, I bet you experience the frustration from the providers and that's how they move into your world. So give us some insight onto that.

So everything you said was absolutely spot on. And there is a there are numerous physicians who are looking at this and saying, how do I get out of those hospitals? Or how do I get unemployment, private equity? Because their fulfillment, we have some of the smartest, most well educated, empathetic people in our communities who want to take care of their fellow citizens.

Not everybody in this country, in the world can become a physician, whether or with their work ethic, whether they just don't care about other people, actually try to heal them. But the problem is, we don't look at this and say, well, who's trying to heal our healers? And that's what I think a big, big, big problem is we talk to physicians every single day who are managing 2500 to 3000 patients.

Like you said, in a 7 to 10 minute visits. They think they are just part of assembly line. And that is not fulfilling to why anybody chooses to go into medicine to be a doctor. We like to say that medicine is the intersection of art and science. At the core of it, our physicians are scientists. There are ways to go, but these are the scientists who like to experiment, are able to tie in a lot of different factors in order for diagnoses.

And we're losing that, right. You mentioned how primary care is obviously the crisis right now. We need more physicians coming into primary care. That that also lays on the shoulders of a lot of the medical schools out there who some of these medical schools will flat out tell the students that this school does not create primary care doctors.

We create neurosurgeons, we create these high level, you know, subspecialties. I don't know if they're looking for $200 for what, but there is a stigma against primary care, whether it's income or whether that is the the lower part of the class. I don't really know. It's a frustrating, experience for sure. I was raised by two primary care physicians, so I always thought they were kind of smart people.

And took care of their community. So I got to see how important a trusted physician is within the community. But it goes back to what primary care is these days, and they are very well paid triage. That's kind of what it is right now. People gain access. People want to go see their primary care physician in order to access a specialist, or in order to get, some other tests done.

When in reality, our primary care physicians, being trained as generalists, have a very wide breadth of knowledge and skills that if we just invested the right amount of mostly time, but also doctors like and was saying into our primary care relationships, we would see a massive, massive savings and what we call downstream care. There just wouldn't be the opportunity or the wouldn't be a necessity to see all these specialists in surgeries.

We would be making sure that we save those specialties and surgeries for those who absolutely need it. So at the end of the day, we're turning our our well-trained families in primary care into data clerks and, doctors.

Absolutely wonderfully spoken. We appreciate those comments. I had to look up and I literally was able to do that is what's the average salary for a primary care provider in the United States? And I don't know if you know that, Christopher, I'm sure you've dealt with that.

I've heard it's, depending where you are. Right. It's about 200, 250 these days and it's starting to take up more. So we are starting to see as a society, hey, we need to reward these people because we need more of them.

I think people are always surprised when they hear that, because I've heard people complain like, oh, these doctors are cranking you through so they can make a lot of money. Primary care providers, after all those years of education, all the probably debt, probable debt that they have end up making only $200,000 a year. So they're not they shouldn't take this to be to become rich, as you said, they they actually care about people.

They want to spend their time making people healthier. So yeah, that that is an important part. And as I think we've already now established that it's really important for the doctors to have the time to be able to practice their talent, which I love the idea of an intersection between art and science, because it really is. You're creating a relationship.

Go ahead.

Yeah, absolutely. And that's what you know. It's fun to talk about the word quality medicine. What is quality care actually look like? And in our world, quality and quality care means that you have time with the patients. And every single physician that I've ever encountered in the entire world will define quality by how much time I get to spend with the patient.

And it is such a switch, mentally and psychologically, that you know they're not running through a matrix. And there is a time and a place for that, you know, depending on who's paying the bill. But when consumers and patients are able to pay for themselves, the the definition of a lot of these terms, you hear start to change.

And we start to get back to the root causes and, and try to actually heal people.

You know, there's talk about, the medical home. I remember the Institute for Health Care Improvement some time ago talking about the medical home model. And that is so critical. And we've kind of lost that and this model of care when we're cranking people through. And the thoughts on that.

I'm happy to to jump in. So a couple things because our organization really was formed to promulgate that model back in in 2006. And I think, you know, over a decade that that model was widely adopted. And where organizations have continued to embrace the model. I'm thinking of Blue Cross, Blue Shield of Michigan Community Health Centers, you know, a number of places.

And the model is delivering results. But what it needs to be accompanied with not just this great delivery model. And I'll explain it in a moment, but you also need to make sure that you're investing in that model. And we believe we also need to get off of the fee for service payment system, because that slices and dices care.

So the patient center medical home is a model of care where you really know your patients and you know who's in your panel and what conditions they have. And you are using technology and a team based approach to, help you patients who have congestive heart failure or diabetes or obesity or whatever it is, you're proactively providing that care and where it's properly resourced, it works great.

Unfortunately happens is, we didn't resource the model. And again, as I said, less than $0.05 on the dollar is not a properly resourced primary care foundation. You know, that is the foundation of our of all high performing health care system in Europe and elsewhere. They say they pay double or triple to primary care. So we're really an outlier in terms of of our investment in primary care.

So, you know, we see that, payment reform, investing more in primary care through value based models. We can support, patient centered medical home adequately. We can support other advanced models of primary care that integrate behavioral health, that have a team that helps you, you know, change your diet and get exercising and whatever it is, because it's a team sport and we have a shrinking number of physicians, nurse practitioners and players that are going into primary care.

So we need a broader team, to help manage patients. And also people have different skill sets that they bring to the table now.

Well said. So she brought mid-levels Christopher kind of thoughts on mid-levels. And is that going to fill this void that we're dealing with?

I think mid-levels IPAs you name it, there's absolutely vital role in patient care for them. I hesitate to say that they are the solution to what ails the access problem, into primary care. Just the way that we train nurse practitioners and Pas. The facts are the physicians spend a lot more time in school and have a lot more residency or internships, and so they need to be really the backbone of any type of a good quality care decision.

Like I said, it is absolutely teamwork. So there are things that a mid-level might not be as great, as performing as doctors. And I will say that there are fantastic practitioners who are fantastic physician assistants out there. There are bad doctors out there. So, you know, all these things. It's it's hard to apply a one size fits all approach.

I think that's a lot of the problems that Washington's approach has been, is that we're going to just create this massive thing. It's going to apply to 350 million Americans out there. That's why we get into a lot of problems. But mid-levels have the absolute title. I would say, you know, from a national conversation, when we say we need more primary care access, I'm not going out and saying, look, I really support expanding scope of what somebody who isn't trained to take care of these big medical issues.

I don't I'm not a fan of expanding that scope, but I am a big fan of is revising and looking at residency funding. I'm I'm a big fan of looking at accreditation bottlenecks. Why can't we have private residences anymore? Why is everything so controlled by CMS dollars? I think there's a there's a much more significant position to be had around how we train physicians, coming out of medical school.

And what happens is those people don't match. And, you know, there's a lot of different layers to becoming a physician that we're just kind of putting that aside. Last I looked, residency funding for new physicians was tied to Clinton era funding within CMS. Which makes me wonder why CMS is even in the business of subsidizing training facilities.

So, there is a vital need for everybody who wants to take care of their neighbors. There absolutely is. We just have to be very careful as society of making sure that our solutions aren't creating more problems down the road.

I love all the topics you just brought up in that one answer. That was great and reminded me of so many other issues that are out there. On that same vein now. So we have a lot of DPC programs coming out, and the term DPC is kind of vague, and it's about is, well defined as transparent PBMs.

We laugh about that and said anybody can label themselves a transparent PBM, but that is a bit of an oxymoron. But, CPCs can mean anything for an employer setting up a direct primary or a top tier primary care relationship where there's no additional fees passed on to the plan. Members. It could be a nurse or onsite clinic, could be concierge services.

I would like to take some time exploring kind of the value and differences between these models, because a lot of employers are depending on those, because they are trying to fill this void that is so important to them. And maybe let's talk about what employers should focus on in order to drive great health outcomes, improve plan, spend efficiency over time.

Kind of thoughts on that?

Yes. Yeah. I have a lot of thoughts. So, I think in the long run, what employers have been given this, right. They've been saying our employer health plans, we're going to give you special tax treatment that individuals don't get. So there's a history of license, plans paid through your employer. I got a feeling about that again.

But I think from from as a business owner, what I wanted to do is play the hand that I'm dealt. That means I want to make sure that if this is my sandbox, I want a plan that works for my people who I know that they're going to get the best care for. And I need this game budget.

I think that's the big thing right now. A lot of people are looking at this and saying, I cannot sustain as a business. 12, 13, 16, 18, 25% increase year over year. And my employees still have no idea who to go see. They don't have access to doctors. We have no idea what these terms mean. Going back to what you're talking about from a definition of primary care, that's what worries me in a fledgling new industry within health care, how the Wild West in a part of our economy that basically like 20% of our GDP goes to this, right.

And that's what scares me, because there's a lot of opportunity to take that term, which on its on its surface means that a patient is paying a doctor directly. That's a direct part of it, and it's primary care. Most of this model has flourished within the primary care part of it. We are looking at, you know, working with specialists.

So that is coming. So if if we get into these models and a patient isn't putting their card down to buy services from a physician, in my mind that's no longer direct primary care. That is something else. You can have an employer sponsored membership medicine that works. You can have your site on site. That's fine. But if I'm really going to be a stickler about definitions, that's how I define DPC, which is fine.

Not everybody that works. It doesn't work for everybody. That's fine. Again, from the employer side, I'm trying to be concise here, Mary. From the employer side, what I want is I want a plan that I understand that my health care dollars that I'm spending on behalf of any of my team members are actually going to good use, not necessarily just being utilized.

And don't go away with nothing to show for it. I want to know that my people understand the benefit and that they actually provide value. They actually see the value in the benefit. And we see this uptick in a lot of the value is being able to go see a doctor when you actually need them, not just waiting three weeks saying, I'm going to, maybe have a surprise bill in six months.

You're putting your people back into the typical, complaints and typical frustration that people have whenever they talk about health insurance.

Yeah, it's why people avoid care. I just recently had someone say I went for my primary care visit. I had my annual physical woman is maybe 24 years old, ended up with a $400 bill from labs. So my first pause was, who in the heck did that many labs on a young, healthy person? And how much did how much was reimbursed?

So you're exactly right. I'll kind of end with this one. I love and take on this as well. And just just to be on the floor and all that conversation, you know, I've always just had because for some reason, we were hard wired to think that we have to go see a dentist twice a year. But yet we pat ourselves on the back for getting the stiff arm.

The physicians, it never actually going to get even the bare minimum of an annual physical. You talk to the doctors, they're like, I want you to call me, text me, come see me. Any sign of trouble that that's how we define actual access to a primary care person, catching the issues before they become massive, life threatening, very expensive problems. Later on record and thoughts?

Yeah, I could not agree more on it. And it takes me to, Barbara Star Fields for CS, which is really, I think defines what we want from primary care. We want primary care to be the first contact. That's your C not go to the Ed not go to urgent. They don't know you and it's going to be costly.

So we want primary care to be your content. We want to have a continuous relationship over time. You know, your needs, evolve and change. But as someone who knows, you take that into account when we're advising you about what to do next. Comprehensive primary care that provides a whole range of services. Services is the most cost effective.

Systems like, for example, Denmark, have drastically reduced the number of hospitals and specialists use because they're managing so much in primary care that is extremely cost effective. And guess what? Patients really like it. I don't think most patients like ping pong around to a million different specialists, and then being asked to be the general contractor and figure out, okay, this one to that, that one said this, this seem to contradict each other.

So, you know, comprehensiveness is very important. And then I think the four C coordination is critical because we've got a extremely complicated healthcare system and you really need a partner, should you need services outside of primary care, you need someone to help guide you and advise you, and that and that is primary care. So I, I completely understand why the primary camera model or on site near site primary care, an employer sponsored, direct primary care or whatever, you know, terminology you want to use is so attractive because I think it gets back to those sources.

This is the kind of care that gets us back to those sources, and it is satisfying both to the patients and satisfying to the primary care clinicians. And why are we here? I mean, you know, there's I frankly, I think there's a lot of blame to go around. We we didn't innovate quite quickly enough. In terms of health plans to come up with new primary care payment and delivery models.

And so employers got really set up. And then I said, okay, we're just going to go around the health plan. I think that is is one, one. Cause I think we talked earlier about hospital based primary care, not very satisfying in many cases, or patients and the primary care clinicians. So a lot of things have happened in the ecosystem, to make, primary care less attractive to people who are trying to, get those kinds of services and the folks who are providing it.

And it is time to make the bold changes we need, need to make to really, reinvigorate primary care. And we believe that those changes, need to be driven at least in part by policy. We also believe there's, you know, great market solutions out there, but we also believe that policy can play a role.

So you made so many great points there. And it's interesting because you brought up the hospital ownership. But now we also are dealing with the carriers who kind of made more. I will place a little blame, you know, cause some of this problem now are buying up primary care practices and, you know, then they run it through the mill so that they can make the profit off of it.

So it's so complex. But there's there are a lot of things happening. The other thing I want to talk about a little bit explored more is that you talked about the onsite clinic near clinic model. Yeah. Place variables and get a little bit.

Sure. But can I say something about the whole point? Yeah. Well, I think there's a lot of different types of health plans out there. And some health plans are very committed to value based care. And those health plans understand how critical primary care is. And they are taking steps to strengthen primary care. So, you know, the primary care practices that they contract with are either capitated for primary care or they have a hybrid payment where they get some capitation and some fee for service.

Health plans are experimenting with that, but it is meant to give people not only more dollars at the primary care level, but also more flexibility in how they provide care. I mean, you know, the model that Chris is talking about, you get a monthly, sum and then you have a lot of flexibility on how you provide care.

We need to trust our primary care clinicians that they have their best interests of the patient, at heart. And, how do they want to, provide care? And I also believe a really good accountability measures. I'm I'm a big fan of accountability measures, but I think our, 9000 codes in the schedule is a problematic way to be paying for primary care and we undervalue, the cognitive services, which is really what primary care does. And we overvalue the procedural services.

Great points. Great points.

Yeah. Yeah. And and you know, talking about coding, most employed physicians, they're charged with just maximizing revenue and putting all kinds of codes in there. And you can read about all the headlines every day about hospitals getting sued for overcrowding. I think what we're talking about is, you know, going back to the beginning of this discussion was about the importance of independent physician and how those are really going away.

We see a massive conflict of interest with employee physicians being in primary care. And then it's not exactly, the best kept secret in the world, but they are under pressure to generate referrals. Most hospitals will lose half $1 million on any primary care physician office and generate about $2 million in revenue. That's a great investment. But again, we're dealing with people and, widgets.

And so now you have now you have pretty, pretty big ethical concerns. I would say if I'm the hospital and I know that my bottom line is dependent on 1 in 3 people going in for surgery, whether they need it or not. There is a huge problem with that. And so that's why, you know, we were like, I don't think insurance companies are blameless, but they're not the only ones to blame at all.

If the government came over and said, hey Chris, your business can only earn 4% net income because your minimal loss ratios have to be paid out. I would rather have 4% of $1 billion instead of 4% of $100. So I'm going to try to maximize as many type of claims and payouts, as I possibly can. The hospitals playing the same game.

So it, it's it's a lot of finger pointing to go around between government, big hospitals and insurance companies, doctors and patients continually. Our are sitting here holding the bag and saying, hey guys, what about us? What if we actually wanted to have a call? I actually wanted it to get better. What am I supposed to do? And that's why I am such a fan of independent decision making.

Because you don't see that conflict of interest, right? Like if you have an independent primary care doctor, a primary care doctor needs to make a living by taking the best care out of their patients and making the best, always fiduciary, decisions that they can on behalf of that patient and their family.

Three points. Great points. I want to step back a little bit because we talked a little bit about GPC. And I want employers to learn from this conversation what quality DPC means. And when we went through the four C’s it and laid out right away my mind went to some of these programs are set up that you hadn't get any one of the physicians that happens to be there when you walk in and your physician is done at 5:00 and there's no no after hours service.

You know, there's there's some things in these models that are not really getting us to the highest quality. I'm what bet you both have looked at this. So kind of thoughts on that.

I'm happy to kick it off. There's an amazing amount of dollars and headaches saved when the physician answers a text message at 8 p.m. and avoids. And you are there's a there's a massive direct savings into what makes you invest in primary care. And that doesn't mean that you need to just add primary care expense on top of what you're already paying out, but you get to see an immediate savings within things like, you know, pharmaceuticals and air avoidance.

And then as your workforce grows healthier and healthier, you see continued savings down the line. That is a huge part. I think people are just starting to wake up to that. You can spend a lot of money and do these in onsite nursing clinics, but if they turn into three week waiting periods, you're right back where you started for your employees.

I wouldn't say I see the three week waiting period, but what I get is, oh yeah, we've worked. We hire our doctors because they only want to work from 8 to 5, and we don't have any after hours service. And, you know, they work part time. And when you come into the nurse like clinic, you see, whoever is there, it lose loses that continuous relationship, which I think is absolutely the most powerful thing that we have in this totally.

Great. Yeah. Okay, good.

Oh, you're hearing cognitive care. And there's a relationship like, doctors need to understand your patient history and family history that influence says what's going to happen in your future. Obviously your current behavior does, and it makes patients more compliant. You know, my issue is value based care. And some of these other models is what if your patient just flat out refuses?

What are we going to do. Right. Why penalize for providing more care? Because, I have a noncompliant patient. I want them to get better. Am I going to get penalized if I see these different types of, you know, value based care and all that kind of stuff? So, completely agree. I think I think that relationship is, is really what's missing and trying to get it back.

Yeah. I think we've shifted to much more transactional care. So it's a transaction. It's not a relationship. And we lose a lot when that happens. I also, I think not only our patients less inclined to follow the advice that they get from someone who doesn't know them. They're also less inclined to, follow up with the care that they need.

They're also less inclined to trust that particular individual. And in this environment, it is absolutely essential that there is someone who you feel has your back when you you know, are faced with something that is a serious, medical issue. It's a very confusing and complex system. And, you know, you really need someone who knows you and his is in your court.

I do think the the level of burnout in primary care is such that there's been a lot of guardrails, but I'm leaving at five because people are sober now. Now, many of those folks are leaving at five, but they're spending two hours doing pajama time work at home to do the, coding and and quality reporting it. It's really not sustainable.

There are estimates that 20 to 30% of what primary care is doing. There's nothing in the schedule to build for or there are codes, but it it is more costly to do all the administrative work to build a code. So the juice is not worth is. So 20 to 30% of primary care training is not compensated. This is nuts.

So we've got we've got a lot of work to do. Mary, I'd love to, talk about some of the work that is happening on the policy front, because I think employers, even though it seems distant and incredibly arcane and this is not my business to know how policy they can make a difference. And I think it's critical that they get into the conversation.

Please educate us and give us hope.

I think Chris has talked about a financing model that sort of outside of insurance and, you know, that is gaining popularity. I understand that, but what do we do within the insurance model, whether it's Medicare or Medicaid or commercial insurance? I think that we need to reform primary care payment so that we go from less than 5% to 10 or 15% of our expenditures are focused on health prevention and well-being.

Like that's where we should be putting our money. And if people say, you know, to the expenditure that I just made, $25,000 for, you know, employer sponsored coverage, I actually get value for that. No, I mean, my employees are sicker than ever. High rates of presenteeism, absenteeism. I'm just not getting value. And it's because we're not spending the money in the right place.

So the Trump administration just put out a draft Medicare physician payment rule, and it does begin to rebalance payment between primary care and specialists and also modernize the payment system, which right now is based on serving physicians. Some of the services are in the single digits, mind you. To make determinations about pricing services. So this new rule says, you know, we need, much better data.

We need. Yeah, sure. Data we need, time and motion studies. We need logs from from the surgical suite. There's some other data we have to, inform, how we should provide services. So we're very excited about this new rule. Come to the PCC board and you can, listen in to a webinar about the, proposed rule.

We have materials that you can download. Comments on this rule are due by November 12th. We urge you to get a letter in. It can be very simple. It can be one page. But just let us know that you think we need to be spending more on health and wellness. We believe. And we're we're, excited that Congress is going to restart conversations about how to reform Medicare payment next year and why this matters.

Is that how Medicare pays sets the table for everybody else. And so reform of of pricing, but also moving us to value based models. And that's what we hope the legislation does to really center primary care. So we welcome employers. Joining with us to work on these issues because you may be able to solve for, you know, your particular employee base in a particular geography by doing direct primary care or onsite nursing care.

But what about your, employees and in, different arrangements all around the country, you probably feel like you can't solve for them. So that's why we really need to have a change in policy that rebalances our payment system to care.

Very good, very exciting. And I hope that there is some progress here. And I always think what's interesting is every time there's a failure in our system, we start a new industry or service product. But guess what? Every one of those things makes more profit margin takes more administrative dollars out of the system. So this will mean now DPC, all of this stuff is just other people making a lot of money out of it.

And one of the things I do want to address, because we have an employer, yes, employers are trying to solve for their population. And as I said, there's counties that don't even have a primary care provider available that in fact, we have a client that uses a doctor who goes in a bus to do physicals around the state, but then we can see there's no follow up care.

So these people will go to the ER when they need anything. So we're not solving for this. So what now we're seeing employers do is to put in a virtual total virtual primary care, including a virtual physical. And just because I want our employers to know, are they purchasing the best thing. They're doing the best they can. But what could they be missing here? Any thoughts on that?

The question comes down to there's a lot of new things coming up there, and I'm going to be the first one to say they have not reached maturity, right. From a disease standpoint, there's maybe 2 or 3000 doctors in the country doing this. That is not enough. We need more. Most of my battles are educational, letting doctors know that they have options.

And then once we have those options, it's like, great, now you can represent the community. The timing's always funny, right? Universe has a sense of humor. In a world where workforces are getting more distributed, more remote, we're trying to set up more brick and mortar, trying to bring them back in. So it was kind of a mismatch of timing, but it was quickly picking up.

I would say from the employer standpoint, like they have to do what they think is best. To your point, some access is better than no access for sure. I think there's a massive, benefit to follow up to having a relationship like we've established. But if there's no cure around, the worst thing you can go is to the E.R., because asking to see your employer plan in what we like to do is say, like, you know, that's not a conversation.

If you're an HR professional and you're trying to direct your employees on where they should go for their health care access, that's a hard conversation. I think person wants to have. That's a hard conversation that most benefits, professionals don't want to have. That conversation should be had by the physician with their patient, with the understanding. Like I mentioned earlier, I'm kind of acting as this fiduciary kind of, a financial advisor on where you need to get downstream care.

So I guess my close is it. Yeah. I fully admit that there are flaws in the amount of patients that this industry that I'm active in and actually providing care for, it's growing like crazy. We need more physicians. We need more nurse practitioners doing that. The supply has to catch up with the demand. And that's always a fun conversation, too.

Because, you know, we talk to companies like you said that are saying, hey, I love this stuff. I got five patients scattered around. What do I do about them? And I'm am I going to get penalized because I can't provide the same benefits for everybody? You know, and it's just like, well, there has to be some reform, you know, at the end point.

Agreed. There's a lot of different options out there. And so I guess my my closing thought would be, if you're looking at this from a benefit side, don't wait till the last minute, like due to a lot of research, figure out what people want and just know that there are a lot of different options popping up with help from the government and also in spite of government policies. Just like a lot of how innovation actually occurs.

Very good. And it. I think is so critical for policymakers to understand what's happening in the market in terms of innovation, because you don't want to put in place a policy that will be constraining that innovation. You want to be able to support it so it can scale and spread. So we we work a lot. We've got a primary care innovators group, and we work a lot to try to, stay abreast of, you know, some really remarkable innovation that's going on across the country.

It's very, very exciting. And yet scaling it is really challenging. I think there was this turn during Covid and obviously, you know, to have, virtual care. When I talk to employers, they're finding that their employees are not so satisfied with virtual care. It's it's okay for a follow up, but they want to establish a relationship first. So fully virtual, I think it's harder.

That's what I'm hearing. But, you know, our, our rural counties are really in, trust shape of not having, you know, primary care at all. So I understand why folks are experimenting with other, approaches. We haven't talked about artificial intelligence, but I think that it's going to it holds out some, really important potential for reducing the administrative work that primary care does.

You know, the billing and the quality reporting. And that will be very welcome. Then they will have more time for patient care. It also can really help folks, quickly understand the the patient in front of them, you know, instead of, spending, you know, an hour or more to comb through electronic health records and try to, you know, understand what's going on with this patient.

You can have a patient summary in three seconds. And that is incredibly, important in terms of, you know, supporting primary care. No one, no one likes when, you know, their primary care clinician is heads down on the computer when you're trying to talk with them. Ambient listening is really incredible because they can speak with you and and all that data is captured.

So I think that, I think I hold out a lot of promise. I think we also want to make sure that what doesn't transpire is, oh, now that you have AI, instead of 2500 patients in your panel, you can manage 5000. Because. Exactly right. How would you ever know that patient? How would you have a relationship?

So we have to really think about technology. Well, a thing what primary care does is making sure that the, the technology, doesn't, you know, disrupt, that really important relationship.

Now, that's a really good point, because the whole idea of technology is to reduce the mundane activities and allow the artists to do what they are technically savvy. And so, again, we're going to go back to Christopher's thoughts on it's the art and the intelligence, the science that are going to come together. And if technology can get rid of that mundane, burdensome stuff, maybe that holds out hope in it that if these people can make more money.

And I just want to clarify one thing, Christopher, I try to throw up a softball on the cost of this stuff and you didn't catch it. So I'm going to try again when we had our conversation, you know, mention that employers need to think twice about when they're paying a pep, for in your site location, and they may or may that in your site may or may not engage these people, or may just be treating them like a minuteclinic and not having that continuous relationship that there may not be the same ROI versus a dollar per patient. Could you do mine just going into it? I think it's something employers need to understand.

Sometimes you need to translate that for me, right? I didn't, I didn't have my eye going out there to translate, you know, and pay points. I will say that there needs to be a somebody proofreading any type of I kind of stuff so I can be like, Mary sweet, to your point, most, most your site on site clinics are built off of you pay a certain amount for every single person in their company, regardless of whether they see you or not.

Right. I have a lot of issues with that one, because what you're actually doing is incentivizing the clinic provider to kind of cherry pick and have this ideal percentage of how many people are actually going to come see you. Most of the time, it's about a 50 to 70%. I think from what I've seen, they want about a 50 to 70% utilization, maybe even a little lower than that, because above that, they're losing money because they're not charging enough.

And below that you need employers to look at this and say, well, why the heck am I paying for this if nobody's actually using it? So there's this weird little sweet spot and it goes goes back to incentives, right? The underlying current this conversation is incentivizing the right type of actions. Anybody in HR knows that that is the hardest part of the job is incentivizing building out those plans or whatever is the right type of behavior.

But in my mind, if somebody looked at and said, we want to use your clinic, say, great, only pay me for the people that use it. What that does is puts the emphasis on the emphasis on my team and our physicians to go out and talk to your employees of why this is good for them and their families.

Too many employer clinics, site on site. I mean, the sites that are going out there and saying, well, I only want half of your people. So we're going to kind of, we're going to try and if we get more than 70, 75, we're not really sure what's going to go. We're gonna have to come back and raise your prices next year.

So read the fine print, read what people are doing, and make sure services are going to be at a level where people actually use it and build incentives that you want 100% of your employees to go use it. What would happen if your clinic was seeing 100% of your people? What would those economics look like? And that should be the goal of any employer.

Yeah, no, I think your points are well-taken. And I want the employers listening or whoever is listening to this to know that I'm not saying that this is the case with all we, but I want employers to understand how to think critically about what they should expect. And I also want to bring up an example where we had a situation where this clinic did have high utilization engagement, and what it was is that they convinced the employer to incentivize people to show up one time a year, or maybe was every quarter to talk to the physician and literally all they did is come in and have a card punched.

So it was absolutely worthless. There was no relationship. So think about real. We believe in performance guarantees or goals that are real outcome measures that we could look at just like we would. And you can appreciate that in anything else in health care. So I hate to draw this to a, close, but we really do, have, unfortunately, a limit of time with all of you.

And I wish we could go on forever and continue to go deeper. But as I mentioned, and I hope our audience realizes now this issue is very serious and is really directly impacting the health outcomes and increasing costs in the US health care system. So we've got to do something about it. We will definitely have more conversations on this topic.

I'm actually hoping to bring together another podcast with carriers to find out what their opinions are, what are, what are their suggestions to move forward? I want to try to summarize really our critical takeaways and and give me a zinger that I didn't know about that less than $0.05 on the U.S health care dollars spent on primary care.

That's up. This obviously needs to change. I'm actually going to take that. Another, comment you made and is, look at our reporting and see if we can develop reporting for employers to look at what percentage of their health care dollars on primary care versus other, and then look at their health care trends. So that's we've got a new report to develop from that.

So thank you. I believe you said that less than 20 or about 20% of primary care providers are independent. 80% are owned by P or hospital system. So that gets rid of our, you know, independent thinking that we want from these health care professionals. I have Christopher talking about the intersection of art and science. I brought that up many times.

I absolutely love that. And I think it's true there. It is a fine art to get someone who can communicate, who can understand, and then have the clinical knowledge to identify and be able to create change. And quality time is critically important. Christopher brought that up and, laid out the patient centered medical, home and team based care and how critical that is to drive outcomes.

And then, boy, if I could only read my writing better, Christopher said, we have to support the people, not the budget, and remember that we're not there in a bunch of widgets we're trying to get through and I think we all know that. But we forget that the way the system set up and then in your four C's are beautiful.

And I know you quoted that from someone else, but it's care. Forces to primary care are contact continuous relationship comprehensive services range of services and coordination. So that's really critical.

Well, Mary, I love your idea about employers, reporting on the spend, relative to primary care, there are, business coalitions around the country that have done this kinds of reports. I'm happy to share them with you. States have requested now, of course, is exempt that the carriers that they regulate report. What, what is being spent on primary care in nearly ten states?

They have taken those reports and they're very eye opening. You might see anywhere from 3% to 15%. They use them to then set a target for increasing expenditures on primary care without growing total cost of care. California has a target. Over a number of years to get to 15%. So, you know, I think there is a real role for purchasers to be involved either in business coalitions, in your own communities, in these state efforts.

And also consider joining us, to try to change how Medicare pays because it has such a big effect, on commercial payments. So thank you so much for inviting us. It was a delightful conversation. Well, thank you guys both. I thank you for a truly insightful and inspiring discussion.

And to our audience, I hope today's conversation is giving you valuable insight to reflect on your current strategies and perhaps spark some ideas about your best next steps. In our next episode, we'll dive into a critical topic the employer's fiduciary responsibility. This is one area that actually gives me a lot of hope.

As employers take a more active role in managing their plans, the potential to drive better outcomes becomes very real. We'll explore everything from key contract language considerations to strategies and documentation that can support sound, defensible decisions. Thanks for listening to this episode of The Pulse. Share the link with others so we can all start to demand something new and follow us on LinkedIn.

The Pulse is produced by Vital Incite an Alera Group Company. Alera is on a mission to help organizations identify medical spending waste through data driven strategies, while helping improve the health of their employees. If you want to make health care easier to understand and manage and improve your organization's bottom line, reach out to us at VitalIncite.com.

I'm Mary Delaney. Thanks for listening.