A Back-to-Basics Roadmap Through the Perverse Incentives to Advanced Primary Care, With Ryan Jacobs
Episode Description
Advanced primary care has a robust evidence base. It manages risk, improves outcomes, and lowers costs. So why isn't it everywhere? Because in a healthcare non-market where health systems drive revenue from heads in beds and profitable surgeries, the entire goal of advanced primary care — keeping patients out of hospitals — is a direct threat to some of the largest organizations in the sector. Fewer than 45% of frontline clinicians trust their organization's leadership to do what's right by patients. The perverse incentives are not incidental. They are structural.
In this episode, Stacey Richter speaks with Ryan Jacobs, SVP Strategy and Partnerships at Marathon Health, about the two root barriers blocking advanced primary care at scale and a three-step roadmap for founders, clinicians, and plan sponsors who are done waiting for the invisible hand to fix things.
WHAT YOU'LL LEARN
✅ Pit Trap 1 — Conflicting fiduciary duties: health systems and payers are both driven by volume and market-power growth, while advanced primary care's explicit goal is to reduce hospital utilization — and in a non-market where bigger players get bigger regardless of quality, spending capital to improve care that doesn't translate to more volume is a rationally poor investment decision
✅ Pit Trap 2 — The black box of complacency: in healthcare, innovators often don't lose to better competitors — they lose to the status quo, because dominant organizations with market share can rationally do nothing, collect the volume anyway, and avoid spending money on improvement that the market won't reward with additional share
✅ Step 1 of the roadmap — Perform a reality-based assessment: follow the dollar, identify who has a negative financial incentive when patients stay healthy, and abandon magical thinking — a great patient experience that doesn't drive a financial impact for whoever is actually deploying the funds will hit a wall
✅ Step 2 — Anticipate the stakeholder's math: whoever controls the fiduciary responsibility will do their own calculation, so show up with the same spreadsheet — framing value the way a CFO, benefits leader, or plan sponsor does, not the way a clinician does
✅ Step 3 — Proceed from your strategic conclusions, which for many plan sponsors means direct contracting: connecting the ultimate purchaser directly to the actual deliverers of care bypasses the conflicting fiduciary responsibilities sitting in the middle and creates a functioning demand curve where volume follows value
✅ Why self-insured employer ER spend is now running at about 6% of total plan costs — and how increased primary care access drives a downstream impact on how the rest of the system gets used, creating the financial return that makes the math work for plan sponsors
WHY THIS MATTERS
You can't change a system by fighting its existing reality. As Stacey frames it by way of Buckminster Fuller, you have to build a new model that makes the existing one obsolete. Self-insured employers who have gone directly to advanced primary care organizations have effectively done this — creating their own market outside the traditional channels because the traditional channels were not working. The roadmap Ryan Jacobs lays out is not idealistic. It is a clear-eyed account of how the money actually flows, who it flows to, and how to navigate around the organizations that have a rational incentive to see nothing change.
=== LINKS ===
🔗 Show Notes with all mentioned links:
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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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