An insurer and a private equity firm team up to provide "primary care"

Why the corporate push into primary care is so pernicious

The health insurer Elevance Health — formerly Anthem — this week announced a deal with the private equity firm Clayton, Dubilier & Dice “in its latest bid to expand access to advanced primary care,” according to industry publication Fierce Healthcare.  The deal would integrate three provider divisions across the two firms that would together provide care to some 1 million patients. 

Elevance Health’s press release was full of gobbledygook about the beauties of integrated, wholistic, wholesome, cost-reducing primary care that would emerge from this partnership:

The strategic partnership’s advanced primary care models take a whole health approach to address the physical, social, and behavioral health of every person. The foundation of the new advanced primary care offering will be stronger patient-provider relationships supported by data-driven insights, care coordination and referral management, and integrated health coaching. It will also leverage realigned incentives through value-based care agreements that enable care providers, assist individuals in leading healthier lives, and make care more affordable.

Yes, this makes me queasy.  However, it is worth asking why corporate investors are increasing investing in primary care. 

After all, we are used to hearing that primary care is underfunded and unprofitable.  It is, in one sense.  In another, however, that is changing, not because of any meaningful embrace of primary care as a foundational clinical service, but instead because primary care providers are increasingly central to profitability in a “value-based” healthcare ecosystem.  In particular, they drive risk-adjustment (i.e. through coding activities) which determines how much revenue each patient brings into a health system — an ever-more critical part of the contemporary healthcare business model.  A perspective piece by Soleil Shah, Hayden Rooke-Ley, and Erin Brown in the NEJM last year summarizes this trend well:

An overarching revenue strategy underlies investors’ appetite for primary care. As Medicare and commercial payers move toward total-cost value-based payments, such as capitation, and away from fee-for-service reimbursement, primary care practices may hold the key to increased profitability of health care under value-based payment systems.¹ Primary care practices can generate substantial profits by growing their population of patients covered by Medicare Advantage (and other lucrative payers), maximizing the “budget” for each patient’s care using risk adjustment and quality bonuses, minimizing their health expenditures with utilization management, and referring patients to other product and service offerings, such as pharmacy. Primary care providers are health care’s front door not just for patients, but also for investors who see those patients as a revenue stream. Primary care practices offer corporate investors access to these patients and their data, both for risk-coding advantages and as potential customers for other lines of service.

It has become something of a generic lament to acknowledge that primary care is inadequately funded, that primary care is inadequately resourced, that we don’t have another primary care doctors, that not enough medical students are choosing primary care, that we need to improve quality of work for primary care doctors, that we need to mitigate disparities in pay between primary care and specialists, etc. etc. etc. But what is rarely noted is the way our increasingly financialized, corporatized healthcare financing system is distorting (degrading) the fundamental role of primary care physicians.     

I believe we do need a fundamental shift that puts primary care at the center of our healthcare system in a meaningful, clinical sense — as part of a larger single-payer financing reform of American healthcare.  But we would be naïve to neglect the way that business interests are today centering primary care in a perverse way now — as drivers of revenue production through coding and referral and utilization management, instead of as pillars of clinical medical practice.