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In this healthcare podcast, I\u2019m talking with Brian Klepper. If you haven\u2019t heard of him, Brian\u2019s a longtime healthcare analyst and former CEO of the National Business Coalition on Health.

This interview takes off like a shot, as most of my conversations with Brian Klepper do. We\u2019re talking about primary care and its various iterations. We start out with Exhibit A\u2014the HMO version of primary care from the \u201990s. This is a great comparator to really get a handle on what\u2019s going on today. During the heyday of HMOs (back in the \u201990s), primary care was basically a glorified gatekeeper kind of doing two things. On one hand, they were restricting access. It wasn\u2019t an accident that it was really hard to get an appointment with a PCP.\xa0

On the other hand, it also wasn\u2019t an accident that, once you got there, the PCP only had 7 minutes to spend with you, which basically meant that you left with an appointment to see a specialist at, of course, the health system that probably had just bought that PCP practice. Everybody\u2019s happy then, right?

Specialist volume goes up, they make a ton of money for the health system, plans make a ton of money because they make a percentage of total healthcare spend \u2026 Oh right, everybody\u2019s happy except the patient who can\u2019t get care and the PCP who can\u2019t do their job.

By the way, for more information on why the \u201990s version of the HMO industry crashed and burned, listen to my conversation with Alex Jung on this exact topic. A big part of the \u201cwhy\u201d really actually took me by surprise.\xa0

But back to primary care \u2026 Today, in broad strokes, we have three kinds of PCPs. And when I say three kinds of PCPs, we\u2019re not really counting urgent cares or what amounts to urgent cares in that mix\u2014meaning, not counting a lot of the retail clinics because they don\u2019t really manage patient care like you\u2019d hope a PCP would manage care. Last I checked, none of them were managing much more than an episodic visit. You can\u2019t manage a chronic condition in 15 minutes.

So, like I said, there\u2019s three kinds of PCPs that are around today; and let\u2019s call the first kind the OPCP, the original PCP. This version of the PCP office is primarily fee for service (FFS). Maybe they have a couple of capitated contracts. But the distinguishing factor isn\u2019t really what their payer mix is. It\u2019s that they\u2019re not taking on much risk or any risk of real consequence.

Second, we have direct primary care doctors. This group tends to cut out insurers and work directly with either employers or patients themselves. They take a monthly fee, and, in general, a patient can see them however much they need to. Again, no risk or little risk is assumed here beyond the primary care services themselves that are rendered.

Third, we have what Brian calls industrialized primary care\u2014or some people call it advanced primary care, or APC\u2014but I\u2019d probably call it something different. I\u2019d call it \u201ctaking risk for the full continuum of care\u201d primary care. Maybe I wouldn\u2019t even call it primary care at all because this third category really is starting to color outside of the lines of primary care.

This third iteration requires many things to accomplish. It requires an unimpeachable relationship with the patient; you cannot be successful with this otherwise. It requires great virtual/digital capabilities. It also requires data\u2014data to help ensure that care gaps are filled but also to make sure that patients are referred to high-quality, high-value specialists downstream who will actually create outcomes. It also includes optimizing specialty pharmaceutical usage, for example. Brian gets into this and how a state employee health plan is on track to save $1.3 billion in this fashion.

Brian believes that this third iteration of primary care\u2014this APC industrialized primary care\u2014is the third leg of a three-legged stool that is needed to transform healthcare. If you must know, the second leg is identification and the use of high-performing specialty services; and the third is value-based reimbursement environment.

Most of the second half of this conversation with Brian is about why there\u2019s just a flurry of investment into various forms of these advanced or just maybe even regular primary care models and how they might evolve moving forward. I ask Brian about Carbon Health and their recent claim that they can do primary care with about 25% to 30% EBITA, even at Medicare FFS rates. So, there\u2019s that.

One last thing: Next week, we\u2019ll be posting an \u201cAsk an Expert\u201d with Brian Klepper, where he gives the backstory about how the RUC\u2014that AMA committee\u2014basically killed primary care. So, come back for that show after you\u2019re done with this one. It\u2019s a plot full of intrigue, that\u2019s for sure.

Brian Klepper, PhD, is a healthcare analyst, commentator, and entrepreneur. He is a Principal of Healthcare Performance Inc, a healthcare strategy and business development practice, and CEO/Principal of Worksite Health Advisors, a benefits consultancy focused on linking high-performance/high-impact healthcare organizations with purchasers. He founded and moderates a popular professional healthcare Listserv, Healthcare Hackers, which is a discussion forum on healthcare high performance and value and which has about 850 participating benefits managers, benefits advisors, and innovative vendors.

An active author and speaker, Dr. Klepper has provided healthcare commentary to CBS Evening News, the Wall Street Journal, the New York Times, and the Washington Post. He has published widely in healthcare trade and academic publications and in newspapers nationally.

Brian is a regular contributor to Employee Benefit News, the Health Affairs Blog, The Health Care Blog, The Doctor Weighs In, Kevin MD, and other expert healthcare blogs. He is a reviewer for Health Affairs and The Journal of Ambulatory Care Management.

He is an advisor to the Lundberg Institute and to several for-profit healthcare organizations.

In his spare time, Brian is an offshore sailor.

05:10 Is the HMO model of primary care a good model?
07:48 \u201cIndustrialized medicine is exciting.\u201d
08:59 What does primary care have the opportunity to do?
09:21 \u201cThe problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.\u201d
10:15 Where does direct primary care and advanced primary care fit into this model?
13:35 \u201cAt the end of the day, what primary care really needs to be about is \u2026 the management of life issues as well.\u201d
14:05 EP295 with Rebecca Etz, PhD.
14:19 \u201cBetter relationships quantifiably translate to better care.\u201d
21:48 \u201cAlmost nobody in healthcare wants any of this to happen.\u201d
23:58 Why the huge amounts of money being invested into primary care is actually a big problem.
28:11 \u201cWe should be able to get wildly better health outcomes for about 40% to 45% of the money that we\u2019re currently spending.\u201d

@bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

Is the HMO model of primary care a good model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

\u201cIndustrialized medicine is exciting.\u201d @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

What does primary care have the opportunity to do? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

\u201cThe problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.\u201d @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

Where does direct primary care and advanced primary care fit into this model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

\u201cAt the end of the day, what primary care really needs to be about is \u2026 the management of life issues as well.\u201d @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

\u201cBetter relationships quantifiably translate to better care.\u201d @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

\u201cAlmost nobody in healthcare wants any of this to happen.\u201d @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

Why the huge amounts of money being invested into primary care is actually a big problem. @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

\u201cWe should be able to get wildly better health outcomes for about 40% to 45% of the money that we\u2019re currently spending.\u201d @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

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