Hello, all you Relentless Tribe members. Here's the backstory for this episode. Remember episode 519 with Lisa Rosenbaum, MD, where we played a high-stakes kind of game show called "Is the Current State of Primary Care an Absolute Inevitability, or Is It a Needless, Suboptimal Inefficiency?"
In that conversation, Dr. Rosenbaum, who was my contestant, made a compelling point. She said that if we want to fix primary care, we probably have to pay our primary care clinicians more. We need to invest in them and level up teams and infrastructure.
For a full transcript of this episode, click here.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
Now, if you have listened to Relentless Health Value for any length of time, you know you can count on me for a rant any given Tuesday about ceasing to pay way too much to corporatized consolidated, for example, health systems, especially the ones that already have quite robust endowments and huge real estate portfolios. Their crocodile tears do not move me. Same with other corporate intermediaries. Sharks with great PR departments.
But yeah, it's hard to argue that our frontline primary care clinicians are chronically underfunded and relatively underpaid.
So, when private equity enters the primary care chat with bags of capital, I could think, "Great! Primary care is finally gonna get the investment that it deserves."
But riddle me this: If private equity gets in the mix and there's now more money flowing, will primary care actually get better? Or will the doctors and other clinicians on the ground and the patients they care for become, I don't know, pawns in just one more healthcare inflationary business model?
Said another way, is the capital actually gonna build sustainable whole-person care, or is it just corporate arbitrage in a different Halloween costume?
So, when I heard health economist Dr. Yashaswini Singh had just completed a whole bunch of research into private equity investing in primary care, I was on it like white on rice.
I wanted to find out if this professional capital will actually or actually has been translating to better outcomes for patients or not.
And to find out, I put Dr. Singh through the exact same three-category game show categories that I went through with Dr. Lisa Rosenbaum but specifically relative to private equity, PE-backed primary care clinics.
So, with Dr. Rosenbaum, we talked about primary care kind of writ large and the inevitabilities and the kind of decimation of primary care that we see across the country. This show today is specifically … so, same three categories, which, let me remind you, are these three that we tackle: Cognitive atrophy amongst clinicians. That's what we talk about first, the de-skilling of primary care. Secondly, primary care becoming referral machines as a, is that inevitable? And then thirdly, we examine transactional fragmentation versus continuity of care.
So, for each of these categories we go through, is it inevitable that this is gonna happen; or is this something that potentially, if a practice is purchased by private equity, can be avoided?
Again, this is Relentless Health Value. My thanks go out to Aventria Health Group, who is our founding sponsor.
I also very much want to thank Payerset, our 2026 series underwriter. Do go over to their site. They have some very interesting resources dealing with healthcare transparency.
Additionally, my deepest thank yous go to Patient Rights Advocate, which is a nonprofit; and I thank them so much also for their generous donation this year, helping us keep the show on the air.
And with that, here is my conversation with Yashaswini Singh, PhD.
Also mentioned in this episode are Brown University School of Public Health; Center for Advancing Health Policy through Research (CAHPR); Lisa Rosenbaum, MD; Arielle Bose; Aventria Health Group; Payerset; Patient Rights Advocate; Guy Culpepper, MD; Andrea DeSantis, DO, FAAFP; Andrew Tsang; Suhas Gondi, MD, MBA; and Tom Nash.
For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.
You can learn more at sph.brown.edu and cahpr.sph.brown.edu. You can also follow Yashaswini on LinkedIn.
Yashaswini Singh, PhD, MPA, is the Thomas J. and Alice M. Tisch assistant professor of health services, policy, and practice at Brown University. Her areas of expertise include healthcare consolidation and corporatization, including by private equity firms, and the downstream effects on healthcare spending, access, quality, and the clinical workforce. Dr. Singh's research has been published in high-impact peer-reviewed journals, featured in national media outlets, and frequently cited in policy discourse. She has presented her research to the U.S. Congress, the Federal Trade Commission, National Conference of State Legislatures, and National Academy for State Health Policy and testified before state legislatures on strategies to address healthcare corporatization.
Dr. Singh has received honors and awards from the American Society of Health Economists, the International Health Economics Association, and AcademyHealth; a teaching award from Johns Hopkins University; and the Community-Academic Research Partnership Award and Richard B. Salomon Faculty Research Award from Brown University. In 2025, Dr. Singh was named an Aspen Ideas Health Fellow, an honor recognizing healthcare leaders with the ability to transform ideas into action.
Dr. Singh holds a PhD from Johns Hopkins University, a graduate degree in international finance and economic policy from Columbia University, and a bachelor's degree in mathematics and economics from Bryn Mawr College. In addition to her academic career, she has extensive private sector experience in antitrust and competition.
00:00 Introduction to this episode.
00:39 EP519 with Lisa Rosenbaum, MD.
03:21 Dr. Singh's research on private equity investing in primary care.
04:16 The three categories covered in today's episode.
05:36 The conversation with Dr. Singh.
06:51 Private equity study in Health Affairs.
06:58 Private equity study in JAMA.
07:02 Findings these private equity studies have found about primary care.
12:00 Does private equity make cognitive atrophy inevitable?
14:49 In PE-backed, single-specialty primary care, is it easier for PCPs to have full-spectrum clinical scope?
17:14 Why perverse financial incentives cause problems but aren't necessarily an inevitability.
22:17 Fragmentation and private equity in primary care.
25:46 Indie primary care versus PE-backed primary care versus hospital system–backed primary care.
29:54 LinkedIn post by Andrea DeSantis, DO, FAAFP.
30:40 EP521 with Andrew Tsang.
32:22 What Dr. Singh is thinking about and looking to solve for next.
34:30 Inspiring physician-led work and a reason for hope.
36:22 EP523 with Suhas Gondi, MD, MBA.
Recent past interviews:
Click a guest's name for their latest RHV episode!
Shawn Gremminger, Mark Cuban and Cora Opsahl, Dr Cristin Dickerson, John Quinn, Dr Suhas Gondi, Ge Bai, Andrew Tsang, Stacey Richter (EP520)
NOTE This file was generated by Descript
00:00:00 --> 00:00:02 Episode 528.
00:00:02 --> 00:00:08 The Current State of Primary Care, inevitable or fixable?
00:00:08 --> 00:00:11 Will It Be Private Equity to the Rescue?
00:00:11 --> 00:00:16 Today I am speaking with Yashaswini Singh, PhD.
00:00:24 --> 00:00:27 American Healthcare entrepreneurs and Executives You want to Know, Talking.
00:00:30 --> 00:00:32 Relentlessly seeking Value.
00:00:35 --> 00:00:36 Hello, all you Relentless Tribe members.
00:00:37 --> 00:00:39 Here's the backstory for this episode.
00:00:39 --> 00:00:46 Remember episode 519 with Dr. Lisa Rosenbaum, where we played a high
00:00:46 --> 00:00:53 stakes kind of game show called "Is the Current State of Primary Care an
00:00:53 --> 00:00:59 Absolute Inevitability, or Is It a Needless, Suboptimal Inefficiency?"
00:00:59 --> 00:01:03 In that conversation, Dr. Rosenbaum, who was my contestant,
00:01:03 --> 00:01:05 made a compelling point.
00:01:06 --> 00:01:11 She said that if we want to fix primary care, we probably have to
00:01:11 --> 00:01:15 pay our primary care clinicians more.
00:01:16 --> 00:01:20 We need to invest in them and level up teams and infrastructure.
00:01:22 --> 00:01:23 Hi, this is Arielle Bose.
00:01:23 --> 00:01:28 I've reflected on this a great deal and honestly feel that listening to Relentless
00:01:28 --> 00:01:33 Health Value has given me more actionable insight than I could ever hope to receive
00:01:33 --> 00:01:38 from another graduate degree, and it costs me absolutely nothing to listen and learn.
00:01:39 --> 00:01:42 If you want career growth and healthcare or insurance, this is
00:01:42 --> 00:01:44 the pod you need to be listening to.
00:01:44 --> 00:01:47 I highly recommend signing up for the weekly newsletter.
00:01:47 --> 00:01:50 It's a great resource because it includes all of the links
00:01:50 --> 00:01:54 mentioned in the show, plus a full transcription of Stacey's intro.
00:01:55 --> 00:02:00 Now, if you have listened to Relentless Health Value for any length of time,
00:02:00 --> 00:02:06 you know, you can count on me for a rant any given Tuesday about ceasing
00:02:06 --> 00:02:11 to pay way too much to corporatized consolidated, for example, health
00:02:11 --> 00:02:17 systems, especially the ones that already have quite robust in endowments
00:02:17 --> 00:02:19 and huge real estate portfolios.
00:02:20 --> 00:02:22 Their crocodile tears do not move me.
00:02:22 --> 00:02:25 Same with other corporate intermediaries.
00:02:25 --> 00:02:27 Sharks with great PR departments.
00:02:28 --> 00:02:32 But yeah, it's hard to argue that our frontline primary
00:02:32 --> 00:02:36 care clinicians are chronically underfunded and relatively underpaid.
00:02:37 --> 00:02:44 So when private equity answers the primary care chat with bags of capital, I could
00:02:44 --> 00:02:49 think, Great primary care is finally gonna get the investment that it deserves.
00:02:50 --> 00:02:51 But riddle me this.
00:02:52 --> 00:02:58 If private equity gets in the mix and there's now more money flowing, will
00:02:58 --> 00:03:00 primary care actually get better?
00:03:00 --> 00:03:03 Or will the doctors and other clinicians on the ground and the
00:03:03 --> 00:03:08 patients they care for become, I don't know, pawns in just one more
00:03:08 --> 00:03:10 healthcare inflationary business model?
00:03:11 --> 00:03:15 Said another way, is the capital actually gonna build sustainable whole person
00:03:15 --> 00:03:21 care, or is it just corporate arbitrage in a different Halloween costume?
00:03:21 --> 00:03:27 So when I heard Health Economist Dr. Yashaswini Singh had just completed a
00:03:27 --> 00:03:31 whole bunch of research into private equity investing in primary care,
00:03:31 --> 00:03:33 I was on it like white on rice.
00:03:34 --> 00:03:38 I wanted to find out if this professional capital will actually,
00:03:38 --> 00:03:43 or actually has been translating to better outcomes for patients or not.
00:03:45 --> 00:03:51 And to find out, I put Dr. Singh through the exact same three category
00:03:52 --> 00:03:56 game show categories that I went through with Dr. Lisa Rosenbaum,
00:03:57 --> 00:04:03 but specifically relative to private equity, PE-backed primary care clinics.
00:04:04 --> 00:04:09 So with Dr. Rosenbaum, we talked about primary care kind of writ
00:04:09 --> 00:04:13 large and the inevitabilities and the kind of decimation of primary
00:04:13 --> 00:04:15 care that we see across the country.
00:04:16 --> 00:04:21 This show today is specifically—so, same three categories, which let me remind you,
00:04:21 --> 00:04:26 are these three that we tackle—cognitive atrophy amongst clinicians.
00:04:26 --> 00:04:30 That's what we talk about first, the de-skilling of primary care.
00:04:30 --> 00:04:36 Secondly, primary care becoming referral machines as a, is that inevitable?
00:04:36 --> 00:04:42 And then thirdly, we examine transactional fragmentation versus continuity of care.
00:04:43 --> 00:04:47 So for each of these categories we go through, is it inevitable that this is
00:04:47 --> 00:04:52 gonna happen or is this something that potentially, if a practice is purchased
00:04:52 --> 00:04:55 by private equity can be avoided.
00:04:55 --> 00:04:56 My name is Stacey Richter.
00:04:56 --> 00:04:59 Again, this is Relentless Health Value.
00:04:59 --> 00:05:04 My thanks go out to Aventria Health Group who is our founding sponsor.
00:05:04 --> 00:05:10 I also very much want to thank Payerset our 2026 series underwriter.
00:05:11 --> 00:05:12 Do go over to their site.
00:05:12 --> 00:05:17 They have some very interesting resources dealing with healthcare transparency.
00:05:17 --> 00:05:18 Additionally.
00:05:18 --> 00:05:23 My deepest thank yous go to Patient Rights Advocate, which is a nonprofit,
00:05:24 --> 00:05:28 and I thank them so much also for their generous donation this year,
00:05:28 --> 00:05:30 helping us keep the show on the air.
00:05:30 --> 00:05:35 And with that, here is my conversation with Yashaswini Singh, PhD.
00:05:36 --> 00:05:39 Yashaswini Singh, welcome to Relentless Health Value.
00:05:39 --> 00:05:41 I'm so thrilled to be back.
00:05:41 --> 00:05:42 Thank you so much for having me, Stacey.
00:05:43 --> 00:05:45 Well, it is thrilling to have you back.
00:05:45 --> 00:05:47 Dr. Singh was on the show earlier.
00:05:47 --> 00:05:51 We will link to that earlier show in the show notes, which kind of gives the
00:05:51 --> 00:05:57 basic, I'm gonna say, primer of private equity in the healthcare industry.
00:05:57 --> 00:06:03 Today though, we are gonna talk about some research which specifically delves
00:06:03 --> 00:06:08 into private equity in primary care.
00:06:09 --> 00:06:13 Do you wanna, let's just level set here if we're just talking about kind of the
00:06:13 --> 00:06:19 basic overview of what you studied and what you were looking to figure out.
00:06:19 --> 00:06:24 Primary care is different from settings like dermatology or orthopedics that
00:06:24 --> 00:06:29 are more kind of procedure heavy and rely largely on a fee-for-service
00:06:29 --> 00:06:30 reimbursement environment.
00:06:31 --> 00:06:35 In primary care, we've seen various disruptions in care models, the rise
00:06:35 --> 00:06:40 of value-based contracting as well, and so there are enough both pushes
00:06:40 --> 00:06:45 and pulls that will lead you to believe that the effects of PE might play out
00:06:45 --> 00:06:49 a little bit differently in primary care than what we know to be true in
00:06:49 --> 00:06:51 dermatology or ophthalmology, for example.
00:06:52 --> 00:06:56 And so what we found in primary care now across four or five studies
00:06:56 --> 00:07:00 published in journals like Health Affairs and JAMA and some still in
00:07:00 --> 00:07:04 working paper format, is a couple of findings that I'll highlight for you.
00:07:04 --> 00:07:08 So first on, on the cost perspective, using price transparency data, we've
00:07:08 --> 00:07:14 shown that the negotiated prices that PE affiliated primary care physicians
00:07:14 --> 00:07:18 receive for your routine office visits are about eight to 10% higher than what
00:07:18 --> 00:07:22 independent primary care physicians are able to negotiate for themselves.
00:07:23 --> 00:07:24 Now, this is not surprising.
00:07:24 --> 00:07:29 It's broadly consistent with kind of this growing body of research now on PE
00:07:29 --> 00:07:32 and healthcare costs, and I guess it's reassuring in a way that some part of
00:07:32 --> 00:07:37 how PE plays out is consistent regardless of specialty, where you have practices
00:07:37 --> 00:07:39 that are rolled up into large entities.
00:07:39 --> 00:07:42 The number one kind of policy impact of that is higher negotiated
00:07:42 --> 00:07:46 prices that commercial payers pay, and then eventually patients will
00:07:46 --> 00:07:48 bear the cost of in some form.
00:07:48 --> 00:07:51 Now, the more interesting finding perhaps, is on the traditional Medicare
00:07:51 --> 00:07:56 side where we did a recent study that identified about 200 practices
00:07:56 --> 00:07:58 nationwide that were acquired by PE.
00:07:58 --> 00:08:02 Now, these are kind of single specialty, primary care practices, right?
00:08:02 --> 00:08:04 These are not multi-specialty settings.
00:08:04 --> 00:08:08 These are not practices that are VC backed or affiliated with health systems.
00:08:08 --> 00:08:11 These are independent practices that sold to PE firms.
00:08:12 --> 00:08:16 And we wanted to understand how do physicians practice differently once
00:08:16 --> 00:08:18 they experience a buy out of this nature.
00:08:18 --> 00:08:22 And we found that physicians not only see more patients, but they also
00:08:22 --> 00:08:25 end up doing more preventive care.
00:08:25 --> 00:08:29 So things like immunizations, preventive screenings, depression
00:08:29 --> 00:08:30 screenings, cancer screenings, so on.
00:08:30 --> 00:08:34 But also the Medicare Annual Wellness Visit, which is, you know, this sort
00:08:34 --> 00:08:40 of peculiar preventive screening that CMS and Medicare has wanted independent
00:08:40 --> 00:08:44 primary care doctors to complete for a very long period of time now.
00:08:44 --> 00:08:52 But is also very kind of time intensive and has a lot of paperwork involved
00:08:52 --> 00:08:55 and a lot of, you know what, doctors don't necessarily go to med school to
00:08:55 --> 00:09:00 do like a lot of checklists and just like administrative stuff, which, you
00:09:00 --> 00:09:04 know, PE for better or worse might have both the muscle and manpower
00:09:05 --> 00:09:07 to help doctors facilitate that.
00:09:07 --> 00:09:12 And so we found about a 20% increase in preventive services after PE acquisitions
00:09:12 --> 00:09:14 of these primary care practices.
00:09:14 --> 00:09:18 We look to see whether the increase in these services are low value,
00:09:18 --> 00:09:22 using well-established claims-based algorithms of identifying low
00:09:22 --> 00:09:23 value care and health data.
00:09:23 --> 00:09:27 And we did not find any evidence that these are low value care.
00:09:27 --> 00:09:31 And then in a separate study we look to see what this ultimately needs
00:09:31 --> 00:09:34 for patients who are receiving these additional preventive screenings.
00:09:34 --> 00:09:38 And we found overall big picture, not a lot changes.
00:09:39 --> 00:09:45 At best, there is a marginal about a 1.5 to 2% reduction in emergency
00:09:45 --> 00:09:48 department used by these patients at PE affiliated practices.
00:09:48 --> 00:09:53 So on net, you have evidence that costs go up by about eight to 10%.
00:09:54 --> 00:09:57 There's some evidence that patients are receiving more preventive
00:09:57 --> 00:10:02 services and at best is not a lot changing when it comes to quality.
00:10:02 --> 00:10:07 And so we can get into what, what that means as a PE prognosis as a whole but
00:10:07 --> 00:10:10 there's a lot of interesting things to unpack there that I think run
00:10:10 --> 00:10:14 contrary to some of what my work has shown too in other areas of where PE
00:10:14 --> 00:10:18 has invested and certainly how PE is portrayed sort of in the popular press.
00:10:19 --> 00:10:20 Dr. Yashaswini Singh.
00:10:20 --> 00:10:26 What I'd like to do is put you through the same series of questions
00:10:26 --> 00:10:31 that I asked Dr. Lisa Rosenbaum recently on an earlier episode.
00:10:31 --> 00:10:35 What we were talking about is kind of the over overall structural forces
00:10:35 --> 00:10:41 that have decimated primary care such that there are so many really brilliant
00:10:41 --> 00:10:46 internist, brilliant clinicians that are leaving status quo and going elsewhere.
00:10:46 --> 00:10:48 That's what triggered that whole conversation and do go back
00:10:48 --> 00:10:51 and listen to it, because there was a lot of nuances there.
00:10:52 --> 00:10:57 What I would like to ask you is sort of the same parameters, but
00:10:57 --> 00:11:04 specifically we're talking about primary care clinicians when working
00:11:04 --> 00:11:08 for a private equity backed clinic.
00:11:09 --> 00:11:18 So the first category, cognitive atrophy and just to tee that up in case anyone
00:11:18 --> 00:11:23 has a visceral reaction, if we're asking brilliant clinicians, brilliant primary
00:11:23 --> 00:11:29 care doctors to sit in a room and 15 minute visits and check boxes and not use
00:11:29 --> 00:11:35 clinical judgment, do things that don't require a medical degree to do, volume
00:11:35 --> 00:11:38 matters what a lot of times could happen, and it could be a generational loss.
00:11:38 --> 00:11:41 So everybody practicing today who's old enough will just
00:11:41 --> 00:11:42 keep doing what they're doing.
00:11:42 --> 00:11:45 But then the younger doctors coming into the profession don't
00:11:45 --> 00:11:49 have anyone to emulate if they come in as a preceptor, right?
00:11:49 --> 00:11:51 Like they don't have anyone to learn from.
00:11:51 --> 00:11:57 So you wind up the next generation of doctors coming in have cognitive atrophy
00:11:57 --> 00:12:00 in comparison to their older peers.
00:12:00 --> 00:12:07 If we're talking about private equity backed clinics here, as you said, a
00:12:07 --> 00:12:09 corollary to doing wellness visits.
00:12:09 --> 00:12:09 Right?
00:12:09 --> 00:12:15 And you mentioned the box checking is a cognitive atrophy
00:12:15 --> 00:12:18 situation, is that inevitable?
00:12:18 --> 00:12:18 Hmm.
00:12:20 --> 00:12:23 So best case scenario, right?
00:12:24 --> 00:12:29 You have incentives that are built around box checking that you don't need primary
00:12:29 --> 00:12:30 care physicians to spend their time on.
00:12:30 --> 00:12:36 So in the best case scenario, you would have other staff at your practice who
00:12:36 --> 00:12:42 can take care of the box checking, which would allow PCPs to focus on
00:12:42 --> 00:12:47 the patients that have the highest complexity needs that that need
00:12:47 --> 00:12:49 45 minutes of their doctor's time.
00:12:49 --> 00:12:51 So I don't think it's inevitable.
00:12:51 --> 00:12:54 I don't think you would have cognitive atrophy in that scenario.
00:12:55 --> 00:12:58 What we don't know is whether the best case scenario is what's playing
00:12:58 --> 00:13:02 out, because I suspect, and again, we don't have enough data to back this
00:13:02 --> 00:13:07 up, but I suspect that while you have the non-physician folks do the box
00:13:07 --> 00:13:11 checking at the same time, you have the physicians kind of under this
00:13:11 --> 00:13:16 clicking time bomb pressure schedule where you're not allowed to spend 45
00:13:16 --> 00:13:18 minutes with your complex patients.
00:13:18 --> 00:13:20 You get 15 minutes regardless of what you're seeing.
00:13:20 --> 00:13:23 And so that's where I think where we are with the status quo.
00:13:23 --> 00:13:27 Again, I don't think it's inevitable, but sadly that is where I suspect we are.
00:13:28 --> 00:13:32 What you just said could certainly correlate to, if primary care
00:13:32 --> 00:13:37 doctors owned by PE tend to have increased throughput themselves.
00:13:37 --> 00:13:39 I mean, if we're talking about their entire team, you probably
00:13:39 --> 00:13:41 could have increased throughput.
00:13:41 --> 00:13:46 If what's happening is what you're talking about, where you've got the mid-levels,
00:13:46 --> 00:13:51 et cetera, who are handling some of the visits and then leave the primary care
00:13:51 --> 00:13:55 physicians themselves to see, as you said, the more complex patients or the patients
00:13:55 --> 00:13:58 coming in with a more complex need.
00:13:59 --> 00:14:04 So let's move on to our second category of our show here, which again was
00:14:04 --> 00:14:11 discussed in great detail with Dr. Lisa Rosenbaum, but it is full spectrum
00:14:11 --> 00:14:19 clinical scope versus PCPs viewed as kind of like referral machines.
00:14:19 --> 00:14:23 Which is something we've talked about over and over and over again on this show.
00:14:23 --> 00:14:27 Just the financial incentives, especially for PCPs that are owned by
00:14:27 --> 00:14:35 health systems to, you know, health system playbook, health system 101
00:14:36 --> 00:14:40 is go around, buy up all the PCPs in your local area, and then use them in
00:14:40 --> 00:14:46 order to basically be a gateway to get patients into profitable service lines.
00:14:46 --> 00:14:49 Like it's oldest the trick in the book, right?
00:14:49 --> 00:14:57 With PE backed, and you said single specialty primary care is it easier
00:14:57 --> 00:15:01 for a primary care doctor to have full spectrum clinical scope?
00:15:01 --> 00:15:07 Is that what's gonna happen or is it inevitable that this referral engine
00:15:07 --> 00:15:10 utilization of primary care persists?
00:15:12 --> 00:15:17 Another fantastic question, and I might give yet another unsatisfying
00:15:17 --> 00:15:19 answer, which is it depends.
00:15:19 --> 00:15:21 I don't think it needs to be inevitable, right?
00:15:21 --> 00:15:23 And so let me explain what I mean by that.
00:15:23 --> 00:15:27 We started talking about these single specialty practices that are PE acquired.
00:15:27 --> 00:15:32 I'll add an asterisk to single specialty because that is the best data we have.
00:15:32 --> 00:15:36 I don't think that is the best representation of how these
00:15:36 --> 00:15:40 practices are sort of formally owned and managed and operated.
00:15:40 --> 00:15:43 And what I mean by that is there is a lot of common ownership.
00:15:43 --> 00:15:47 You have a handful of financial investors that might own a share of a
00:15:47 --> 00:15:51 gastroenterology practice and a primary care practice and an orthopedic and
00:15:51 --> 00:15:53 an oncology and cardiology practice.
00:15:53 --> 00:16:00 Now, the challenge is we don't have the right type of data or reporting or
00:16:00 --> 00:16:05 disclosure requirements that would help us parse through these different ownership
00:16:05 --> 00:16:09 structures to really understand who has an operating or ownership stake in whom.
00:16:10 --> 00:16:16 This was a point that Dr. Singh brought up in the first episode with
00:16:16 --> 00:16:18 her about PE in healthcare in general.
00:16:19 --> 00:16:26 That who owns any given practice or healthcare entity is fuzzy.
00:16:26 --> 00:16:28 It's unclear, it's hard to figure out.
00:16:28 --> 00:16:33 And that matters if you're trying to discover where the perverse incentives
00:16:33 --> 00:16:37 lie, or if you're trying to follow the dollar for like any number of reasons.
00:16:38 --> 00:16:42 I will put a link in the show notes to the first episode with Dr. Singh, and if you
00:16:42 --> 00:16:47 are interested in private equities, impact on healthcare or the things to watch out
00:16:47 --> 00:16:48 for, do go back and listen to that show.
00:16:48 --> 00:16:50 It is a gold mine of insights.
00:16:52 --> 00:16:57 And so the best that we do as researchers is then because of these gaps in data
00:16:57 --> 00:17:02 and reporting, is study each kind of specialty setting as though it were a
00:17:02 --> 00:17:06 single specialty setting, independent of the different forces and incentives
00:17:06 --> 00:17:09 that come into play when your ultimate owner also has an ownership stake
00:17:09 --> 00:17:11 in an oncology practice, right?
00:17:11 --> 00:17:16 And so because we don't have that data visibility, I think it's entirely possible
00:17:16 --> 00:17:22 that practices that are affiliated with PE firms that also, a cardiology
00:17:22 --> 00:17:27 practice, for example, are not immune from the types of referral incentives
00:17:27 --> 00:17:31 or nefarious referral incentives that we've seen to be true in other settings.
00:17:31 --> 00:17:32 It's not inevitable.
00:17:32 --> 00:17:36 I think it's largely a byproduct of, again, payment policy, right?
00:17:36 --> 00:17:40 A lot in healthcare comes down to financial incentives that are often
00:17:40 --> 00:17:45 well-meaning, but sometimes create really messed up, complicated, sticky
00:17:45 --> 00:17:48 situations, but we don't have to accept that as an inevitability.
00:17:49 --> 00:17:53 At present, Medicare and then commercial insurers largely follow suit as well,
00:17:53 --> 00:17:59 but Medicare pays often double or triple times the amount it would pay for, say,
00:17:59 --> 00:18:04 an MRI at a hospital setting compared to just a doctor's office across the street.
00:18:04 --> 00:18:09 So this difference in payments based on the site of care has been this
00:18:09 --> 00:18:13 driver of hospitals acquiring physician groups, other entities acquiring
00:18:13 --> 00:18:19 PCPs to steer referrals then to wherever they can get the higher cost.
00:18:19 --> 00:18:23 And so this payment arbitrage, I think is one reason why we've seen
00:18:23 --> 00:18:27 referrals being kind of the number one desirable thing to get out of PCPs.
00:18:27 --> 00:18:29 But again, I don't think it's an inevitability.
00:18:29 --> 00:18:33 I don't think PE ownership is immune from these types of Incentives
00:18:33 --> 00:18:36 either they're just a little bit harder to detect in the data.
00:18:36 --> 00:18:41 So many interesting points that you just made, just kind of ticking them
00:18:41 --> 00:18:42 off maybe in no particular order.
00:18:42 --> 00:18:48 The first one that you said is that relative to the incentives to refer,
00:18:48 --> 00:18:54 it's a little unclear maybe the PE, that same exact private equity firm
00:18:54 --> 00:18:57 has done roll-ups and for example, other specialties like they own,
00:18:57 --> 00:18:59 they also own all the GI practices.
00:18:59 --> 00:19:05 So the Primary care practice is single specialty, but there still may be
00:19:05 --> 00:19:11 these underlying financial incentives to refer, and you called it payment
00:19:11 --> 00:19:15 arbitrage, and it's, you know, you've got the site of care differences
00:19:15 --> 00:19:17 where a hospital gets paid more.
00:19:17 --> 00:19:21 It's also pretty well known that specialists visits pay
00:19:21 --> 00:19:22 more than a primary care visit.
00:19:22 --> 00:19:27 So if PE owns both, there's certainly an incentive to get that patient over
00:19:27 --> 00:19:30 to the higher paying specialty practice.
00:19:30 --> 00:19:34 You know, if, if ortho, there's a huge orthopedic roll-up.
00:19:34 --> 00:19:36 Obviously there's surgery that's it involved, like, so there
00:19:36 --> 00:19:41 certainly could be refer early, refer often incentives there.
00:19:41 --> 00:19:46 I just heard a crazy story the other day about a private equity
00:19:46 --> 00:19:50 trying to stand up a primary care practice that was entirely referrals.
00:19:50 --> 00:19:53 Like they didn't even want, in fact, they told someone, they told a potential
00:19:53 --> 00:19:57 customer that the economic model didn't work if the patient actually had to come
00:19:57 --> 00:20:01 and see a doctor, like it was an AI model where the patient basically just like
00:20:01 --> 00:20:05 typed in, filled out a form or something like that, and then was like a automated
00:20:05 --> 00:20:11 referral .That is just like an end state of what of what we're saying here.
00:20:11 --> 00:20:15 And if we're talking about, if the question is full spectrum clinical
00:20:15 --> 00:20:21 scope versus using the primary care name only as a referral machine,
00:20:21 --> 00:20:23 like that's probably the ultimate.
00:20:23 --> 00:20:25 I'm gonna be thinking about that example for a long time.
00:20:25 --> 00:20:28 That is, that's, that story is wild.
00:20:28 --> 00:20:30 I'm gonna be thinking about it for a long time.
00:20:31 --> 00:20:35 And now let's discuss the exact opposite referral problem.
00:20:35 --> 00:20:40 Swinging wildly from every patient gets a referral to patients do not
00:20:40 --> 00:20:44 get a referral even when they need one, which might have more to do with
00:20:44 --> 00:20:48 financial incentives, not for PCPs but on the other side of the referral.
00:20:49 --> 00:20:52 I saw something that Dr. Guy Culpepper recently wrote.
00:20:53 --> 00:20:57 He wrote, "The daily Struggle in primary care of managing mental health Problems
00:20:57 --> 00:21:01 that are beyond our level of comfort or expertise has exploded. But we have
00:21:01 --> 00:21:03 no choice because we have no help."
00:21:03 --> 00:21:08 Dr. Cole Pepper wrote, "Our own giant regional hospital in our area.
00:21:08 --> 00:21:13 Just sent us a letter declining our patient referral due to a capacity
00:21:13 --> 00:21:14 shortage in psychiatric care."
00:21:15 --> 00:21:19 Okay, I, Stacey Richter have heard the same concern with nephrology
00:21:19 --> 00:21:23 and other specialties too, especially the more rural you get.
00:21:23 --> 00:21:24 I could go on a tangent here.
00:21:25 --> 00:21:25 I will not.
00:21:25 --> 00:21:31 But bottom line, let's just say that when a referral to be or not to be becomes
00:21:31 --> 00:21:37 mostly about the financials of somebody in the chain here, not what is best
00:21:37 --> 00:21:43 for the patient, that's when like first principles, Houston, we have a problem.
00:21:44 --> 00:21:50 What I'm taking away is full spectrum clinical scope is very hard to scale,
00:21:50 --> 00:21:57 and if you've got PE firms that are very interested in scaling, then they may
00:21:57 --> 00:22:02 not necessarily be compatible under the current payment regime at least.
00:22:03 --> 00:22:10 All right, third category of our show here, which is transactional
00:22:10 --> 00:22:17 fragmentation, is that inevitable versus longitudinal relational care?
00:22:17 --> 00:22:20 If we're talking about PE in primary care.
00:22:21 --> 00:22:24 Is transactional fragmentation inevitable?
00:22:24 --> 00:22:27 Are we gonna lose longitudinal relational care?
00:22:28 --> 00:22:32 So the term fragmentation is so interesting in the PE context, right?
00:22:32 --> 00:22:37 Because if you look at the value proposition that investors often
00:22:37 --> 00:22:41 bring to the table, it's often tied to reducing fragmentation in healthcare.
00:22:41 --> 00:22:46 The argument is always, there are hundreds of solo practitioners
00:22:46 --> 00:22:48 and independent offices.
00:22:48 --> 00:22:51 It's very hard for patients to kind of see their doctors across the
00:22:51 --> 00:22:55 different specialties and get the type of coordinated care they need.
00:22:55 --> 00:22:59 And so we as investors will help bring economies of scale to the function.
00:22:59 --> 00:23:03 Will consolidate smaller, fragmented entities into a larger, cohesive,
00:23:03 --> 00:23:07 well performing platform, reduce fragmentation, improve care.
00:23:07 --> 00:23:09 So that's sort of one of the value propositions.
00:23:10 --> 00:23:13 Now in reality, again, I think it's a little bit different than
00:23:13 --> 00:23:15 the best case ideal scenario.
00:23:15 --> 00:23:18 In reality, you know, everything is always more complicated.
00:23:18 --> 00:23:22 And so what we've seen play out in reality is that because of these
00:23:22 --> 00:23:28 performance based pressures on how to practice medicine, that investors
00:23:28 --> 00:23:31 often bring following a buyout.
00:23:31 --> 00:23:36 We've seen a lot of workforce churn, physician turnover, a lot of staffing.
00:23:37 --> 00:23:40 Just disruptions, you know, higher APP hiring for sure.
00:23:40 --> 00:23:44 But then physicians are also not very happy with all of the changes that
00:23:44 --> 00:23:48 come about, and that manifests in the term of physicians leaving their
00:23:48 --> 00:23:52 practices, sometimes leaving entire regions to seek alternate employment
00:23:52 --> 00:23:54 independent of PE affiliation.
00:23:55 --> 00:24:00 And so when I see study findings like that, that hold kind of, you know, at
00:24:00 --> 00:24:06 at a national scale, it's very difficult for me to, at the same time accept the
00:24:06 --> 00:24:09 argument that PE reduces fragmentation.
00:24:09 --> 00:24:13 Because from the patient perspective, if you don't have the certainty that you'll
00:24:13 --> 00:24:17 see your doctors two times in a row for visits that are spaced maybe three
00:24:17 --> 00:24:21 or six months apart, that raises some serious fragmentation concerns for me,
00:24:21 --> 00:24:23 because your care continuity is at risk.
00:24:23 --> 00:24:27 That patient physician trust relationship is also at risk.
00:24:28 --> 00:24:32 And so fragmentation might be reduced, I think perhaps from the investor's
00:24:32 --> 00:24:37 perspective, maybe from supply chain management perspective, but when
00:24:37 --> 00:24:41 it comes down to how the patient experiences the healthcare system and
00:24:41 --> 00:24:45 how the clinicians, physicians, and non-physician staff experience kind
00:24:45 --> 00:24:51 of their employment landscape, I think we've seen enough evidence now that I
00:24:51 --> 00:24:55 would argue fragmentation or at least that from care experience increases.
00:24:56 --> 00:25:01 When you were on the show the last time, you talked at length about the
00:25:01 --> 00:25:07 increase in turnover and the increase in physicians who leave practices
00:25:07 --> 00:25:13 when private equity purchases their practice, and that is relevant here
00:25:13 --> 00:25:15 as well, is what I'm hearing you say.
00:25:15 --> 00:25:18 Because if every time a patient, you know, we're, if we're talking
00:25:18 --> 00:25:23 about longitudinal relational care, you're not gonna get a relationship
00:25:23 --> 00:25:24 in air quotes without practice.
00:25:24 --> 00:25:29 You're gonna get a relationship with a physician who you know, like and trust.
00:25:29 --> 00:25:34 So if every time you go for a visit, you're seeing someone different, be
00:25:34 --> 00:25:39 that A PCP or even the advanced practice clinicians or, or mid-levels or every,
00:25:39 --> 00:25:44 if like every time you go, it's a new day there with a new staff, it's very,
00:25:44 --> 00:25:46 very difficult to have a relationship.
00:25:46 --> 00:25:50 If you were just gonna take a moment to kind of compare, I don't know, call
00:25:50 --> 00:25:55 this a wrap up of what we just talked about, to compare what tends to happen
00:25:55 --> 00:26:05 in an indie practice versus a PE backed practice versus even a, a hospital
00:26:05 --> 00:26:08 system, like what, how would you sort of just like sum this whole thing up?
00:26:09 --> 00:26:13 Oh, that is just the best question to ask and I think it's also the right
00:26:13 --> 00:26:17 time to ask that question because we are at sort of this crossroads now, right?
00:26:17 --> 00:26:21 We, we've known for about a decade now, hospitals have been buying
00:26:21 --> 00:26:24 physician groups, not just in primary care, in other specialties as well.
00:26:24 --> 00:26:29 More recently, in the last five years, PE has emerged as another kind of
00:26:29 --> 00:26:33 alternate form of whether it's financing, employment, consolidation, we can
00:26:33 --> 00:26:38 figure out terminology, but something, alternative to hospital employment.
00:26:39 --> 00:26:42 And then you have health insurance companies and their affiliates too, which
00:26:42 --> 00:26:45 I would put a third category of corporate.
00:26:45 --> 00:26:47 You have entities affiliated with Optum.
00:26:47 --> 00:26:52 You have the kind of risk bearing PE, health insurer, joint
00:26:52 --> 00:26:55 venture type practices where Humana has a large footprint.
00:26:56 --> 00:27:01 And then you have maybe a category that doesn't, that's different from the rest.
00:27:01 --> 00:27:04 And so it perhaps might not be appropriate to kind of group them in
00:27:04 --> 00:27:09 this corporate typology, but kind of your direct primary care concierge.
00:27:09 --> 00:27:12 Because you know, it's not clear always that there's corporate
00:27:12 --> 00:27:16 involvement, but it's a distinct practice model, distinct business model.
00:27:16 --> 00:27:19 And so it perhaps, you know, warrants kind of its own separate discussion there.
00:27:20 --> 00:27:22 So then the question is, how do these compare against each other?
00:27:22 --> 00:27:25 Can we say something about which of these is more desirable
00:27:25 --> 00:27:27 from a societal perspective?
00:27:27 --> 00:27:30 Which of these deserves additional scrutiny?
00:27:30 --> 00:27:31 And if so, what form that takes?
00:27:32 --> 00:27:34 Sadly, again, an unsatisfying answer.
00:27:34 --> 00:27:40 Sadly, we don't have enough of a rigorous evidence base to have a definitive answer
00:27:40 --> 00:27:44 on how these different forms compare and compete against each other, right?
00:27:44 --> 00:27:49 They're evolving in real time researchers, policy makers, we're all playing catch up.
00:27:50 --> 00:27:53 And so I think it's a reflection on the state of just lack of
00:27:53 --> 00:27:56 transparency and data that allows this type of work to happen.
00:27:56 --> 00:28:00 So we're, from kind of a researcher perspective, we're still lagging
00:28:00 --> 00:28:02 behind some of these dynamic trends in the marketplace.
00:28:03 --> 00:28:08 What we do know is when it comes just to cost, like the cost of care, thanks to
00:28:08 --> 00:28:12 again, price transparency data, which is really unprecedented in its ability to
00:28:12 --> 00:28:18 give us that visibility into real time, almost negotiation dynamics, we know that
00:28:18 --> 00:28:24 hospitals and hospital affiliated doctors negotiated prices that are significantly
00:28:24 --> 00:28:26 higher than independent doctors.
00:28:27 --> 00:28:29 And so do PE affiliated doctors, right?
00:28:29 --> 00:28:32 But then when you look at hospital and PE, the hospital affiliated prices
00:28:32 --> 00:28:37 are still much higher than what PE affiliated doctors can negotiate.
00:28:37 --> 00:28:39 So it's almost like a hierarchy, if you will.
00:28:40 --> 00:28:45 You know, PE oftentimes is appealing to doctors because they are promised kind
00:28:45 --> 00:28:51 of this potential to negotiate higher prices to compete with the kind of brute
00:28:51 --> 00:28:53 force of hospitals in their local areas.
00:28:53 --> 00:28:58 Independent doctors are offered this lifeline, you know, help you negotiate
00:28:58 --> 00:29:00 reimbursement rates so you can compete with the hospital in your market.
00:29:01 --> 00:29:04 And what that does is create this sort of upward pricing pressure in the
00:29:04 --> 00:29:09 market where PE consolidates increases prices, but then those prices are still
00:29:09 --> 00:29:13 somewhat lower than what hospitals can negotiate for their doctors.
00:29:13 --> 00:29:15 So, research is still emerging.
00:29:15 --> 00:29:18 I think we know now, again, because of price transparency data that regardless
00:29:18 --> 00:29:23 of specialty, regardless of the type of service, hospitals and PE affiliated
00:29:23 --> 00:29:26 doctors negotiate higher prices than independent doctors with hospitals
00:29:26 --> 00:29:29 having a slightly bigger edge there.
00:29:30 --> 00:29:34 Actually, I'm gonna link in the show notes to a post that
00:29:34 --> 00:29:36 Dr. Singh wrote on LinkedIn.
00:29:37 --> 00:29:40 First of all, it has links to the papers that we've been discussing here.
00:29:41 --> 00:29:46 But also on that post are some really insightful comments from a bunch
00:29:46 --> 00:29:50 of different folks from across the industry who really add some depth
00:29:50 --> 00:29:53 to some of the points that have come up in this conversation so far.
00:29:54 --> 00:29:59 There's one in particular by Dr. Andrea DeSantis that I'm gonna read here
00:29:59 --> 00:30:00 'cause I thought it was fascinating.
00:30:00 --> 00:30:04 She wrote, "No doubt there are private equity firms out there doing the
00:30:04 --> 00:30:06 right thing by patients and practices.
00:30:06 --> 00:30:11 However, I find that most are focused on short-term investment and return on profit
00:30:11 --> 00:30:13 and not the quality of the caregiving.
00:30:14 --> 00:30:18 They also locate themselves in areas of relative wellness and wealth.
00:30:18 --> 00:30:23 Just because one increases billing, i.e. upcoding, double, triple billing,
00:30:23 --> 00:30:27 doesn't necessarily mean that the patient is getting appropriate or better care."
00:30:28 --> 00:30:31 Um, and then when it comes to some of the other things we've talked about
00:30:31 --> 00:30:35 today, like what it means, a low value care or patient trust, or workforce
00:30:35 --> 00:30:39 morale, turnover, things like that, the honest answer is we just don't know.
00:30:40 --> 00:30:44 As you're talking, I'm reminded of something that Andrew Tsang said in
00:30:44 --> 00:30:45 an episode a couple of weeks ago.
00:30:45 --> 00:30:49 He said, who succeeds in healthcare in the healthcare industry these days are
00:30:49 --> 00:30:56 those who can administer or out leverage their competition, not necessarily
00:30:56 --> 00:31:00 those who produce the best healthcare or the best healthcare outcomes.
00:31:00 --> 00:31:04 And yeah, as you were talking, that's what I was thinking.
00:31:05 --> 00:31:05 Yeah.
00:31:05 --> 00:31:08 And that also doesn't need to be an inevitability, right?
00:31:08 --> 00:31:12 Because if we align incentives to center outcomes, which we don't at
00:31:12 --> 00:31:17 present, then you could have a win-win scenario where you have the folks who
00:31:17 --> 00:31:23 invest in kind of your admin powerhouse and your technology powerhouse also
00:31:23 --> 00:31:25 delivering the best care for patients.
00:31:25 --> 00:31:29 I do believe that's possible, and I do believe that there is a role for
00:31:29 --> 00:31:31 private investment in needing that need.
00:31:32 --> 00:31:36 I just think that investors, whether they're health systems
00:31:36 --> 00:31:38 or insurers or whatever form.
00:31:38 --> 00:31:41 I just think they respond very well to incentives and we don't
00:31:41 --> 00:31:42 have the incentives right.
00:31:42 --> 00:31:44 Whether it's payment policy or regulatory policy.
00:31:44 --> 00:31:48 We just don't have them set in a way that prioritizes what's best for patients.
00:31:49 --> 00:31:57 Well let us relentlessly pursue incentives that are with the outcomes that we would
00:31:57 --> 00:32:02 actually like to achieve and ensure that, you know, as you, you put it
00:32:02 --> 00:32:12 well-meaning policy is also validated against what the intermediaries are likely
00:32:12 --> 00:32:20 to do, and really game theory out how to make those incentives actually align.
00:32:21 --> 00:32:25 Dr. Yashaswini Singh, if we're thinking about key unanswered questions or
00:32:25 --> 00:32:30 additional research, what are you looking really to solve for next or solve for?
00:32:31 --> 00:32:35 Yeah, so I'll tell you one thing that keeps me up at night is how some of
00:32:35 --> 00:32:39 the forces we just talked about, right, the growing acquisitions of physician
00:32:39 --> 00:32:44 groups by all of these different types of corporate entities, how they evolve
00:32:44 --> 00:32:46 and intersect in the near future.
00:32:46 --> 00:32:51 And one example of that is, you know, PE investors by definition are short term.
00:32:51 --> 00:32:54 And so by definition they will seek to exit their investments,
00:32:54 --> 00:33:00 sell to a strategic buyer, sell to another PE firm, maybe go public.
00:33:00 --> 00:33:03 You know, there are only so many forms and exit can take.
00:33:03 --> 00:33:07 But in healthcare, increasingly we've seen physician groups be flipped
00:33:07 --> 00:33:13 to health insurance affiliated entities, some of which are affiliated
00:33:13 --> 00:33:15 with Optum and others as well.
00:33:15 --> 00:33:22 And so understanding whether some of what PE does is specific only to when PE
00:33:22 --> 00:33:27 is directly involved or if it persists even after PE has flipped to Optum.
00:33:28 --> 00:33:29 That's kind of one question, right?
00:33:29 --> 00:33:30 That keeps me up.
00:33:30 --> 00:33:34 Another related one, is the practice better or worse or even any different
00:33:34 --> 00:33:38 under an entity like Optum and Optum's a shorthand for some type
00:33:38 --> 00:33:40 of strategic acquire that's not PE.
00:33:40 --> 00:33:43 It doesn't matter if PE has sold or not sold.
00:33:43 --> 00:33:46 Like what does it mean for the practice when it experiences this
00:33:46 --> 00:33:48 type of rapid ownership change?
00:33:48 --> 00:33:51 What does it mean for physicians and physician leaders who are
00:33:51 --> 00:33:53 navigating this ecosystem?
00:33:53 --> 00:33:55 Again, this is all happening in real time.
00:33:55 --> 00:34:02 We've seen just in the last year or two, really large retina practices be
00:34:02 --> 00:34:07 sold to drug distributors, so that's another type of vertical integration.
00:34:07 --> 00:34:11 We've seen oncology practices as well be sold to drug distributors.
00:34:11 --> 00:34:14 Gastroenterology practices that were PE on that have sold to Optum.
00:34:15 --> 00:34:17 Primary care prior practices that were PE on that have sold at Optum.
00:34:17 --> 00:34:19 So we're seeing this.
00:34:20 --> 00:34:24 Vertical integration 2.0 that regulators certainly are not
00:34:24 --> 00:34:25 paying close attention to.
00:34:25 --> 00:34:28 Well, it sounds like we're, we're gonna need to have you
00:34:28 --> 00:34:30 back for a round three here.
00:34:30 --> 00:34:34 Is there anything that could be considered inspiring?
00:34:34 --> 00:34:38 We have a lot of listeners who are doing physician led work and
00:34:38 --> 00:34:41 actually very successful doing it.
00:34:41 --> 00:34:43 How does that play into the story here?
00:34:44 --> 00:34:48 I'm so thrilled you asked that question because I definitely don't want to paint
00:34:48 --> 00:34:52 a picture of only doom and gloom because that's not at all, all of how I feel.
00:34:52 --> 00:34:54 I think there is a lot of reason for hope.
00:34:54 --> 00:34:59 I don't think we as patients, but also as physicians, need to be
00:34:59 --> 00:35:03 sort of passive observers of any of these trends we've talked about.
00:35:03 --> 00:35:03 Right?
00:35:03 --> 00:35:08 And we've seen so many exceptional examples, including, you know, so many
00:35:08 --> 00:35:12 of your wonderful guests who've shared their journeys of how folks are refusing
00:35:12 --> 00:35:16 to be these passive observers and taking charge of developing what this
00:35:16 --> 00:35:19 kind of new business model looks like in this current climate that we're in.
00:35:20 --> 00:35:25 Thankfully, there are enough folks, far smarter than I am who are breaking out
00:35:25 --> 00:35:28 of that conventional status quo model and thinking about what these disruptive
00:35:28 --> 00:35:32 care models mean and what it means to compete in an ecosystem where you have
00:35:32 --> 00:35:38 these very large, very dominant, very consolidated entities with their bargining
00:35:38 --> 00:35:41 strength and leverage, and you have physician leaders who are disrupting
00:35:41 --> 00:35:42 the space with their new models.
00:35:42 --> 00:35:44 And so I think we need more of that.
00:35:44 --> 00:35:47 I think we need more creative thinking around payment policy as well to
00:35:47 --> 00:35:50 encourage and incentivize more of that.
00:35:50 --> 00:35:54 I think folks in policy need to be paying more attention to how
00:35:54 --> 00:35:58 they can make the practice of independent medicine easier, right?
00:35:58 --> 00:36:02 Not just regulate what we know is undesirable, but also let's make
00:36:02 --> 00:36:05 it easier for doctors to just practice independently if that's
00:36:05 --> 00:36:07 what they decide is right for them.
00:36:07 --> 00:36:10 And we've seen some examples in the form of tax credits and so on.
00:36:10 --> 00:36:13 And so I think there's a lot of reason for hope, and I would just encourage
00:36:13 --> 00:36:18 listeners to do more of that and kind of move away from the status quo, kind of
00:36:18 --> 00:36:20 conventional way of practicing medicine.
00:36:21 --> 00:36:26 To that end also, I am reminded of the, the conversation that I had with Dr. Suhas
00:36:26 --> 00:36:33 Gondi talking about the Sleeping Giant in air quotes of physicians taking agency,
00:36:33 --> 00:36:38 waking up, which is something that also, we, I keep mentioning the episode with
00:36:38 --> 00:36:45 Dr. Lisa Rosenbaum, but she mentioned that same thing, and both Dr. Rosenbaum and Dr.
00:36:45 --> 00:36:47 Gondi were talking about that unprompted.
00:36:47 --> 00:36:52 So, hopefully we are seeing a bit of a zeitgeist here to your exact point,
00:36:53 --> 00:36:58 Dr. Yashaswini Singh, where can people learn more about your work?
00:36:58 --> 00:36:59 Where would you direct them?
00:36:59 --> 00:37:02 We will put links in the show notes to all of these studies
00:37:02 --> 00:37:03 that you've talked about so far.
00:37:03 --> 00:37:04 Yeah.
00:37:04 --> 00:37:05 Thank you so much.
00:37:05 --> 00:37:07 This has been such a phenomenal conversation, and I mean,
00:37:07 --> 00:37:09 you're such a talented host.
00:37:09 --> 00:37:11 Thank you again so much for having me on.
00:37:11 --> 00:37:14 I, as I mentioned, you know, I'm a professor at Brown.
00:37:14 --> 00:37:18 I'm also affiliated with a research center called the Center for Advancing
00:37:18 --> 00:37:20 Health Policy to Research or CAHPR.
00:37:21 --> 00:37:26 We have incredible resources in the form of research summaries, policy briefs, also
00:37:26 --> 00:37:29 interactive, fun tools on payment policy.
00:37:29 --> 00:37:34 I'm also easy to find, LinkedIn, email, and I really welcome the collaboration
00:37:34 --> 00:37:36 and expertise from your community.
00:37:36 --> 00:37:40 So I hope folks will feel comfortable and free to reach out in any form or way.
00:37:41 --> 00:37:44 Yashaswini Singh, thank you so much for being on Relentless Health Value today.
00:37:44 --> 00:37:45 It's entirely my pleasure.
00:37:45 --> 00:37:46 Thank you so much.
00:37:48 --> 00:37:51 Hi, this is Tom Nash, editor and producer of the Relentless Health Value Podcast.
00:37:51 --> 00:37:55 I bet you're wondering, how can I help Relentless Health Value?
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00:37:58 --> 00:37:59 The newsletter is great.
00:37:59 --> 00:38:01 It tells you when each episode's coming out.
00:38:01 --> 00:38:05 It gives you an introduction to the episode with all the mention links.
00:38:05 --> 00:38:07 And a way to click through and listen to the podcast.
00:38:08 --> 00:38:09 But there's more ways to help.
00:38:09 --> 00:38:10 You can always go over to LinkedIn.
00:38:10 --> 00:38:11 Are you following the page?
00:38:12 --> 00:38:12 You should be.
00:38:12 --> 00:38:15 There's great conversations each week on all the episodes.
00:38:16 --> 00:38:19 So go to LinkedIn, find the Relentless Health Value page and follow us.
00:38:20 --> 00:38:23 Have you ever left a review for us on Apple Podcast or Spotify?
00:38:23 --> 00:38:24 That would help greatly?
00:38:24 --> 00:38:27 While you're doing that, be sure you're following the podcast so
00:38:27 --> 00:38:31 you get notified each week inside of Apple Podcasts or Spotify.
00:38:31 --> 00:38:33 Okay, so you've done all those things already.
00:38:33 --> 00:38:37 Another thing you could do, you could head over to our website and donate to the tip
00:38:37 --> 00:38:39 jar, maybe become a sustaining member.
00:38:39 --> 00:38:42 In many ways, Relentless Health runs like an unofficial
00:38:42 --> 00:38:44 nonprofit, a very, very nonprofit.
00:38:44 --> 00:38:47 So anything that you give would help us pay the bills.
00:38:47 --> 00:38:48 Thanks so much for listening.