Rebooting Primary Care From the Bottom Up

Zubin DamaniaFor the better part of a decade, I practiced inpatient hospital medicine at a large academic center (the name isn’t important, but it rhymes with Afghanistan…ford).

I used to play a game with the med students and housestaff: let’s estimate how many of our inpatients actually didn’t need hospitalization, had they simply received effective outpatient preventative care. Over the years, our totals were almost never less than 50%.

For my fellow math-challenged Americans: that’s ONE HALF! Clearly, if there were actually were any incentives to prevent disease, they sure as heck weren’t working.

In a country whose care pyramid is upside down—more specialists than primary care docs, really?—we’re squandering our physical, emotional, and economic health while spending more per capita than anyone else. Four percent of our healthcare dollars go towards primary care, with much of the remaining 95% paying for the failure of primary care. (The missing 1%? Doritos.)

Worse still, the oppressive weight of our non-system’s dysfunction falls disproportionately on the shoulders of our primary care providers—the very instruments of our potential salvation. To them, there’s little solace (and plenty of administrative intrusion) in the top-down reform efforts of accountable care organizations and “certified” patient-centered medical homes.

But what about a bottom-up, more organic effort to reboot healthcare? A focus on restoring the primacy of human relationships to medicine, empowering patients and providers alike to become potent, positive levers on a 2.8 trillion dollar economy? What if we could spend twice as much on effective, preventative primary care and still pull off a net savings in overall costs, improvements in quality, and increased patient satisfaction?

What if George Lucas had just quit after the original Star Wars series? Wouldn’t the world have been better without Jar Jar Binks?

While the latter question is truly speculative, the former ones aren’t. We’re trying to answer them in Las Vegas (hey now, I’m being serious) at Turntable Health, where we’ve partnered with Dr. Rushika Fernandopulle and Cambridge, MA based Iora Health.

We aim to get primary care right by doing the following:

1. Fix incentives.

Fee-for-service reimbursement structures encourage providers to do things TO people, instead of purely FOR them. My father, a dedicated primary care doc, used to encourage me to specialize because “there’s $500 in everyone’s colon. Go in with a scope and retrieve it!” This ridiculous incentive system has no place in primary care where it rewards episodic rushed sick-care visits (with often unneeded referrals and testing).

By banishing fee-for-service insurance in favor of a flat-fee membership model, we incentivize strong relationship building and longitudinal population management. Ditching insurance billing means up to 20% less overhead and 2434.76% less aggravation. We eliminate copays and barriers to care, encourage use of convenient methods of patient engagement (phone, video, email, group visits, yoga classes), and free providers to focus on outcomes, cost, and patient satisfaction for their entire panel.

Unlike “concierge” models reserved for the wealthy, our services are offered with wrap-around insurance plans by the not-for-profit Nevada Health CO-OP and are eligible for federal subsidies on the state health exchange. That’s a model that puts the “care” in Obamacare, folks.

2. Shift the culture.

There’s no “I” in “team” and but there’s a “we” in “well.” Apart from making the lamest bumper sticker ever, this sentiment is valid and should drive a new culture of care away from cowboy autocracy and towards non-hierarchical, collaborative teams where everyone practices at the top of their training. We have doctors working with nurses and licensed clinical social workers, but the unique twist comes with our health coaches.

Drawn from the very communities they serve, they’re hired for empathy and emotional intelligence and trained for the skills needed to motivate and support patients in setting and attaining goals. Each morning our full care team “huddles” to discuss all the patients who are to be seen that day, and all the patients who AREN’T but who merit outreach to keep them out of trouble.

There’s teaching, learning, and feedback. It’s goose-bump inducing stuff, folks, and should inspire our young physicians-in-training.

3. Make tech the glue.

Most electronic health records are glorified insurance billing platforms with some patient care stuff thrown on top. So our partners Iora Health had to build one from scratch. Issue-based, with seamless assignment of tasks to a members of the collaborative team, it facilitates effective preventative population management while stripping away boilerplate nonsense designed to please no one but a bean counter at an insurance company.

Patients can read (and soon write in) their record because, well, it’s THEIRS, isn’t it? Tech should create connections, not barriers.

The results of all this? Significant improvements in hypertension, diabetes, and depression control. Evangelical patients whose satisfaction scores skirt the 90% range. Providers who love coming to work each day.

And an overall reduction in costs DESPITE the higher upfront spend on primary care. It’s the Wikipedia definition of “no brainer.”

Which is why academic medical centers should be exposing their trainees to what we and others, like ChenMed and Qliance, are doing to innovate in primary care. They should implement similar clinical models for their own institutions, models that encourage collaboration and break down hierarchical, autocratic structures.

Because what’s better for patients is also better for students, who know full well that they are entering a horribly dysfunctional system. We’ve seen how inspired they become when they see primary care at its best, when doctors are freed to simply do the right thing for patients. They recognize that this is what the future of healthcare needs to look like.

And it could look like this, if academic medical centers step up and become part of the solution.

ZDogg MD aka Zubin Damania, MD (@ZDoggMD) is CEO and founder of Turntable Health. An earlier version of this post appeared in the March 2014 edition of the AAMC Reporter.

53 replies »

  1. @Ballard
    Perhaps this could be studied. I.e. is drug advertising appropriate?
    Diabetes experts can tell us what percentage of type II diabetics should be on Metformin. Are ads for Metformin excessive compared to the ads for other oral drugs for diabetes II ? If they are way out of line, then we might know that Pharma is tryikng to screw with our heads. But they may simply want to advertise drugs which yield great profits–can’t blame a businesss for that, can we? So, maybe this is not such a good way to study it? Forget this post if you want. ;=).

  2. @Ballard
    Were’nt you surprised at how the drug companies put all the contraindications and side effects out there, blatantly, in their ads? It borders on ad nauseum It’s quite counterintuitive but it shows extreme acuity to do this as the non-obvious reason is to build up trust in the public. It does with me. And, all this stuff was done with focus groups first, I bet.

    I’m not so sure that any harm is done by advertising drugs. We naturally do not want to whet inappropriate demand and hence raise prices, but are we sure this is true? Maybe it stimulates appropriate demand via docs who are not able to keep up in the literature? I just don’t know.

    I guess the proof is in the continued use of ads by Pharma. It must stimulate demand….but what kind? Good or senseless?

  3. “Rebooting primary care from the bottom up” is a great idea, but one of the biggest barriers facing medical care in general (including primary care by default) is the impact of advertising. Some of us are old enough to remember when the idea of advertising prescription medicines was unheard-of. Whenever I hear one of those “be sure to tell your doctor” advisories it makes me wince. We need to tell the doctor about our signs and symptoms, family history or all kinds of personal stuff — but if we have all our medical care ducks in a row we don’t need to tell doctors anything about what drugs (and supplements) we are taking or anything else (past surgeries, allergies, etc.) that should already be part of their records. In other words, rebooting primary care means having a PCP who then becomes the interlocutor for all the rest of our increasingly complicated medical life.

    Maybe I watched old TV shows too much, so somebody correct me if my idea of a PCP is off base.

    One other part of the medical landscape that bothers me (aside from ads for designer drugs) is the endless PSAs to get tested for everything under the sun — cancer, heart disease, hormone deficiencies — the list is not long but the messages are unrelenting. Isn’t that the purpose of annual physicals and followups? One or two “well-care” visits per year should cover all those needs, and the ads and PSAs are basically trolling for business. Seems to me an avalanche of expensive advertising and marketing is contributing more to the swollen costs of health care than any other variable.

    Just a couple of afterthoughts to this discussion. I don’t expect either of these ideas to have any traction (eliminating ads for drugs or insuring that specialists coordinate care via a designated PCP for every patient) but I wanted to toss them out in case anyone else has the same thoughts.

  4. No apologies needed, it’s a great discussion! Agree about fixing the financing, it’s crucial to everything. Another interesting angle is philanthropy: I can think of fewer more efficient uses of foundation or philanthropic money than to purchase memberships for disadvantaged patients with chronic diseases. Benefits go to the patient and to the rest of the system, which saves untold dollars in preventable ER and hospital visits.

  5. Leslie, excellent points and question. Re: Kaiser, yes they have certainly explored this territory. A full accounting of the challenges Kaiser faces is beyond the scope of this commentary, but a short answer for us is: focus the resources on primary care first (ensuring longer visits and appropriate care resources, leveraging non-clinicians maximally as well as asynchronous communication), ensure you have a scalable collaborative culture from the get-go, focus on quality and not necessarily on being the cheapest up-front option, and hire the right folks. Challenging, yes, but doable if you’re starting from the ground up and remain relatively nimble.

  6. Not sure I get your point. I see the sarcasm, but what’s the point?

    are you asserting that the rest of the team wants to be the MD?

    I’d rather not have the debt, or the responsibility and pull in the hefty salary of the RN!

  7. Thanks for this.
    If as much energy were spent seeking competitively-priced health care as competitively-priced insurance the price of both would be better controlled.

  8. Your one hundred ten thousand deductible typo is not so far off these days….;=)

    The actuarial value of a plan is the percentage of ‘covered services’ that the plan will pay, on average, for a group of patients. It can be thought of as the generosity of the plan. It’s a statistical term and it doesn’t mean that an individual patient will have to come up with co-payments and co-insurance and deductibles exactly equal to his share in the AV calculation. It could be a little more or less. You can think of the word “covered” as meaning the normal drugs and intervenrtions and surgery that we typically do for such a disease as the patient’s. So the platinum plans are 90%, gold 80%, silver 70%, bronze 60%….and now the Administration is talking about copper plans with 50% AVs.

    With current unreal prices, you can see that as the AV gets lower, the OOP expenses could be unaffordable by most patients…especially if the hospital bill is several tens of thousands of dollars. In other words, the lower the AV, the less the insurance value becomes–the protection against risk–until a point is reached where a person with such a plan really doesn’t have any insurance at all. Certainly, the lower the AV, the less authority and justification the plan sponsors or the government have to announce what should be in such a plan (as regards benefits). This is because the patient gains more and more “ownership” of such a plan if he is paying 40% or 50% of the costs. A copper plan means that you are sharing equally the costs and benefits of your plan with the government. You should be seated at the conference table in the Board room with the CMS or the BCBS folks if you have a copper plan.

    It’s a deliciouls paradox that in these low AV plans, which of necessity will be the most popular in the exchanges, the OOP expenses will probably be equal to or more than the OOP expenses in a CAT plan with a high deductible like an HSA account plan. Yet OOP in the former is OK but not in the latter. This is because the government hates the concepts of HSAs and high deductible plans because of some ideology…the logic of which is beyond everyone who exdamines it. The folks who like this approach believe that it causes some beneficial shopping to occur while someone is paying down the deductible. Prices are becoming intolerable and must be fought by either shopping or monopsony and the gov won’t do monopsony.

    This beneficial shopping behavior does not occur whilst someone is paying co-payments and deductibles in an ACA metal plan because these are demanded after one is in a course of treatment, not before the treatment begins. A patient thus feels that he has to pay the deductible or co because he has already begun his chemo or whatever and he doesn’t want to interrupt the momentum of his treatment by going shopping for cheaper services. I guess in some CAT plans you can go wherever you want while you are paying down the deductible.

    Anyway the two different varieties of OOP payments bring up this wonderful irony.

  9. Sounds like a good model. Now, how is it different from a smaller version of Kaiser? (You don’t run your own hospitals, obviously.)

    I ask because KP has leveraged tech, capitated payments, team, etc. And although it’s a good system overall, most primary care visits are short, PCPs are worked pretty hard, and patients have mixed feelings. (“You’re nothing but a number there” is what I heard from one.)

    Regarding reimbursement, agree w Rob that there’s something to be said for having to justify one’s service just to the patient, and not to a 3rd party payor.

    But what if that didn’t mean direct-pay? States have turned to “Cash and counsel” for some Medicaid non-medical services. It could be an option for patients to control their primary care cash, and they could decide to sign up for Turntable, or Doc Rob, or DocTalker, or whomever has the arrangement that makes them most comfortable.

    I would not make this the default because for many people it’s a burden to decide on the spending, but would be interesting if it were an option people could exercise.

  10. Well, I don’t see a reply button for you Ryan, So I will reply in the thread here.

    1) It is quite plausible to imagine a unified state/payor system. It doesn’t look pretty to me.

    2) I am indicting the portion of the system that has increased rather than decreased complexity, further alienated the patient and the provider from each other. I am not promoting throwing out the baby with the bathwater. If patients were truly allowed to consider various [real] insurance options, and providers/patients were allowed to negotiate services free of government intrusion, that also might improve the system without imposing a centralized government solution.

    3) I am not promoting MORE charity care. The “charity” care you mention is forced legislatively upon emergency rooms. Apples vs lemons. I thoroughly agree with your last paragraph. I just don’t draw the same conclusions for solutions to this problem that you do.

  11. Finally, I apologize to ZDogg for turning the conversation towards financing rather than care delivery systems, but I believe that the two are fundamentally linked: the current financing system makes the unification of patient and provider incentives — in the way that Turntable Health IS doing — very difficult indeed. Hats off to them.

  12. It’s too bad there isn’t something you could have paid into with reasonable premiums over the course of your whole life that would have provided first-dollar coverage now, instead of your being faced with an insurance policy with an $11K buy-in…

    Snark aside, I do want to reiterate – especially since you have said that you want to be involved in CHANGE – that you (and you are certainly not alone) are using complaints/problems DEFINITIONAL of the current system to indict a future system that would not likely share those same problems: non-sequitur.

  13. Isn’t it quite plausible to imagine a unified state/payor licensure/credentialing system if the state and the payor are one in the same?

    It seems that you are using an indictment of the current, fragmented, system, to oppose a future consolidated/rationalized system.

    See: “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers”


    As for why not simply use more charity care: we already have charity care and it’s a defining feature of the current system; indigent care in any setting (though obviously ED/inpatient is the real $ killer) is “charity”.

    Ultimately you, me, and everyone else paying in to the system (health insurance premiums or taxes) is funding that charity, though with a healthy slice of administrative overhead and corporate profit at every stage that could be eliminated under a simplified funding scheme.

  14. it’s easy to huddle on the patients that are coming in today, or that were in the office recently, but much more difficult to optimize resources around an entire patient panel if you don’t have good access to data on the deviations between what you expected patients to be doing outside the clinic and what is actually happening (e.g. ER / hospitalizations)

  15. Right now I am working from within as a patient to try to improve the system. I have a much stronger voice as a patient and physician than as an outsider avoiding the system.

    With a $110000 deductible the most favorable insurance product I can obtain (thank you Mr O) although I can access care outside the VA system, it makes economic sense for me to continue there.

    That good enough for you?

  16. Its the regulatory environment the insurers live in, not the number that is the problem. Why do I have to be credentialed BY AN INSURANCE COMPANY if I am credentialed by the State? I am waiting 4 mo for Medicare to allow me to bill as a par provider at my new location after 35 years of practice without a blemish. That is crazy. And single payor will be worse. Why subsidies for the poor (more taxes) and not local sliding scale/charity handled by the community?

  17. @Epador
    The hundreds of insurers are killing us. Our minds are distracted by ICD 10s and EHR compliance. The hospitals can’t focus on patients because they are focusing on foundations and fund raisers and new programs to gain market share. The health care providers are metaphorically climbing Everest and the line of a 1000 porters–aka stakeholders–behind them have to eat. The business of medicine and the regulations of medicine are overwhelming the science and art of medicine. Where are we now? , if not downhill? Besides roughly half of the health care dollar is ambulatory and I let this loose into the free market. … with subsidies for the poor.

  18. I am old enough to have seen, worked and trained in City and County healthcare facilities. I have worked at the VA and I am a VA patient. I have absolutely no idea why anyone would think those systems are the way to go, unless you want to go downhill. Fast. Or they just don’t know their medical history.

  19. @Rob
    I’ve always liked the concept of county–hospital-district single payer without any third party–or its apparatus of billing or claims. Non-ambulatory care would seem free.This would apply to hospital care only and people would have to manage ambulatory care themselves using any payment technique or insurance they wanted. You might recall that Canada tried this early on. I.e. it covered only hospital care initially.
    Triage at the front door would consist of asking three questions: could this patient’s illness kill him? or disable him? or bankrupt him? If the answer to any of these is yes, the patient would be admitted to the hospital. There would be no billling or charges. No means testing. Only medical records would be kept.

    Providers, administration, and executives in the hospital would be on salary.

    As a non-profit hospital, it would try to join with other voluntary hospitals to form purchasing cooperatives and gain monopsony power. It’s money would come from possible Medicaid and Medicare waivers and county or health-care-district tax funds. I realize this is fanciful, but to exclude all billing activities seems a bright goal and might save enough to do the job.

    Triage would be key. We triage now and we are pretty good at it. There would be many exceptions: e.g. we would admit a new lupus patient or a patient with fresh rheumatoid arthritis. We probably would not admit someone with hidradenitis suppurativa. Hence the hospital would have a slight admixture of outpatient activity going on.

    Another hope would be that most outpatient services could be handled in a much more competitive environment with HSAs and high deductible CAT plans, but governments would not enter into these arrangements.

    Poor folks would still receive subsidies from the county or district and they would need means-testing as well as medical-need testing. A suitable size for these districts might be the size of the House of Representative district.

    Just freeing ourselves from innumerable stakeholders might save enough to accomplish this dream.

  20. Rob –

    Dr. Zamania said “We receive a capitated rate from the CO-OP.”

    …Which is a third-party payor.

    Pure self-pay primary care models are -exceedingly- rare in modern health care economies.

    If you want to get there, godspeed, because I know of no other developed country that has adopted one.

    If we accept that there will always be someone/thing in between your patient and your reimbursement, the goals should be to a)pay as little as possible in overhead/admin (admin costs of HC are a staggeringly large proportion of our HC $ spent) and b) align incentives to create best outcomes at lowest cost.

    As for the issue of implementation, yes, Healthcare.gov sucked, but ultimately this will/would have little to do with what the government looks like as a payor. If you want to know what that looks like, check out the VA or Medicare.

    So forget diseconomies of scale – I’m not suggesting that we nationalize providers or facilities – but it seems like medicare is working -pretty- well, overt politicization aside, and layering a national insurer/payer over a network of providers that look like Turntable Health seems to pretty clearly meet both criteria I mentioned above.

  21. Word, Rob. I do take money from Nevada Health CO-OP because it’s a very akin to our membership fee, they’ve been great partners (and are not-for-profit), and it allows us to extend our model to folks who would never be able to afford the monthly fees in the absence of the federal subsidies they are receiving for their CO-OP insurance. But I hear you overall.

  22. If Zubin is like me, it’s not a question of who pays for care; it’s about changing the model for primary care. I personally don’t want to ever take money from 3rd party payors, as it lets them demand proof that they are getting “their money’s worth,” which is what has created the coding and documenting chaos we now have. If the patient is the consumer of primary care services (which they are not in ANY third-party system), then they are the judge of the idea of “money’s worth.” The joy of living in this kind of practice is that there are no third-party eyes snooping at our care to determine if we are doing good enough; we work for our patients. Obviously, insurance for catastrophic care is still important (I don’t expect to ever see “direct care hospitals”), so an insurance system will need to exist, but the goal of the primary care system will be to prevent unnecessary use of that insurance. That is what patients want and it is what insurers want.

    Am I right, Dr. Z?

  23. A single national payer model might not work very well, but how about a state or county-based model? This is how other countries (Germany; Canada) have opted to attack single payer to avoid diseconomies of scale.

  24. We like to think of it like this: our Turntable hardware and network runs the Iora operating system (iOS). So Iora hires the docs/coaches/nurses/social worker and runs the clinical operations, and Turntable builds the physical clinics, runs the marketing and patient payment portals, negotiates the contracts with health plans, employers, and individual patients. In addition, Turntable may create the associated speciality networks, hire hospitalists, etc.

    To belabor the star wars thing, Turntable is the light saber and Iora is The Force. OK, that was stupid.

  25. Zubin, other that your poor evaluation of Star Wars characters, I think what you have going is fascinating.

    What I would find really interesting is what there is more to Turntable than what Rushika & co have done elsewhere. In other words is this an Iora Health franchise model, or is it Intel inside, or Apple/Foxconn, or a Star Wars Disney version, or some other metaphor,

    I’d love to hear more details on what Iora brought and what you added. (Either in the comments or in a separate piece about the nuts & bolts of your setup)

  26. No but the Dutch, Israelis, and Taiwanese all have much more sensible healthcare insurance models and in the process have much lower costs on that end.

    There will just never be the political will here due to the heterogeneous population in the US nor the fat (eg private sector profits) that would have to be cut to enact such a similar system.

  27. Zappos sells shoes. You have merchandising leverage to help your margins in a business like that. You cannot buy any of the inputs into primary care more cheaply if you have 100 primary practices. It’s not yet clear if ANY of these new primary care models, direct-pay, direct to employer, you name it, actually do scale.

    I keep hearing the “single payer” canard everywhere, as if the recent health reform debacle doesn’t comprehensively indict our federal government’s ability to implement ANYTHING. Who’s the single payer- the government of Sweden? It’s OUR federal government that has to implement it and our Congress that has to “architect” it. Even if the Repubs were’t trying to starve health reform in its crib, the Dems would still have screwed it up.
    Our health system is $3 trillion dollars.

    Does anyone honestly think our federal government can “run” a $3 trillion economic activity if it cannot even purchase its share of the present system sensibly. Dream on, single payer-ites. It isn’t happening.

  28. All of the above. Although most of my thievery is directed at Rushika Fernandopulle and Iora Health, I make sure to save some for Dr. Rob as I’ve been following your exploits for years, brutha.

  29. Hi Eric.

    Can you elaborate on your comment about using technology to amplify the cultural shift to team-based approaches?

  30. Hi Brad,

    CO-OP provides full “wraparound” insurance, with us as the primary care for those particular plans. So patients can choose the plans on or off exchange, and then use us for all primary care with the wraparound covering everything else. We receive a capitated rate from the CO-OP. Hope this answers your question!

  31. ZUbin
    The Nevada Health CO-OP eligible for federal subsidies on the state health exchange you mention–is this just wraparound? I am assuming the subsidies buy a plan with full EHBs, yes?

    Your plan fills in the edges or you provide similar services, but in a difft fashion?


  32. Obviously different in many ways, but the emphasis on team culture, customer service and building an engaging tech solution sounds pretty familiar

    Your other points are fair ones

  33. I don’t quite see the Zappos connection (and yes, I do -know- the connection), and I was not diminishing Turntable Health. In fact, I think they’re doing everthing right!

    My point was broader: I think that this is a great model (won’t rehash the original post). But much of the model’s greatness is predicated on a pool of dollars being distributed with a rigorous and practical analysis of a) what drives the best outcomes at b) the lowest total cost.

    The largest possible pool of dollars is national health insurance, with provider groups such as TTH each creating their own operating plan within it.

  34. Let’s say I’m a VC/philanthropist and have, oh, a few billion dollars to throw at our health care system and I like your Idea.

    I listen to your pitch and say: sounds good. Sounds great, actually.

    But how does it scale?

    Serious question, though I think the logical end is single payer. Keeping all of the dollars in one ecosystem allows for the alignment of incentives, high-ROI investments — and admin savings — you outlined.

  35. Primary Care practices now have to compete with Walmart and CVS docs in the boxes. Admitedly, many minor illnesses and injuries can be managed by these types of providers, for less cost and less wait.
    What primary care has to do is now assume care for the costly, complicated patients that cannot be seen and treated immediately. It behooves practices to look for models that will allow continuity and value to the patient, independent of outrageous requirements from government and insurance agencies.
    If nothing else comes of the massive shakeup in the health care system, may doctors be able to break away into models that can benefit patients, yet avoid some of the non-clinical activities that take up so much of physicians’ time.

  36. agreed entirely. We work with many High Performance Primary Care groups that have eliminated FFS in favor of a flat fee primary care or shared savings model. Almost half of them are building their own EHRs and supplementing it with analytic tools like ours (Amplify Health) because current tech is optimized for FFS billing.

    Our data suggests that shifting the culture to a team based approach is effective but only if it is amplified (ahem) through technology. Culture shifting alone doesn’t appear to be nearly as successful in focusing resources on the neediest patients.

    Very excited to watch the progress of all of these new primary care groups.

  37. Huddling is very Important as you aver. The wisdom of crowds will get you the acute intermittent porphyria diagnosis instead of appendicitis. It’ll find the bird allergy in a hypersensitivity pneumonitis. We need lots of brains to get us the correct diagnosis and intervention. And don’t forget to use the patients brain. This is called the “history”.

  38. Another exposition upon the Atul Gawande lame analogy. Consider for a moment, the NASCAR “team.” This consists of the owner, sponsor, team manager, crew chief, car chief, engine specialist, tire specialist, engineer, general mechanic, pit crew, trucker, etc.. Oh yes, and the driver.
    Out of all those individuals, the only one who gets the idol worship, fame, fortune and girls (or boys) is the driver, partially because the driver is also the one who has most at stake if they lose.
    No one really gives a crap about any of the other team members, who are essentially anonymous to the general public.
    And furthermore, if you asked any of the other team members if they would rather have their job or be the driver, I think you know what would they say most of the time.
    Same concept holds for fighter pilots on aircraft carriers, classical music soloists, etc.

  39. great post!

    But why provide quality, difference making changes in peoples lives that will only hurt the bottom line of the hospital systems that most primary care docs actually work for now.

    Instead: click a bunch meaningless widgets, get meaningless stamps of approval from meaningless paramedical agencies and call yourself a meaningless medical home for whatever that means.

    i applaud you practice and would love to set one up but the hospital has me captured for 1 year and 10 miles. Because you know if one internist left our hospital system with over 16,000 employees it would cause them significant financial hardship

  40. This may help:

    It’s hard to know how much of “charges” actually has to do with actual health care because there is a huge, huge portion used for non-medical expenses (administrative and legal costs, infrastructure, corporate profits, shareholder profits, executive compensation and other benefits, costly disposables, designer drugs — you get the picture). And don’t forget the numbers typically don’t include optical, dental or mental health expenses which most American’s don’t think of as “healthcare dollars.”

  41. I see that 4% number thrown around, but I cannot verify it anywhere. Can someone point me to the source?

  42. What a refreshing post!
    I like this part a lot…
    Four percent of our healthcare dollars go towards primary care, with much of the remaining 95% paying for the failure of primary care. (The missing 1%? Doritos.)