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

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. 

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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.