EP504: A Back-to-Basics Roadmap Through the Perverse Incentives to Advanced Primary Care, With Ryan Jacobs
Relentless Health Value
Scale, Market Power, and Perverse Incentives
Stacey and Ryan discuss how consolidation and scale drive behavior that can oppose primary care expansion.
Why Advanced Primary Care Doesn't Scale: Conflicting Incentives, Complacency, and a 3-Step Roadmap
Stacey Richter interviews Ryan Jacobs (SVP Strategy and Partnerships, Marathon Health) on why evidence-backed advanced primary care (APC)—focused on managing risk, improving outcomes, and lowering costs—still isn't widespread.
They argue APC struggles to scale due to two root barriers: conflicting fiduciary duties (health systems and payers driven by volume, "heads in beds," and market-power growth, while APC keeps patients out of hospitals) and a "black box of complacency," where innovators often lose to the status quo because dominant organizations can rationally avoid investing without gaining share.
Jacobs offers a three-step roadmap: perform a reality-based assessment by following the money and identifying who is financially harmed by prevention; anticipate stakeholders' math by framing value as CFOs, benefits leaders, and plan sponsors do; and proceed from strategic conclusions such as direct contracting to bypass misaligned intermediaries.
=== LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP504
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00:00 A refresher on advanced primary care (APC).
02:36 Why APC isn't everywhere.
04:39 The problem of complacency in the healthcare system.
05:27 Ryan Jacobs' roadmap.
08:59 The pitfalls of advanced primary care.
09:58 What primary fiduciary responsibility means.
10:51 Growth on the payer side.
11:51 SUMS5 with Jacob Asher, MD.
12:36 EP483 (Part 1 and Part 2) with Jonathan Baran.
12:48 EP465 with Chris Crawford.
13:27 The reality of the healthcare system in the United States.
14:11 The flywheel created by the tension within the healthcare system.
15:25 EP391 with Scott Conard, MD.
15:51 The tension between APC's goals and fiduciary responsibility.
17:52 The black box of complacency.
19:25 EP436 with Elizabeth Mitchell.
20:05 What's driven most of the change in the advanced primary care space.
20:54 EP398 with Jacob Asher, MD.
21:01 What would happen if there was a functioning market in healthcare.
21:41 EP286 with John Rodis, MD, MBA.
21:52 Why complacency may be a rational move in healthcare.
22:41 EP438 with John Lee, MD.
23:22 A roadmap to success in advanced primary care.
23:55 Step 1: Follow the money.
24:50 Step 2: Someone's gonna do math.
25:17 What strategic thinking looks like as an employer.
28:34 Step 3: Proceed based on strategic conclusions.
30:20 How self-insured employers have created their own market.
31:07 The strategic decision for physicians wanting to create change.
32:25 A reiteration of the episode's discussion.
33:49 Better payment structures.
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