2. How do we take care of them when people are sick?
I agree on point 1. Even if we add a lot more PCPs tomorrow, we may not make big changes in keeping people healthy - as that is driven by societal factors ("health begins where you live, work and play).
Point 2 relates to making it easy to access care when people are sick or need follow up for chronic disease. This was not an issue 20-30 years ago. When you called your local PCP, you were able to see them within 1-2 days. If you were admitted to a hospital, your PCP would see you in the hospital. It promoted longitudinal care.
When PCPs are in private practice, they generally don't relocate, allowing them to build long-lasting relationships with their patients and the community. In contrast, employed PCPs often experience high turnover rates in large healthcare organizations. This "revolving door" effect hinders the development of longitudinal relationships between doctors and patients.
Healthcare is local. A private practicing doctor in a local community also knows people around them in other aspects of life e.g. living in same neighborhood, kids go to school together.
When you know someone in the community, empathy increases. You are more likely to take that phone call, or fit them in.
All these non-measurable factors disappear with employment and doctor churn at large organizations. All the quality measurement programs cannot hold a candle to human relationships that develop in small practices.
Also, over the last 30 years, revenue for PCP practices has consistently declined - so it not a surprise that private practices adjusted to the new financial reality with decline in services, including reduced access to appointments & care.
DPC is financial mechanism to try to bring back this relationship, but it also creates a 2 tier system - people who can afford the membership fees and those who cannot.
The challenge here is not DPC or FFS - but giving financial freedom to doctors to own and run the practice in their community. This is why I am such a big proponent of small private practices (and FWIW - all DPC practices are private practices).
I recall during my training and early years in academic medicine, how much private practice was somewhat looked down upon from the academics. Now looking back, in private practice, you are managing your patient population, and you have to have a great product - otherwise the business doesn't survive. The power differential between patient and provider is the smallest in a private practice. Whereas in employed models or academics, that power differential is wide.
I remember too that Academic hospitals looked down upon private practices. And larger academic hospitals also looked down upon smaller community hospitals when receiving patient transfers! The hierarchy is completely made up to preserve the "supply" of physicians in academia.
The interesting, and often overlooked fact is that while academic doctors looked down on their private practicing colleagues, the administrators/liaisons and specialists would constantly show up in private practices soliciting patient referrals!
Not sure what you mean by power differential between patient and provider. Information asymmetry leading to paternalism (my understanding of root cause of power differential) has been declining slowly everywhere with the rise of internet, which has empowered patients.
I wholeheartedly agree it needs to be deconstructed and rebuilt.
I’ve had the same Internist/PCM for over 35 years (he’s been the family doc for 3 generations - I’ll be crushed when he retires) and he has been my partner on a long journey managing the complexity and chronicity of a TBI for over 3 decades. I wouldn’t be where I am without his support, knowledge and desire for me to continue to follow my lifestyle medicine approach to healthy living.
In an overly specialized system, individuals with complex chronic issues need a partner, a home base, someone helping them keep track of everything and to stay on the right path. My experience for the better part of the last 4 decades is that’s exactly what primary care physicians are meant to do, and it makes them invaluable members of an individual’s health and wellness team.
I agree. I wonder how we can create those long term relationships when there is this supply and demand mismatch... rising senior population and less doctors to care for them. I think there is a pathway through technology - a bit of self service, async care with a trusted provider, virtual care, remote monitoring, etc.
Don’t forget having to wait on hold 30 minutes and then chat with a barely audible customer service rep for 20 minutes just to schedule or change an appointment that is a month away. It is madness.
I think there definitely are some like that. Others I've seen is just how to best manage your time and using the 'easier' button. I find myself doing this too. A teen who is obese - spend 20 mins talking about nutrition or check the box and refer to a nutritionist (that they may or may not see). When you have a lot of patients waiting and behind schedule, those pressures do mount.
To provide a helpful comment requires us to agree on the nature of the problem -- and we don't. Primary care isn't being driven by a need to provide better outcomes. It's being driven by an ability to achieve greater billing and profits as it is for every consulting field (engineering or medical). And just like every corporate culture, there is no such thing as enough profit. Please note that my PCP won't necessarily even know that I required hospitalization -- and certainly NOT consulted. See <www.killAbill.com> for a more complete explanation.
What's being missed is that the laws on healthcare and the in-network contracts (Insurer Provider Agreements) haven't changed, giving us the right to the same healthcare and coverage our parents could count on. However, we HAVE to know our rights and then advocate for ourself. The evolving healthcare system is simply counting on us to remain uninformed, compliant and an an easy victim. It's all about the money not healthcare. But, there is a clear path to the care and coverage we are still owed if we take a moment or two to understand the fraud in the game. See www.killAbill.com.
I switched to direct primary care about 6 months ago. I can say that I will never go back. The quality of care is just so much better. And I didn't leave a bad doctor.
Hi there, I’ve enjoyed your work. I’m a long-time gastroenterologist and I just joined Substack as well. I’ve been blogging for 16 years, but on another platform. Best wishes.
Especially when there is an industry built to actively prevent that from happening. Payers in particular have no interest in sharing that practice level data with us.
Hi Dr. Shah! Interesting insight about private models versus academic ones. I strongly agree about enabling alternative payment models to encourage more personalized and preventative care.
I’m actually writing an article about reforming the ONC Certification Program for Health IT. It’s my belief that utilizing TEFCA, and a more outcome focused ONC program would allow digital health to thrive.
I’m curious what you think? Or if you identify a different chokepoint?
Look practicing in a Poor Country can add positively to single country centered narratives:
1.- Poor treatment of patients and/or customers is a way to deal with over demand. It is a way to limit access to resources already over-utilized. Meaning too many people see Primary Care Providers, not the opposite.And too much money is spent on low or poor quality interventions that only increase costs, even harms to patients...
2.- People pay what people value what they pay for. If people don´t want to pay for Primary Care, most likely it is because they see no value in it. That does not mean they are wrong. Economics has shown for decades, aggregates of people can value things without knowing the fundamentals to do so. It is solidly shown in many areas of Markets and Economics. How many years of life does it give to a Diabetic patient taking their Pills for how many years among how many hundred of similar People?. For instance...
3.- Providers tend to exaggerate the value they claim they contribute with their work. That has also been shown several times: "Oh, I´ve seen patients living with that cancer for decades!", without saying "I´ve also seen my patients dying on the first day of chemo". That has been narrated even by ooother Physicians.
Some even claim they do things won´t work for most People: Like preventing chronic diseases running their course in over 99% of People (that is not an NNT btw). Simple as that, and People know that even if they don´t know how: that´s how markets and their incentives work, like an invisible hand...
4.- Physicians had not openly discussed how many more patients they killed by using antihypertensives that killed more people than they saved for decades.
Nor admitted they were willing to prescribe Cox-2 inhibitors, despite the known biochemical risk they cause thrombosis.
Nor their widespread use of ASA for primary, not secondary prevention of CVD, and thereby killing more elderly people than saved with that.
Nor their use of HRT that induced more cancers than prevented bone fractures and increased, if I remember correctly, increased CVD risk.
Nor the inefficacy and high cost of biphosphonates for Osteoporosis.
Nor I ever heard a single Health Care Provider telling a Patient a CT Scan has a risk of 1 in 2,000 to 1 in 10,000 of causing a cancer, before asking for an informed consent from the patient.
And in that Primary Care Physicians: GPs, Family, OBGYN, Internists and Pediatricians are the main responsible folks.
There are more examples, probably of that irresponsibility: they didn´t answered, the opioid epidemic is just one more example...
Definitely hear you on the issues. My question would be what is the solution? Payment mechanism, training, technology checks. We do have an abundance of regulatory oversight, that seems burdensome and not that great too. state medical boards, hospital privileging, specialty board societies, etc.
1.- Well, if there is resource overuse: less use of the resource.
2.- If the value is poor or low, then allocate resources to other stuff, meaning use less money for GPs, not more. That means less GPs, not more...
3.-For practitioners what they have being doing: quit and devote yourself to something else. Not only is morally wrong to be treated badly, it is legally dubious to work willingly and knowingly under circumstances that are risky or harmful for patients.
So far it describes reality, what is happening, right?.
4.- For prospective medical students or those already there: quit, devout yourself to something else. In a few years after graduation, after getting your MD, like many Physicians you will not only be thinking about quitting, you will be actually quitting.
5.- As for moving forward as a society: Honesty and transparency. Answering those questions I asked is a first, and a must...
So far, 4 and 5 have not happened. Those are things only current Medical Practitioners can answer those and make them public in a broad way: Don´t go into Medicine, it has a lot of problems that won´t be solved within medicine nor with medical research. Medical Research as has been written extensively as harmful for patients, and it leads to Medicine having low value for other People. And has become progressively more expensive to get, and more expensive to provide, with less value added over time.
There's also so much low value primary care that goes on... Looking at you, the letter to attest my daughter has a disability... Not the PCPs fault, but when you end up as the one filling in all these puerile forms, it's hard to think this is a speciality I want to go into ... Plus so much preventative medicine is never going to benefit most patients... Even COVID vaccines never benefit most people... (Looking at the unvaccinated centenarian in my social circle who survived covid just fine... To my disappointment, given the impact of her dementia on her carers)... When your day seems to be so much routine preventative care (I think best case scenario, for a pcp success story, there's something like a one in a thousand chance a cervical smear will help the woman and a one in ten chance it'll result in an unnecessary colposcopy...) and the same-day acute care which was what PCPs "did" in the olden days is now the province of random strangers in urgent care centres who I'm certainly not telling my medical history history to... That acute care which was provided by the dr who lived next door who was a member of the community who knew everybody and everybody knew them, and in my eyes that made primary care far more interesting when it was part of the mix of primary care. As a med student I always thought I'd go into primary care until I discovered how much low value preventative care and paperwork it is (unless you do the poorly remunerated mental illness work) - the general acute care mix of my childhood PCP (I grew up in a remote area) doesn't exist anymore, sadly.
I do hugely value my personal PCPs, but it's those I've managed to wrangle an old-style relationship with, when I'll make the last appointment of the day and we'll just chat for an hour... Those who will fit me in for a same-day appointment for that idiotic piece of paperwork I need for work... or that UTI script... Because you have a huge gate-keeping role, I do value the priority I am given by you the PCP gate-keeper, but I guess thus far I've been able to manage all my PCP medical issues with my level of medical knowledge, so I haven't personally come across any PCP magic or seen it when a student on placement (the specialist manages my serious illness and really is my go-to if my PCP is ever uncooperative - as in right now my PCP refused to write a copy of my prescriptions for border force purposes so I could carry it with me on international travel to present to Middle Eastern (particularly fussy about prohibited prescriptions) and European border forces, saying it was medicolegally inadvisable to write what is effectively a script for a double quantity of meds, if he writes one for me to carry with me... (He has a point, but given every single border force wants you to carry the prescription and the meds, and border force's advice is don't fly if you don't have the prescriptions...!) Fortunately the specialist had no such qualms and wrote his and my pcps scripts- his idea of a legal issue is something that will land him in the coroner's court and reckoned this wasn't that - and even wrote the prescriptions out on the German pdf prescription form to meet Austrian requirements - so yeah, if you choose to be uncooperative in your gate-keeping role, and I didn't have a specialist on tap, as a patient I would have been screwed and you would have reinforced the "need" for a cooperative PCP.
Good points, I think we just have to fundamentally reimagine the primary care role to be this longitudinal care partner that guides, offers advice, and has the right tooling to scale - async visits, remote monitoring, self service tools, etc.
Direct Primary Care and concierge medicine are indeed growing models, and I fully support leveraging free-market principles to enhance care and create better healthcare experiences. However, I find this approach to be in direct contradiction to the discussion of Medicaid in your next paragraph. How do you reconcile these two models—a system funded by the middle and upper class versus one reliant on government subsidies?
Additionally, do you have any data on patient outcomes within concierge practices?
This is undoubtedly an important and timely conversation, though finding a comprehensive solution to balance these opposing systems may prove exceedingly challenging.
You're right Jordan, often innovation in care delivery stays with those with means and doesn't transcend across socioeconomic groups. But what I'm seeing with Medicare Advantage Plans like SCAN Health or Medicaid Managed Care & Medicaid State Agencies like in North Carolina - there momentum to try new things and a willingness for it. Also so fed regulations like the 1115 waiver for Medicaid allows some flexibility to try out new models. Definitely not to the place where those who can afford concierge medicine. But if there is 1st grant or philanthropy funding to innovate new model of care for a hard to reach group, and then 2nd use that research to take a swing with a MA plan or Medicaid MCO.... it could be possible?
This article raises 2 questions:
1. How do we keep people healthy?
2. How do we take care of them when people are sick?
I agree on point 1. Even if we add a lot more PCPs tomorrow, we may not make big changes in keeping people healthy - as that is driven by societal factors ("health begins where you live, work and play).
Point 2 relates to making it easy to access care when people are sick or need follow up for chronic disease. This was not an issue 20-30 years ago. When you called your local PCP, you were able to see them within 1-2 days. If you were admitted to a hospital, your PCP would see you in the hospital. It promoted longitudinal care.
When PCPs are in private practice, they generally don't relocate, allowing them to build long-lasting relationships with their patients and the community. In contrast, employed PCPs often experience high turnover rates in large healthcare organizations. This "revolving door" effect hinders the development of longitudinal relationships between doctors and patients.
Healthcare is local. A private practicing doctor in a local community also knows people around them in other aspects of life e.g. living in same neighborhood, kids go to school together.
When you know someone in the community, empathy increases. You are more likely to take that phone call, or fit them in.
All these non-measurable factors disappear with employment and doctor churn at large organizations. All the quality measurement programs cannot hold a candle to human relationships that develop in small practices.
Also, over the last 30 years, revenue for PCP practices has consistently declined - so it not a surprise that private practices adjusted to the new financial reality with decline in services, including reduced access to appointments & care.
DPC is financial mechanism to try to bring back this relationship, but it also creates a 2 tier system - people who can afford the membership fees and those who cannot.
The challenge here is not DPC or FFS - but giving financial freedom to doctors to own and run the practice in their community. This is why I am such a big proponent of small private practices (and FWIW - all DPC practices are private practices).
I recall during my training and early years in academic medicine, how much private practice was somewhat looked down upon from the academics. Now looking back, in private practice, you are managing your patient population, and you have to have a great product - otherwise the business doesn't survive. The power differential between patient and provider is the smallest in a private practice. Whereas in employed models or academics, that power differential is wide.
I remember too that Academic hospitals looked down upon private practices. And larger academic hospitals also looked down upon smaller community hospitals when receiving patient transfers! The hierarchy is completely made up to preserve the "supply" of physicians in academia.
The interesting, and often overlooked fact is that while academic doctors looked down on their private practicing colleagues, the administrators/liaisons and specialists would constantly show up in private practices soliciting patient referrals!
Not sure what you mean by power differential between patient and provider. Information asymmetry leading to paternalism (my understanding of root cause of power differential) has been declining slowly everywhere with the rise of internet, which has empowered patients.
I wholeheartedly agree it needs to be deconstructed and rebuilt.
I’ve had the same Internist/PCM for over 35 years (he’s been the family doc for 3 generations - I’ll be crushed when he retires) and he has been my partner on a long journey managing the complexity and chronicity of a TBI for over 3 decades. I wouldn’t be where I am without his support, knowledge and desire for me to continue to follow my lifestyle medicine approach to healthy living.
In an overly specialized system, individuals with complex chronic issues need a partner, a home base, someone helping them keep track of everything and to stay on the right path. My experience for the better part of the last 4 decades is that’s exactly what primary care physicians are meant to do, and it makes them invaluable members of an individual’s health and wellness team.
I agree. I wonder how we can create those long term relationships when there is this supply and demand mismatch... rising senior population and less doctors to care for them. I think there is a pathway through technology - a bit of self service, async care with a trusted provider, virtual care, remote monitoring, etc.
Don’t forget having to wait on hold 30 minutes and then chat with a barely audible customer service rep for 20 minutes just to schedule or change an appointment that is a month away. It is madness.
Or now get rerouted to a bot and never talk to a human!
Few are good. Most just want to refer you to another physician. They seem disinterested in actually doing the right following
I think there definitely are some like that. Others I've seen is just how to best manage your time and using the 'easier' button. I find myself doing this too. A teen who is obese - spend 20 mins talking about nutrition or check the box and refer to a nutritionist (that they may or may not see). When you have a lot of patients waiting and behind schedule, those pressures do mount.
To provide a helpful comment requires us to agree on the nature of the problem -- and we don't. Primary care isn't being driven by a need to provide better outcomes. It's being driven by an ability to achieve greater billing and profits as it is for every consulting field (engineering or medical). And just like every corporate culture, there is no such thing as enough profit. Please note that my PCP won't necessarily even know that I required hospitalization -- and certainly NOT consulted. See <www.killAbill.com> for a more complete explanation.
Recent Acquired podcast episode about Epic really makes this point well. EHRs are billing machines and facilitating patient care second (or fifth!)
What's being missed is that the laws on healthcare and the in-network contracts (Insurer Provider Agreements) haven't changed, giving us the right to the same healthcare and coverage our parents could count on. However, we HAVE to know our rights and then advocate for ourself. The evolving healthcare system is simply counting on us to remain uninformed, compliant and an an easy victim. It's all about the money not healthcare. But, there is a clear path to the care and coverage we are still owed if we take a moment or two to understand the fraud in the game. See www.killAbill.com.
I switched to direct primary care about 6 months ago. I can say that I will never go back. The quality of care is just so much better. And I didn't leave a bad doctor.
Hi there, I’ve enjoyed your work. I’m a long-time gastroenterologist and I just joined Substack as well. I’ve been blogging for 16 years, but on another platform. Best wishes.
Thanks! Looking forward to hearing what you think, where you agree, and more so where you disagree :)
re #3 about tracking own data -- really tough to do without spending more on overhead. I am rooting for innovations in this space
Especially when there is an industry built to actively prevent that from happening. Payers in particular have no interest in sharing that practice level data with us.
Hi Dr. Shah! Interesting insight about private models versus academic ones. I strongly agree about enabling alternative payment models to encourage more personalized and preventative care.
I’m actually writing an article about reforming the ONC Certification Program for Health IT. It’s my belief that utilizing TEFCA, and a more outcome focused ONC program would allow digital health to thrive.
I’m curious what you think? Or if you identify a different chokepoint?
Look practicing in a Poor Country can add positively to single country centered narratives:
1.- Poor treatment of patients and/or customers is a way to deal with over demand. It is a way to limit access to resources already over-utilized. Meaning too many people see Primary Care Providers, not the opposite.And too much money is spent on low or poor quality interventions that only increase costs, even harms to patients...
2.- People pay what people value what they pay for. If people don´t want to pay for Primary Care, most likely it is because they see no value in it. That does not mean they are wrong. Economics has shown for decades, aggregates of people can value things without knowing the fundamentals to do so. It is solidly shown in many areas of Markets and Economics. How many years of life does it give to a Diabetic patient taking their Pills for how many years among how many hundred of similar People?. For instance...
3.- Providers tend to exaggerate the value they claim they contribute with their work. That has also been shown several times: "Oh, I´ve seen patients living with that cancer for decades!", without saying "I´ve also seen my patients dying on the first day of chemo". That has been narrated even by ooother Physicians.
Some even claim they do things won´t work for most People: Like preventing chronic diseases running their course in over 99% of People (that is not an NNT btw). Simple as that, and People know that even if they don´t know how: that´s how markets and their incentives work, like an invisible hand...
4.- Physicians had not openly discussed how many more patients they killed by using antihypertensives that killed more people than they saved for decades.
Nor admitted they were willing to prescribe Cox-2 inhibitors, despite the known biochemical risk they cause thrombosis.
Nor their widespread use of ASA for primary, not secondary prevention of CVD, and thereby killing more elderly people than saved with that.
Nor their use of HRT that induced more cancers than prevented bone fractures and increased, if I remember correctly, increased CVD risk.
Nor the inefficacy and high cost of biphosphonates for Osteoporosis.
Nor I ever heard a single Health Care Provider telling a Patient a CT Scan has a risk of 1 in 2,000 to 1 in 10,000 of causing a cancer, before asking for an informed consent from the patient.
And in that Primary Care Physicians: GPs, Family, OBGYN, Internists and Pediatricians are the main responsible folks.
There are more examples, probably of that irresponsibility: they didn´t answered, the opioid epidemic is just one more example...
Definitely hear you on the issues. My question would be what is the solution? Payment mechanism, training, technology checks. We do have an abundance of regulatory oversight, that seems burdensome and not that great too. state medical boards, hospital privileging, specialty board societies, etc.
1.- Well, if there is resource overuse: less use of the resource.
2.- If the value is poor or low, then allocate resources to other stuff, meaning use less money for GPs, not more. That means less GPs, not more...
3.-For practitioners what they have being doing: quit and devote yourself to something else. Not only is morally wrong to be treated badly, it is legally dubious to work willingly and knowingly under circumstances that are risky or harmful for patients.
So far it describes reality, what is happening, right?.
4.- For prospective medical students or those already there: quit, devout yourself to something else. In a few years after graduation, after getting your MD, like many Physicians you will not only be thinking about quitting, you will be actually quitting.
5.- As for moving forward as a society: Honesty and transparency. Answering those questions I asked is a first, and a must...
So far, 4 and 5 have not happened. Those are things only current Medical Practitioners can answer those and make them public in a broad way: Don´t go into Medicine, it has a lot of problems that won´t be solved within medicine nor with medical research. Medical Research as has been written extensively as harmful for patients, and it leads to Medicine having low value for other People. And has become progressively more expensive to get, and more expensive to provide, with less value added over time.
There's also so much low value primary care that goes on... Looking at you, the letter to attest my daughter has a disability... Not the PCPs fault, but when you end up as the one filling in all these puerile forms, it's hard to think this is a speciality I want to go into ... Plus so much preventative medicine is never going to benefit most patients... Even COVID vaccines never benefit most people... (Looking at the unvaccinated centenarian in my social circle who survived covid just fine... To my disappointment, given the impact of her dementia on her carers)... When your day seems to be so much routine preventative care (I think best case scenario, for a pcp success story, there's something like a one in a thousand chance a cervical smear will help the woman and a one in ten chance it'll result in an unnecessary colposcopy...) and the same-day acute care which was what PCPs "did" in the olden days is now the province of random strangers in urgent care centres who I'm certainly not telling my medical history history to... That acute care which was provided by the dr who lived next door who was a member of the community who knew everybody and everybody knew them, and in my eyes that made primary care far more interesting when it was part of the mix of primary care. As a med student I always thought I'd go into primary care until I discovered how much low value preventative care and paperwork it is (unless you do the poorly remunerated mental illness work) - the general acute care mix of my childhood PCP (I grew up in a remote area) doesn't exist anymore, sadly.
I do hugely value my personal PCPs, but it's those I've managed to wrangle an old-style relationship with, when I'll make the last appointment of the day and we'll just chat for an hour... Those who will fit me in for a same-day appointment for that idiotic piece of paperwork I need for work... or that UTI script... Because you have a huge gate-keeping role, I do value the priority I am given by you the PCP gate-keeper, but I guess thus far I've been able to manage all my PCP medical issues with my level of medical knowledge, so I haven't personally come across any PCP magic or seen it when a student on placement (the specialist manages my serious illness and really is my go-to if my PCP is ever uncooperative - as in right now my PCP refused to write a copy of my prescriptions for border force purposes so I could carry it with me on international travel to present to Middle Eastern (particularly fussy about prohibited prescriptions) and European border forces, saying it was medicolegally inadvisable to write what is effectively a script for a double quantity of meds, if he writes one for me to carry with me... (He has a point, but given every single border force wants you to carry the prescription and the meds, and border force's advice is don't fly if you don't have the prescriptions...!) Fortunately the specialist had no such qualms and wrote his and my pcps scripts- his idea of a legal issue is something that will land him in the coroner's court and reckoned this wasn't that - and even wrote the prescriptions out on the German pdf prescription form to meet Austrian requirements - so yeah, if you choose to be uncooperative in your gate-keeping role, and I didn't have a specialist on tap, as a patient I would have been screwed and you would have reinforced the "need" for a cooperative PCP.
Good points, I think we just have to fundamentally reimagine the primary care role to be this longitudinal care partner that guides, offers advice, and has the right tooling to scale - async visits, remote monitoring, self service tools, etc.
Direct Primary Care and concierge medicine are indeed growing models, and I fully support leveraging free-market principles to enhance care and create better healthcare experiences. However, I find this approach to be in direct contradiction to the discussion of Medicaid in your next paragraph. How do you reconcile these two models—a system funded by the middle and upper class versus one reliant on government subsidies?
Additionally, do you have any data on patient outcomes within concierge practices?
This is undoubtedly an important and timely conversation, though finding a comprehensive solution to balance these opposing systems may prove exceedingly challenging.
You're right Jordan, often innovation in care delivery stays with those with means and doesn't transcend across socioeconomic groups. But what I'm seeing with Medicare Advantage Plans like SCAN Health or Medicaid Managed Care & Medicaid State Agencies like in North Carolina - there momentum to try new things and a willingness for it. Also so fed regulations like the 1115 waiver for Medicaid allows some flexibility to try out new models. Definitely not to the place where those who can afford concierge medicine. But if there is 1st grant or philanthropy funding to innovate new model of care for a hard to reach group, and then 2nd use that research to take a swing with a MA plan or Medicaid MCO.... it could be possible?