Insurance Accepting

Below is a version of an article that was originally published in Fierce Healthcare. In this article, Elation CEO and co-founder, Kyna Fong, discusses the emergence of primary care-led systems of care and their proven benefits to patients, payers and society.

There is an old saying that if you do not make time for your wellness, you will be forced to make time for your illness. This could be the epitaph on the tombstone of the American healthcare system. We’ve neglected the fundamental thing that would transform American healthcare into an affordable system for better health: primary care.

Every single formula for improving health includes keeping patients well, yet the American healthcare industry perversely profits most when we are sick. If we follow the money, we see that hospital systems have gorged themselves on the broken economics of U.S. healthcare. Meanwhile, primary care has been disempowered, held in the vise grip of an industry designed to make them fail on purpose. Despite various efforts to reform the system, healthcare spending continues unchecked, and population-level outcomes remain poor.  

There is good news though: Our healthcare system is on the precipice of a new era. The payment landscape, once heavily weighted toward sick care, is changing. The dollars are shifting toward a system focused on reducing costs and improving outcomes by keeping patients healthy. And primary care is uniquely positioned to lead this transformation. 

Addressing a broken legacy

While expensive hospitals and health systems have often generated huge profits, your pediatrician, internist, and family doctor have not. As a nation, the U.S. has historically spent 95% of its 4.5 trillion healthcare dollars outside of primary care. The irony is that the more you invest in your family doctor for wellness, the less likely you will be to invest in an expensive hospital visit for cancer, heart disease or a stroke.

Yet the very primary care infrastructure that could save American healthcare has shrunken in both size and scope. Primary care’s troubled legacy has left its clinicians stuck in a difficult dichotomy, forced to choose between employment (usually by a health system or hospital) or independent practice (working solo or in small, tightly knit groups). The former finds primary care stripped of autonomy and inherent value, working for a profit-driven system; the latter means living on a razor’s edge of narrow profit margins, robbed of precious time with patients. Neither is sustainable. 

The gigantism and excess of our costly and ineffective healthcare scheme are a cancer in American society, driven by a flawed payment model that rewards this exact dynamic and reinforced by an insurance-driven complexity moat of convoluted rules and hidden pricing structures designed to drive up profits. Past attempts at system-wide reformation have either reinforced the centrality of large health systems and insurance companies, or retrofitted business solutions from other (non-healthcare) industries, which only serve to further commoditize the patient. What all of these past approaches fail to leverage is primary care in the lead.

An economist’s POV on a new primary care dichotomy

New value-based payment arrangements driven by cost savings tied to better health outcomes may be an antidote to this malfunctioning system. In these re-engineered incentive arrangements, profit no longer follows spending run amok on hospitalizations and expensive interventions; it follows prevention of these things. When prevention is the path to success, there is only one way to get there: with primary care in the lead.

Fortunately, there is an innovative variant of primary care sprouting up de novo in the fertile soil of value-based payment models, supported by multidisciplinary teams, enabled by technology and building care processes around what patients really need. In these new delivery models, primary care is divorced from the perverse volume-focused incentives associated with specialty-dominant health systems and is instead resourced and empowered to do what’s best for patients, similar to small independent practices but at scale. Likewise, an explosion in primary care networks, supported by enablement organizations that assume population-level financial risk on behalf of private practices, has provided the tools, data, services and financial safety net that “independent” primary care practices need to transition into new and improved payment arrangements.

Suddenly, we have a new primary care dichotomy. The legacy separation of primary care into “employed” versus “independent” is transforming into “primary care-led” versus everything else.

Executing on the vision for a primary care-led future

The capacity to shift both healthcare services and costs from the most expensive and often futile interventions to the least expensive and most impactful ones lies only with primary care. By making primary care the fulcrum of the healthcare system, we can prevent disease, avert health catastrophes and avoid wasteful healthcare spending. With primary care in the lead, healthcare dollars previously spent on high-cost heroics will be reinvested into interventions that shrink the demand for those expensive services, saving lives, money and the economy.

As the payment mechanisms evolve and the industry is reshaped, primary care-led delivery models will be paid to be accountable for defined populations and liberated in these payment arrangements to deliver care in ways that make the most sense for patients and their communities. Byzantine business practices and transactional payment models led by insurance companies will be replaced by global risk arrangements designed to fully empower primary care. 

Moving into this new era, there will be a tectonic shift away from the legacy trend of consolidation, subspecialty bias, domination by hospitals and health systems and preservation of the status quo via the complexity moat. A new paradigm of primary care-driven systems of care, accountable for populations, will flourish instead. 

The time has come to recognize the power of primary care to lead transformation of the U.S. healthcare system. On track to steer the U.S. economy into an iceberg, American healthcare must chart a new course, and that new course needs a new leader. The emergence of primary care-led systems of care, with their proven benefits to patients, payers and society, are rapidly becoming the new discriminator between modern models that will rescue the U.S. healthcare system and the legacy models that would take it down. Payers, investors, providers and patients should all be placing their bets on primary care.