Crisis in Care: Solving the Primary Care Puzzle for Employers – Part 3

Frontline Perspectives from Physicians & Benefits Leaders

Building on our Part 2 session where carriers discussed what’s working, what’s falling short, and how employers can influence the trend, we’re now turning to the people closest to care delivery and benefit design. In Part 3, practicing physicians and respected benefits leaders will share practical, employer-ready strategies to stabilize access, improve outcomes, and control costs.

What You’ll Learn: 

• Why primary care is under pressure from administrative burdens and poor reimbursement to fragmented relationships and what it means for access and outcomes.
• How innovative models like direct primary care and team-based care are changing the game for both physicians and employers.
• What employers and benefits advisors can do to drive real change: from investing in primary care and reducing red tape, to building trusted partnerships with providers. 
• The power of relationships in primary care and how continuity, trust, and a whole-person approach can lower costs and improve workforce health.

If you’re tired of quick fixes and want to hear what really works in primary care—from the voices on the front lines, this conversation is for you. 

Transcript

0:06

Welcome to The Pulse, where we keep pace with what's trending in employee benefits. I'm your host, Mary Delaney, Managing Partner of Vital Incite an Alera Group Company. 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. We've spent two episodes unpacking the magnitude of the primary care crisis. In Part 1, we discussed the scope of the crisis, including the declining supply of primary care physicians, the growing imbalance between primary care and specialty care. We also discussed the downstream consequences employers are experiencing, including delayed diagnosis, rising ER utilization, avoidable specialty care and worsening chronic conditions. In Part 2 we explored this crisis from the carrier perspective, specifically how misaligned payment models, administrative burden and fragmented strategies are undermining primary care despite overwhelming evidence that strong primary care improves outcomes and lowers total cost of care. Today, we're taking the conversation from diagnosis to design. While we talk about access, we have learned that what's really missing in the healthcare system is relationships. Continuous, trusted relationships between patients and primary care providers. Relationships that allow physicians to practice real medicine, not transactional care measured by CPT codes and prior authorizations. So in this discussion, we're going to explore what it actually takes to rebuild primary care in a way that works for patients, providers, and employers. We'll talk about payment models, accountability, team-based care, direct contracting, and what employers should be asking of carriers, advisors and primary care partners if they want better outcomes. I'm joined today by leaders who approach primary care from very different but highly complementary angles: policy, employer strategy, and direct patient care. And what unites them is a shared belief that primary care is not a commodity, it's the foundation of healthcare. So let me start by introducing Dr. Yalda Jabbarpour. Dr. Jabbarpour is a practicing family physician, Associate Professor of Family Medicine at Georgetown and Director of Robert Graham Center, one of the nation's leading primary care policy research organizations. Her work focuses on the primary care workforce, payment models and medical education. And she continues to see patients while shaping national research and policy conversations. Dr. Jabbarpour, we're thrilled to have you with us today. Thanks for having me. I'm excited for the conversation. Next, I'm pleased to welcome Tina Wilt. Tina is an Executive Consultant with Alera Group, bringing nearly 30 years of experience across self-funding, analytics, compliance and value-based purchasing. She is a trusted advisor to employers looking to improve health plan performance and long-term sustainability. She has led innovative employer-driven purchasing strategies, including community-based health plans. Tina, thank you so much for joining us. Thank you. I'm excited to be here. And finally, I'm excited to welcome Dr. Wayne Dysinger. Dr. Dysinger is a practicing family and lifestyle medicine physician and was the founding Chief Medical Officer for Blue Zones Health. Dr. Dysinger is consulting to support relationship-based whole-person primary care models across hundreds of practices with a focus on improving outcomes, experience and costs. He is also a nationally recognized leader in lifestyle medicine and continues to teach and practice clinically. Dr. Dysinger, we're so glad you're here. Thank you, Mary. It's always great to have a conversation with you, and I'm looking forward to talking through these subjects with this distinguished panel. Yeah, it is a great panel. So with that, let's dig in. We've talked a lot about the primary care shortage, but I'd like to go deeper into the idea of the cost of neglect. From your vantage points, what are the real consequences of under-investing in primary care, and how do today's reimbursement models actively push physicians away from the kind of care that we need? Dr. Jabbarpour, do you mind starting? Yeah, I mean, I think the ultimate consequence is that patients don't have access to primary care. And what do I mean by that? The report that we did with the Milbank Memorial Fund entitled The Cost of Neglect shows exactly how that happens. When we're only investing 5% of total healthcare spend to the backbone of healthcare in this nation, which is primary care, what you end up with is primary care offices that are overburdened with work trying to take care of the entire population, but really under-resourced. And so you have primary care clinicians that eventually burn out. They reduce their clinical time or leave clinical time altogether. You have trainees rotating in these offices that see these overburdened under-resourced clinicians and think, it's great. It's great what you do for the population, but I don't think I can do that. I don't want to be working in this environment. And so you have a hard time not only retaining the current clinicians in primary care, but you have a hard time recruiting new clinicians to primary care. And ultimately that 5% spend - that underinvestment - then leads to a complete shortage of primary care and lack of access for patients. Dr. Dysinger. Yeah, you know, medicine has become transactional here in the US to a large extent, meaning when you show up at your doctor's office, what happens is you get a pill or a procedure. That tends to be the result. And that's not really what patients want. If you look at how we used to do care, and this is 100 years ago, 200 years ago, this is still how care is provided in some societies and some cultures in the world. It was you go in, you sit down, you get to know your doctor well. A lot of what happens in healing is that interpersonal relationship that shows up very well in some of the Blue Zones literature. It shows up very well in the Harvard longitudinal study, the Harvard men's study. Relationships are super important as far as health outcomes. And if you can't even have a relationship with your doctor, which the current approach to primary care, to medicine in general, doesn't really prioritize that, then it's really, really hard to find that healing journey. And I have so many patients who show up and say, I couldn't get any help from the healthcare system. I just couldn't get any help from the healthcare system. So I had to try to figure things out myself. And some of the better resource ones can figure things out themselves, but some people can't. And that's because of this transactional nature. So we need to get back to the doctor and the patient actually having time together. And how we do that, what matters a lot is the payment models. Go ahead, Tina, what are your thoughts? Well, thank you very much, both of you, for explaining this challenge so eloquently. How it really trickles down, I think, for plan sponsors is how do they design plans that actually allow them to invest in primary care in a suitable way to actually create conditions where trusted long-term relationships can exist. Our model is so fractured and so siloed that really a primary care physician is your second thought as opposed to your first thought. And so folks under the current models are self-referring to specialists oftentimes, which then lends itself to maybe not the right setting for a particular malady or something like that. So we have these cookie cutter approaches that were all predicated by insurance middlemen and so it doesn't allow for what I would consider a conducive environment for healing. It's really only just transactional just like you folks said. So I really see a tremendous migration out of the healthcare system by primary care physicians into different, more, I would say comfortable and appropriate models for them where their patient base is not 3,000, it could be 600. And lit's much more manageable and they actually know their patients and they actually can speak more to maintaining health than treating disease. Which is really the foundational beginning to changing the healthcare crisis that we're in today. And I think primary care is pivotal and focal in that goal and what we want to achieve. I don't know that we've ever kicked it off where everyone has agreed to this exact same philosophy of what we need to do. So now that we know we need to create that long-term relationship, I'm going to interject a little blocker in this is that when physicians are becoming unhappy, they many times then join hospital systems, which can create other incentives. Thoughts on that, and what employers or health plans need to consider in that relationship? Who's willing to take that one first? I think, you know, when we think about physicians becoming increasingly employed, in one way it makes sense because I think the way that the, the way that healthcare financing is set up in the country, it makes it really hard to make your bottom line and keep your doors open if you're not employed by a large system. On the other hand, our data shows that increasingly as physicians are becoming employed, other things that we don't want for physicians are increasing, which is lack of autonomy, increasing rates of burnout. There's definitely an association there. I think, as you mentioned, the health system priorities are not the same priorities as the typical primary care clinicians. So a health system - I think we call it a health system, but maybe it's more a sick system - and primary care, we're there to prevent people from getting sick. I mean, that is our number one goal in what we do besides creating those relationships to take care of people who do have chronic disease. Our goal is for none of our patients to ever come up with a chronic disease, right? But ultimately, if you work for a health system and you have only healthy patients, you can see how that doesn't help a health system run. There's hospital beds not being filled. There's specialists not being able to treat diseases, and many health systems do see, unfortunately, their primary care workforce as a referral base. That's not what we train to do in family medicine or primary care. We're not trained to refer patients. We're trained to take care of patients across their lifespan and across their chronic conditions. So I think you're right in that sometimes working for a health system, although it may seem like the easy way out, financially actually ends up being more burdensome for primary care in terms of practicing the way they want to practice. Thank you for that perspective. So what I'm hearing is that a physician, person decides they want to go into primary care because they have the passion to really have that relationship to prevent disease. And yet in our healthcare system, you don't get rewarded for that, right? So that becomes a real hurdle to being able to be successful. Now, Dr. Dysinger, I know you've had a very successful practice. Can you tell us what does a true primary care relationship look like in a practice, and kind of how have you seen that evolve and why does that make such a difference in your patients’ health outcomes? Thank you. And, you know, just to sort of tie into what we just talked about and to answer that question, how healthcare is reimbursed matters a lot. And traditionally healthcare has been reimbursed in this fee-for-service manner. So you come in, the doctor does some procedure, some visit with you, and then the doctor gets paid a fee for the service they provided. That may work in certain specialty situations, but it definitely doesn't work in primary care because if you think about it in a fee-for-service environment, reimbursement environment in primary care, I sort of don't get paid unless the patient walks in my door. So if I'm really keeping my patients super healthy, they're never gonna walk in my door, and I'm never gonna get paid anything. Whereas there's this new thing called value-based care. And value-based care, I get paid a monthly fee for that patient no matter what's going on. And in fact, the way some of the more progressive value-based care reimbursements work is I actually get paid more if I keep the patient super healthy. If they're out of the hospital, they're not going to specialists, they're using less in the way of labs or imaging or whatever. So if they're using less in the healthcare system, I as a primary care physician actually do better. Well, that's nice motivation for me. The nice thing about value-based care is it actually works for systems, too. And, you know, when we say healthcare system, we tend to think of the local hospital or the local network of hospitals, but there's more and more“healthcare systems” that actually don't have anything to do with hospitals. They're organizations that are operating from this value-based care perspective, and they're large and increasingly more powerful organizations. So there's some hope there that primary care physicians who affiliate with some of these newer ways of thinking about it, so you don't have to keep the bed full to actually make money. You actually just have to, you actually keep, you make money by keeping people well. That's where we need to go. And that allows us as a primary care physician, so in my practice, we set it up so that we would have 30-minute visits. And that's for the regular follow-up visit. It's not the 15 or the 20-minute visit. And for the annual visit is 45 minutes or the new patient is 45 minutes. So you have time and that's because if I don't get to know my patient well, if I don't know the details of their life - Who do they live with? What kind of work do they have? Tell me about your family, whether it's your kids or your grandkids, or maybe it's your parents. I need to know your life journey. I need to understand what life has been like as you go through. And your health journey. I need to understand all of that. And if I'm gonna understand all of it, there's technologies that help me understand it all, because you can fill some things out before you ever show up. But a lot of it is just sitting down in the same room with you. We talk about heart connecting to heart. So it's not just me listening to you, it's literally my heart connecting to your heart. You can do that if you have the time and you have the connection, and that's part of your commitment. From both ways - the patient getting to know me, and me getting to know the patient. So that's what we're after. And there's something incredibly therapeutic in that. And there's something that actually saves a lot of money in that. And so if you're in this value-based care approach, then you recognize that, and you can set it up so that that's how your physicians are operating. Do either of you have examples of what that relationship did and the impact it had in being able to more effectively take care of someone? Yeah, absolutely. I mean, I think the longer I have with a patient, not only in terms of the office visit itself, but also longevity in terms of years, the more impact I have. So I can think of one patient in particular when I first started seeing her. She's young, but she's a very medically and socially complex patient. She was probably going to the ER on a weekly basis for her different conditions. Sometimes she'd be discharged and sometimes she'd be hospitalized. And as all of us know, some people need hospitalization, but sometimes when you hospitalize a patient, more and more conditions build up. They might get hospital-related infections, and so, things were not going well with her. She had never had a steady primary care physician. But over the years, we have really developed that close relationship. I have been, I would say, more of a teacher than a doctor to her, teaching her these are the reasons that you would go to the ER. These are the reasons that maybe you don't need to go to the ER, but you could try doing XYZ with your medication or, you know, she suffers a lot from seasonal allergies, but didn't really understand that. You could try doing XYZ with your environment to help avoid an allergic reaction. And so, you know, we've gotten that ER visit down from once a week to maybe once every 6 months, which is actually huge, both for her as a person, for her being able to work, but also right for the healthcare system as a whole. I mean, she was very much a high utilizer. And yeah, that takes time. That doesn't happen overnight. That doesn't happen in a one-year relationship. She's been my patient now for 15 years, and it's taken that time to do that, and it's taken that time to do teaching. But as we've been talking about, we don't necessarily in a fee-for-service system get reimbursed for that teaching. So a lot of that was happening after hours, not something that I could really bill or code for, but something that's just so important to healthcare. What a shame that you don't get reimbursed, because the average ER visit’s what, $2,500, and I can't even tell you what an inpatient admission could be. Yeah, and that's exactly what we need. And those people continue to be overutilizers, don't understand how to manage their own illnesses. And I know, Dr. Dysinger, when we were talking, you mentioned something that really stuck with me. You said that you, many times, are just giving them feedback on things they've read or heard. Again, just teaching more than doctoring, but people need that, especially in our society where you Google everything. Yeah, yeah. And if we have time, I mean, I love sharing patient stories. So Dr. Jabbarpour shared a younger woman. I'll share an older man. He showed up at my practice. He was 70-some at the time. And so he's been with us for 10 years, so he's now in his 80s. But he showed up with this sort of leg ulcer kind of thing that wasn't healing. And he'd been to multiple physicians, different places around the country, specialists, primary care docs, etc. But none of them were giving him hope. And he was getting ready to go on a cruise. And he said, “Doc, I just want to be able to get off the boat and go into the towns when the cruise stops.” So we started working with him. And we applied this thing we call lifestyle medicine, where we help him with his diet, with his exercise patterns, with his sleep and his stress. We help him in his relationships. He did have some extra weight on him, so we helped him lose weight. He has some pre-diabetes. We helped him get rid of that, all without medications, just applying these lifestyle things. And guess what? He went on his cruise; he had no trouble getting off and on the boat. And the next thing I knew, he said, “Yeah, I was out playing frisbee golf.” And I'm, “What? Playing frisbee golf?” But that's the kind of thing that you can do when you have the relationship. Now, we also have in our practice, we have health coaches and we have groups. And one of the big things that happened with this guy, and he and his wife both joined this group. We call it our health maintenance group and they still go to that group 10 years later - every week they're at this group. But guess what? Neither of them have been in the hospital. They've both done great. And they eat well, they exercise regularly, and they inspire other patients who join the group as well. So it's fun to have those kind of stories. That's why we went into medicine, so we could help work with patients to create those kind of stories. But yes, that's the kind of thing that we need as physicians. But it's the kind of thing that we don't get the opportunity to do enough, because we don't have the systems that offer those groups and those healthcare coaches. And the reason we don't do that is because we get paid in this transactional fee-for-service way, not in this value-based care way. But there's hope. There's healthcare systems, like we said, that are building themselves around the value-based care approach. The government is starting to recognize that. I hope that other payers are starting to recognize that if we shift the motivation for the physician, that actually works better for the patient and works with decrease in overall care. And I think in the context of this podcast, I mean, if you're an employer and you're not trying to figure out how to get value-based care for your patient, or for your, I should say for your employee, then that's, you know, maybe start thinking about that. Maybe that's a good thing for you to be looking up and trying to find some of these organizations that really help offer value-based care. Yeah, well that's the whole reason we're doing this. We want to inspire employers to think differently, and don't wait for the carrier to give you the answer because it's not going to happen, but you also can't take the easy off-the-shelf vendor strategy. It takes a much more comprehensive approach to this. And I know, Tina, you've put some time into this. Why don't you talk a little bit about what you've experienced? Yes. I have seen the healthcare system fail on so many occasions. So I'm going to tell a story about a patient - from a patient's perspective, not me, but someone else. So diverticulitis within a 30-year-old - very unusual. That was my son. He was going in to the emergency room chronically for severe pain. He was diagnosed with diverticulitis. And he said, “Mom, what's going on?” And so what was, I guess, culpable in his diagnosis was stress, inactivity, and he was very susceptible to this, you know, manifesting itself within his intestines. So he says, “Mom, I've heard you talk about something.” And actually, I've been beating him over the head with alternative primary care delivery models. And I said, ”Honey, you need a direct primary care physician that can get to know you and can treat the whole person, not just the symptoms, not just the pain. Or not a diagnosis that would normally be associated with someone in their 60s. So we have to get at the root cause.” He has engaged…he has an HSA with his employer plan, and he has now engaged with a direct primary care physician using his HSA funds to be able to pay for that membership. And he says, “Mom, I don't know why anyone would do anything different. I am so frustrated with the healthcare system. This is my lifeline. This gave me my life back.” So my work is very near and dear to me and to my family's health. But also, I look at my clients, employers, who just, they just don't know what they don't know. And so if we can just take the blinders off and we can share with them that there is an opportunity for you to invest in your own community with physicians that very much want to improve the overall health of the region. And honestly, employers and physicians share the same stakeholder base. So if you do outreach to the physicians in your community, get to know them, get to partner with them to improve the overall health of your population, it pays dividends to both parties, and ultimately elevates the common stakeholder to a position that they've never even seen before. I've never put in an alternative direct primary care or primary care model where it has not been a swimming success and people are just taken aback by just how much better they feel, not only from a relational standpoint, but overall health. So, I mean, I went in a couple of different tangents, but hopefully that gives nice perspective I personally feel very strongly about finding independent providers in communities, and supporting them. And if you think about it, primary care, unfortunately, is paid so low, the employer can easily fund those primary care practices, pay them the extra PEPM or whatever they want, and allow them to have team-based care, all the resources they need. I mean, already in these examples, you guys have already showed us thousands of dollars of savings in 3 people. So it's very easy to get to this equation, but many people want the easy button. And I don't think right now that the carriers are going to get us there. And I also don't think the national - I hate to say this - but the national DPC vendors and onsite clinic companies are really doing something that is meaningful on an individual level. So if employers truly want better primary care, what specific expectations should they be setting? Again, they are the payers. So they should be able to talk to their benefit advisors, talk to the Tinas in the world, and say, no, I do want you to work harder and help me set this up. What should they be asking their carriers? And what could they be talking to their provider partners about? What do you guys think? So I can field that question just because that's pretty much what I do 60 hours a week is work with employers to kind of flip the script. That you don't have to accept the status quo as your solution. You can really think more broadly about this. And if you expand primary care, it will – downstream - avoid so many complex financial and health conditions that it's almost like being preventive in the way that you look at healthcare. So the way that I really try to couch this for plan sponsors is, you really have more control than you think you do in predicating the care that your employees receive. Nothing happens until you pay the bill. So think about that when you want to design something that serves your needs and not the needs of a big impersonal system that really doesn't care about your bottom line. All they want to do is get paid for their model that is working, like I said, swimmingly for them. But it's not working for the overall health of our population, or for your bottom line. So think of this a little bit in the micro. Think about the different offices that you have and the physicians that reside in those communities that have invested time into the population. Get to know them, form alliances, form partnerships, do direct contracting. Take the administrative burden off of them and off of yourself by just expanding care to your people. And, you know, we could go in a number of different ways with this, you know, how to do it, how to set it up, what are the things that you need for proper administration? How do you do those things? But really, it's a mindset shift. Anyone else? So, yeah, I love what Tina's been saying. And, you know, again, if you're an employer, just as a reminder, your insurance company and your broker tend to get paid more if healthcare costs more. So they're there to help you, but at some level, they're not on your side as far as saving costs. So I love Tina's boldness in sort of saying, you know, flip the script, and so to me, what you're after is that really, really good primary care provider. And, you know, Dr. Jabbarpour can say better than me all the data, but there's tons of data that a really good primary care system saves money. That's not really even for debate in the literature. So find that really good primary care provider. And then I would say find the primary care provider who's actually paid in this capitated or value-based approach, because they're the ones that are really going to do what they did for Tina's son. You know, DPC is generally reimbursed on a monthly basis. So Tina's son's doctor is paid more if they keep Tina's son really super healthy. So that's…you want that kind of reimbursement system, and you want that strong primary care. And then you can go into various other details of that primary care. But look for that reimbursement approach and look for the really good primary care facility. I think that's the place you start. And then be bold, like Tina said, flip the script. Say, you know, this is how it's going to be in my company. We're going to split off primary care, maybe, and we're gonna pay that and then we'll negotiate around these other things. But then do some shared savings there, because if you really want to save money on your healthcare spend, and you invest in the primary care, almost guaranteed - and I'll let Dr. Jabbarpour comment on this because I think she knows the research better than I - almost guaranteed you're gonna save your overall healthcare spend if you invest in that. Dr. Jabbarpour? Yeah, I mean, absolutely. I agree with everything that's been said. I think that, yes, the literature absolutely shows that you save money with better primary care, and you save money with more continuity of care. We actually just published something that says that for patients with chronic disease - so patients who already have chronic disease – the longer they are with a provider, so the more continuity they have with that provider, the more that they save the health system overall money. Which ultimately also goes back to the employer, if you're saving money on healthcare spend. For people that don't have chronic disease, if they have high-quality primary care, high-quality, usual source of primary care, they actually cost the health system 40% less than someone who does not have a usual source of primary care. So I mean, the savings are pretty big. And this is talking about a health workforce - primary care - that only gets 5% of total healthcare spend. Yet we're still able to save the healthcare system a lot of money. I would also say that for employers, I think direct contracting is wonderful if they can do it. I think there are probably some markets where employers are not able to do that. And they're working with large payers. And you do need to make sure that those large payers, as we've been saying, support high-quality primary care. So what does that mean? That they have models that are value-based, that they are not purely fee-for-service, that if they are increasing their investment in primary care, which we've seen payers do in several states that are legislating higher investment in primary care, that they actually have some sort of accountability metric to make sure that that higher investment is going to the primary care offices. We started the conversation with saying that a majority of primary care clinicians actually are employed by large hospital health systems. The payer is not necessarily paying the primary care practice directly. They're paying that large hospital health system, right? So they have to make sure that, you know, the investment that they're saying is towards the primary care of that large healthcare system is actually trickling down to that primary care office and not just going towards building a new cardiology suite or a new, you know, cath lab, right? So there needs to be accountability back to the payers too from these large health systems. Let's pause to thank our sponsor. This podcast is brought to you by Alera Group. Vital Incite is part of Alera Group, an independent financial services firm offering comprehensive property and casualty insurance, employee benefits, wealth services, and retirement plan solutions to clients nationwide. Working collaboratively across specialties and across the country, Alera Group's team of more than 4600 colleagues offer unique solutions, personalized services, and proactive insights to help ensure each client's business and personal success. For more information, visit Alera Group.com and follow us on LinkedIn. I love this conversation. We just are doing our year-end research. And one of the things we are doing is looking, comparing different carriers. And one of the analysis we're going to do is their average reimbursement for primary care. Because there is no doubt you can see in, you know, what carriers are completely underpaying primary care providers or mental health providers. And then we are in a desert, and we don't have those providers available to us. The other thing I wanted to mention is, you know, Tina, your son is in a high-deductible plan. Thank goodness he has you because I also have children, and the first time they experience a high-deductible plan, they'll call me and go, “This is nuts. I thought you had insurance. Why am I paying for everything? I'm never going again.” Which is most of our society. They feel like they've been bamboozled by this insurance that won't help support them when they need it. So the barrier we've put to people even having that relationship in primary care is terrible in that plan. And I wish that everyone would turn to taking the time and creating that really strong relationship to have more access to primary care, removing the financial barrier. But that does take a lot of work. And I don't think there's a lot of people that are willing to do that right now. So everybody wants kind of some prepackaged opportunity. With that, do you think there are, like, does anybody see prepackaged things working effectively in any areas? I see some rolling of the eyes, I love it. So again, I’m a physician, so I don't know all the power that employers have. I loved Tina's strength and courage to stand up there and say, you've got a lot of power. And it would feel to me like you would have a lot of power because it's actually your dollars.

But I would say do this: 39:30

Split out primary care. Currently, if it's 5%, double that. Make it 10%. And then go to your whatever healthcare resource you have and make sure that those primary care physicians know about value-based care and know about sort of this monthly reimbursement fee. And then make that for free. Make that available to your employees for free. So it's no cost to them. So that's not a barrier. And then you can create a high-deductible plan, which will actually also save you money. Create a high-deductible plan and then use a health savings account for that middle window. So you get primary care, which includes preventive, lifestyle, all these other kinds of things. You get that for free. Your really expensive things are covered by your high-deductible insurance. And then in the middle, you have this space where your employees get to choose - do I want the MRI or will I wait a month and see if it heals on its own? Or, you know, do I go to the super specialist, where I have to pay out of my health savings account? Or do I go to my primary care doc who maybe can help me just as much as the super specialist? So they get to choose that middle window. Primary care, preventive care is for free. Specialists, the hospitalizations, the really expensive things, that's covered under the high deductible. To me, that's the perfect place where we should be. But we're not there very much at all right now. But maybe a bunch of employers can start demanding that kind of thing. And there's enough going on in the primary care world that if you don't have exactly what you want in your space, just keep knocking around. Maybe you can help your healthcare system create it. Maybe you can…you'll be able to find some things. And guess what? More and more is available virtually, too. So in our practice, we have patients who are a long ways away. We say show up once per year in person. And you can even do that by getting on a plane and flying to us. And we'll do the rest virtually. And we'll still help you with the overall healthcare cost. I love the enthusiasm and the excitement. And I'm going to be a…I'm going to crush everyone's hearts on this one. In a high-deductible plan, you cannot give first-dollar service that is not preventative, you know, for free. It has to go through the deductible. So that's been a big barrier because it is an issue with the tax laws for the HSA. I'm hoping, Dr. Jabbarpour, that some of the legislative pushes, you know…all primary care is preventative care. That needs to be in place, versus give people diabetes drugs for free but don't let them see a primary care provider. It's an oxymoron. Thoughts on that? I mean, I agree completely with what Dr. Dysinger is saying, actually. I just feel like we need to create a policy environment that supports a carve-out of sorts for primary care. Primary care should not be treated the same way the rest of the healthcare system is treated. I think primary care absolutely is a basic right for every individual, and we should make sure that we're providing that for people so that it's not just the wealthy that have great access to primary care, but that everyone has great access to primary care, and it will end up saving everyone money. Every individual will save money if we do that. And I love the idea of this middle ground. I mean, I feel like just because, right, legislation doesn't support it right now of, you know, having this primary care carve-out and having the, you know, the first dollar of the HSA has to be spent on primary or preventive. It doesn't mean that we can't do it in the future and we can't advocate for that in the future. And I think that a lot of what, for example, our government relations team does at the American Academy of Family Physicians is advocate for these kinds of payment methods, payment policies on the federal level that just makes sense for primary care and the population as a whole. So will it happen tomorrow? No, but we need great thinkers like the people on this podcast to be able to come up with these ideas. And you never know what can happen in the future. Right? When we started talking about primary care spend legislation over a decade ago, and saying states should legislate how much their payers are investing in primary care, we never really thought it would actually spread the way it is. And for you know, states like California to be at the table saying that you need to double how much you're spending on primary care if you're a payer in my state, I think is amazing. So you never know what can happen if we all push for it. Mary, can I share? Absolutely, please. We are building different models that address the concerns that we've all expressed on this call today. And one of the foundational pillars in what we're building is value-based or direct primary care as a foundational piece. So that is really gaining momentum and we are having success. And guess what? The talk track is different for employers and they actually want to listen. So we can demonstrate savings, and we can actually move folks away from being very frustrated and stymied. We've had the good fortune of working with employers on the data side for over now 14 years. The most successful employers have invested in having that relationship with their local providers, creating the great plan structure so that people can get primary care at$0. Investing, maybe even giving extra PEPM or monthly amounts for those practices to be able to have team-based care. And then, again, making it more expensive and helping, but helping direct them when they do need sources outside of what the primary care can provide. That way they can get around the very expensive imaging costs and labs and things like that that can really burn up a lot of dollars. So there are ways around it. When I mentioned that around the health savings plans, Dr. Dysinger, I just wanted to be careful because there are rules around that, but there are ways to get around it in the way you can set up the structure and it's happening and it's proving to be very successful. Our best client, our best-performing client has seen a reduction in planned spend. They're like at maybe in the last 10 years, a 1% trend only compared to what, 9.2 across the country. And we've seen an improvement in their future risk scores by individuals. So their people are getting healthier, and they're spending less at the same time. So it makes a difference. And I'm more just saying that because I want every employer listening to this to push and say that you deserve something different. So with that, any last-minute closing thoughts that we should share with employers to further inspire them? Although I think you guys have done a lot already today. So I'll just give a little illustration here. So when you get on a plane and fly from point A to point B, who's the most important person on the plane? I mean most of us would probably say the pilot, right? The pilot is the most important person on the plane. But when you're a passenger on that plane, how much do you interact with the pilot? Frequently, you never see the pilot. Maybe you hear the pilot's voice. But that's the most important person on the plane. But you can have a great flying experience with very little interaction with the pilot. So part of what's developing is this concept of team-based care. There's lifestyle medicine, there's whole person care, there's a variety of sort of terms and advanced primary care, a lot of terms that we put into this. But if you think of your healthcare journey being getting on that plane, and think of some of the other things that are important, maybe it's a dietitian, maybe it's a health coach. Maybe it's a group of people like the group I talked about in my story, where these people have been part of a group for 10 years talking about healthcare and how to improve healthcare. These are the kinds of things that we can be bringing in innovative ways that help us have that better experience within healthcare, not that sort of transactional, you know, pills or procedures kind of approach. So think big, think innovative, and push into that primary care experience no matter what, you know, no matter what it is, as long as it's sort of value-based or capitated. That's a great point. If you think about it, if an employer can't change their overall plan design, they can help support by putting a dietitian on site who communicates with primary care providers, or other resources to help support them in that team-based care. Because certainly the primary care provider doesn't make enough money to have that type of resource around them in a traditional system. And I would just say consider these alternative methods that really take the primary care transaction out of a fee-for-service. That really would allow for the time and the relationship to flourish within a primary care physician. And then I would say from a plan design perspective, if you do have the ability to change how primary care is covered in your plan, I would say remove all financial barriers to accessing primary care. I think those two things, along with some of the things that I said earlier about engaging with physicians within your community, are all like first low-risk things that you can do to advance the use of primary care within your employee populations. Excellent. Dr. Jabbarpour. Yeah, I will say that you either pay for it now or you pay much more for it later. And so if, I know it might be more expensive for employers to, you know, double…look for solutions that are doubling the amount that they pay primary care. But what that's going to result in is as we've shown today and as the literature has shown is better prevention down the line so that you're saving money down the line. So you invest $2 more today, you're gonna save $2,000 more down the line for your employees. And I always say invest more today so that you can not have to pay for it later. I love it. And we all know that at least 35% of the US healthcare spend is completely wasted. So as employers are listening to this and thinking, I'm already paying too much, I can't afford to invest in anything else. Take the time, use your data, find where some of that waste is. As you carve that out, start reinvesting it in the right stuff to create long-term success. Well, I knew you guys would do an outstanding job with this, and you certainly did, and I could have this conversation forever, because you actually give me so much hope. So thank you. You pointed out so many things that are so obtainable. And to our audience, I hope you enjoyed today's conversation, and it's given you valuable insight to reflect on your current strategies and perhaps even spark some ideas about where their next best steps can be. Thanks for listening to this episode of The Pulse. If you enjoyed it as much as we did, please be sure to subscribe so we can stay up to date on our most recent conversations. 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, a member of Alera Group. Alera is on a mission to help organizations identify medical spending waste through data-driven strategies, while helping to improve the health of their employees. If you want to make healthcare 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. Let's pause to thank our sponsor. This podcast is brought to you by Alera Group. Vital Incite is part of Alera Group, an independent financial services firm offering comprehensive property and casualty insurance, employee benefits, wealth services, and retirement plan solutions to clients nationwide. Working collaboratively across specialties and across the country, Alera Group's team of more than 4600 colleagues offer unique solutions. Personalized services, and proactive insights to help ensure each client's business and personal success. For more information, visit Alera Group.com and follow us on LinkedIn.