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

Why Evidence-Backed Primary Care Still Can't Scale, and a 3-Step Roadmap to Get Around It. Episode 504.

Why isn't advanced primary care (APC) everywhere, if the evidence for it is this strong? Stacey Richter talks with Ryan Jacobs, SVP of Strategy and Partnerships at Marathon Health, about the two root causes blocking APC from scaling—conflicting fiduciary duties and what Jacobs calls "the black box of complacency"—and the three-step roadmap he uses to help plan sponsors and clinicians get around both.

WHAT YOU'LL LEARN

✅ Why conflicting fiduciary duties push hospital boards and payers to keep driving volume, even when advanced primary care would improve outcomes and lower costs

✅ How the "black box of complacency" lets consolidated health systems and lazy networks do nothing and still keep their volume, since innovators usually lose to the status quo, not to a better competitor

✅ Ryan Jacobs' three-step roadmap: perform a reality-based assessment, anticipate the stakeholders' math, and build strategic conclusions such as direct contracting

✅ Why frustrated self-insured employers are increasingly going direct to APC organizations themselves instead of waiting on payers or health systems to change

✅ Why ER spend now tops out at roughly 6% of total plan costs for self-insured employers, and how limited primary care access feeds that number

✅ Why direct contracting for APC works by connecting the plan sponsor directly to the clinicians providing care, cutting out the conflicted middle

WHY THIS MATTERS

Advanced primary care has a robust evidence base—it improves outcomes and lowers costs—yet it still isn't everywhere, because the incentives of the largest players in a nonfunctioning healthcare market run the other way: health systems and payers get bigger by driving volume, not by keeping people out of the hospital. As Ryan Jacobs puts it, plan sponsors and clinicians who don't follow the dollar and anticipate that reality will keep losing to complacency rather than to a better competitor.

MENTIONED IN THIS EPISODE

SUMS5 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps

EP483 (Part 1 and Part 2) with Jonathan Baran: Part 1 Apple Podcasts | Spotify | Other Apps; Part 2 Apple Podcasts | Spotify | Other Apps

EP465 with Chris Crawford: Apple Podcasts | Spotify | Other Apps

EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps

EP398 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps

EP286 with John Rodis, MD, MBA: Apple Podcasts | Spotify | Other Apps

EP438 with John Lee, MD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Show Notes

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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.

13:27 The reality of the healthcare system in the United States.

14:11 The flywheel created by the tension within the healthcare system.

15:51 The tension between APC's goals and fiduciary responsibility.

17:52 The black box of complacency.

20:05 What's driven most of the change in the advanced primary care space.

21:01 What would happen if there was a functioning market in healthcare.

21:52 Why complacency may be a rational move in healthcare.

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.