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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
Hello, and welcome to Health Affairs This Week. I'm your host, Jeff Byers. We are recording on 10/01/2025. Today, 10/01/2025 marks the first day of a government shutdown. This episode will be published on 10/10/2025.
Jeff Byers:So who's to say what might happen, in those in those days in between? But just know that we are not gonna talk about the government shutdown. Today, we are going to welcome Troy and Brennan from Harvard TH School of Public Health onto the program. He is the former CMO of, CVS Health. Troy just published his book titled Wonderful and Broken, The Complex Reality of Primary Care in The US.
Jeff Byers:And today, we're gonna be talking about that book. It's a very good book. I enjoyed it cover to cover in the pantheon of American sickness or social transformation of American medicine. If you're interested in primary care, you should check it out. And with that, Troy, welcome to the program.
Troyen Brennan:Thank you for having me.
Jeff Byers:This book seems largely written before the second Trump administration took office. I wanna discuss primary care and value based care, but I do think this would be a good scene setting. Since Trump took office and since the book was sent to printers, is there any outlook that you, like, might change or update now that the book is published?
Troyen Brennan:Not necessarily. I mean, I try to write in terms of sort of long term change, and you expect for there to be sort of wrenching differences between administrations, and that's certainly the case from Biden to, Trump too. But, I don't think anything we've seen so far changes the sort of long term outlook. I would say that the, Centers for Medicare and Medicaid Interventions, CMMI, did have several programs around primary care. People were very excited about the new program, Making Care Primary, and the Trump administration canceled that, which required some relatively quick editing of the book before it came out.
Troyen Brennan:They've also begun to take some steps with regard to physician payment and in particular putting efficiency adjustments in place that should drive some more money to physicians who do evaluation and management codes as opposed to procedure codes. That's a good thing. You'll have a relatively small impact. And with regard to the average primary care practice, most of that will be absorbed by the fact that there's going to be a substantial cutback in both the ACA exchange populations and Medicaid. So negative, I would say, from the point of view of the finances of the average practice.
Jeff Byers:And listeners, if you are interested in the cancellation of that value based care model that Troy mentioned, we did have a Health Affairs This Week episode on it. It is from this year. So back to the book, Wonderful and Broken. Troy, I wanna thank you for, citing one of my pieces from Health Care Dive back in 2018. I know it was only one citation that you may or may not be aware of on the UnitedHealth Optum section.
Jeff Byers:You know, I just wanna thank you that the buyer's name lives on, in the footnotes of history there. But the book presents itself as a book about primary care, but it largely relates and hinges on value based care. It paints a convincing argument for primary care and value based care, but it doesn't really present that great of a rosy outlook. How are value based care and primary care intertwined in your eyes?
Troyen Brennan:Well, think, you know, when we think about the American healthcare system, we usually think about two different ways to pay. One is now called value based care, used to be called managed care, can be called capitation, but it's prospective payment and recipient of the payment is responsible for the health of the individual patient. The other approach is retrospective payment, fee for service, and it's obviously dominant in the American healthcare system, and that's where you pay on a piece. Fee for service is what's killing primary care simply because the average visit is under compensated. And so for a provider group or a practice to make ends meet, pay salaries and have a thriving practice, they have to drive through patients at a rapid pace, fifteen, twenty, 30 patients a day, and you cannot get what you need from primary care, which is the long term continuous focus on the health of the patient in that format.
Troyen Brennan:So, in a value based approach, the primary care doctors can take their time, see patients more frequently, see them for longer periods of time, and help them plan how to promote their own health and how to prevent disease. So you need to get to a value based approach for primary care to thrive. And that's how I think they're intertwined.
Jeff Byers:Yeah, and how do you think the movement towards value based care is actually going right now?
Troyen Brennan:Well, everybody supports it. Everybody pays their lip service to it. And when I say everybody, I mean the federal government, the state governments, the state governments that think about these health policy kind of issues, the big insurers, the small insurers, and even sort of venture capitalists who are trying to support various aspects of healthcare. Everybody looks at the literature the same way, understands that you need a thriving primary care sector in order to have a good healthcare system, realizes that you can reduce costs and improve outcomes if you take a value based approach. And so they're promoting it.
Troyen Brennan:And I think the book provides evidence that that promotion is working. It's not something that's sort of dying off, it's not stultifying, It's actually thriving in certain places. And it gives examples of practices that are completely value based, but doing a great job of taking care of patients and financially quite confident.
Jeff Byers:Troy, can you remind me of the stat of like that CMMI was trying to Is it trying to get to like a 100% of transactions into a value based care arrangement and by 2030 is What is that? What was that goal?
Troyen Brennan:I don't think CMMI has exactly sort of published its expectations, but there's a consortium of providers and insurers that have put out a goal that we get to either capitated care or heavily value based care 100% by 02/1930. There's some progress in that direction. So the MSSP program, for instance, continues to thrive and recent literature suggests that, you know, it's doing an ever better job. So you can see places where there is real progress.
Jeff Byers:Yeah. And it's interesting you talk about this idea of people are promoting the idea of value based care or giving lip service to it, which in turn gives it promotion even if it's not happening all the time. So to me, a big underlying theme in this book is the diffusion of ideas and and really how long it takes for an idea to settle or become culturally dominant. You mentioned Catalyst Health was created in 2014, and you noted how Agilent stock is pretty low. I was checking today, and it's about $1 per share.
Jeff Byers:Is the momentum for primary care still building and or is it still proving itself as an idea to physicians and financial interest groups?
Troyen Brennan:Yeah, I think it is. There are certainly examples. I cite the South Central Foundation, which is the large integrated system that provides care for a large portion of the Alaskan native population. And they're completely prospective in terms of their outlook. There's no fee for service whatsoever.
Troyen Brennan:All the clinicians are salary and every patient has an individual doctor and healthcare team that helps take care of them and they get great outcomes. So it's a great example of a program, not dissimilar to Kaiser where you're getting really great outcomes from a prospective payment approach. I'd say the big impetus in the last decade really has been Medicare Advantage, which pays prospectively, and the development of primary care groups that take care of nothing but Medicare Advantage patients and do so on a capitated basis. And they're being challenged right now by the changes in coding that are occurring. I think there was group consensus in health policy and probably appropriately so, that, Medicare Advantage was being overpaid as a result of changes in coding that were, occurring and that there needed to be sort of a restriction in terms of the funds that are flowing there, and that's happening right now.
Troyen Brennan:So there are a number of those programs which are not doing as well as they once did, and I think that's related to the Agilent stock price. But overall, I find enough momentum, even in places that are sort of deep in fee for service, where there's a recognition, a broader and broader recognition that fee for service is not the way to go, that you have to get to a value based approach. So, you know, it's an American healthcare system, you have to be pretty patient, but I think we're headed in the right direction. Hope we are.
Jeff Byers:Yeah. So what might it take to get to peak primary care as a major talking point for policymakers?
Troyen Brennan:I think probably a little bit more, of a commitment on the part of the government to move towards prospective payment. And in this regard, the Trump two administration is at least being very supportive of that approach with regard to specialists. They're continuing the programs that pay specialists on a prospective basis. And then I think it's going to occur in the Medicaid sector no matter what, because they can't afford to provide care in a fee for service approach. They have to do value based care.
Troyen Brennan:And that's probably where I see the most progress is in the federally qualified health centers. Now they will be set back by the big and beautiful bill reduction in Medicaid and likely the demise of the premium supports in the ACA exchange programs. I think that the numbers that they're looking at is something like a 15% reduction in total dollars coming in. And that's extraordinarily unfortunate because that's a vital sector. And in many ways, the federally qualified health centers, think are leading the way with regard to innovation around value based care.
Jeff Byers:Yeah, I was going to mention, you write about a lot of different stakeholders and how they're tackling value based care and primary care. The chapter on Medicaid, which we unfortunately can't get into today too much, talks about innovation a lot. I thought it was a really interesting sector, but, you know, we can't give the whole book away. You know, people gotta buy it here instead of just talking about it on the podcast. But I did wanna just talk about how towards the end of the book, you discuss single payer as a remedy.
Jeff Byers:But how realistic is that considering the diffusion of ideas lens and that it's not really viewed well through like the general population holistically? Like rather do entrench players with deep pockets, are they going to work against this idea?
Troyen Brennan:Yeah, obviously there's going to be, for single payer, there's large insurers and PBMs who are absolutely opposed to it because it's their extinction. And I think it is difficult to see how you move to a single payer program. I published a book last year about this time on the transformation of American health insurance. And I do believe that the employer based segment will fail. It'll just become too expensive and employers will look for an option.
Troyen Brennan:And I think once the government will then be in a position where can they offer a government program to refugees from employer based insurance? And that could take one of two approaches. It could be a single payer, which would be a wrenching change as you suggest, although there are very serious proposals out there in Congress about setting up a single payer program. Or it could be a Medicare Advantage type program where the private insurers continue to play a role and you simply sort of convert people who were in employer based insurance over to a Medicare style program. So I think it's a possibility.
Troyen Brennan:The interesting thing I'd say in follow-up is that most of the primary care doctors I talked to, and especially the primary care doctors who are taking care of poor people or the uninsured, are incredible supporters of a single payer program. So insofar as there's a lot of support from the medical profession and the nurse practitioners and physician associates who are taking care of patients, I'd say there's at least a possibility that single payer could occur.
Jeff Byers:Going back to Medicare Advantage, you write about this paradox in Medicare Advantage of having a lot of fraud and being looked at critically recently with more restrictions on coding coming. We've kind of talked about this a little bit, but MA also has contributed to the advancement of value based care with a need to have standardized coding, which I thought was pretty interesting. For the listeners, can you unpack that?
Troyen Brennan:Yeah, I wouldn't say fraud necessarily. The largest problem with Medicare Advantage is simply that in fee for service, there's no need to do any coding. Any patient who comes in, you just need to put one code down. In Medicare Advantage, you want to put every code down possible because you want to get paid appropriately for the individual patient. What's happened is just that there's been exuberance around coding that the government didn't expect.
Troyen Brennan:And as a result, likely I think MedPAC's correct, overpayment of Medicare Advantage. Now that's a historical function. We've seen times over the course of last thirty years where there's been lower payments to Medicare Advantage and the Medicare Advantage program involutes. Then the Medicare Advantage program expands when payments are appropriate. We're now probably somewhere between 812% over what should be paid.
Troyen Brennan:But at the end of the Obama administration, that same number estimated by MedPAC was about 1%. So, you know, the government's got the levers to be able to control this. It'll be interesting to see how the Medicare Advantage companies adapt to lower payments. And some of those estimates, those lower payments come up to as much as sort of reductions based on simply the coding changes of 10%.
Jeff Byers:You write about private companies investing in and retreating from primary care. Can you share your experience as you can with CVS Health and Aetna on this front?
Troyen Brennan:Well, again, most primary care doctors are pretty suspicious of for profit insurers. On the other hand, I worked for a for profit corporation, CVS, one of the biggest, as one of the biggest insurers. We bought Aetna for $60,000,000,000 when I was there and I was very supportive of doing that. I think that don't realize is that within those companies there's a realization just as there is in the health policy world, the strong primary care base is your best approach to reducing healthcare costs. And as an insurer, what you're trying to do is offer a low cost product to your various different customers.
Troyen Brennan:So you're supportive of the same ideas that many of the people in health policy are. I would say at CVS, at least my vision of what we should do was that we needed to have an insurance company in order to be able to sort of take risks. That's why we bought Aetna. And then we needed to build a primary care base underneath that. And that's something that they've begun to do since I left now nearly three years ago.
Troyen Brennan:And I commend them on that. Others have dropped out of developing primary care. Walmart's probably the best example. They had various different kinds of plans, including plans for outlandish expansion, and now they've dropped out of it completely. So I think it'll be the healthcare companies that continue to do this, but you look at the strategy of Humana, OptumUnited, increasingly Elevance, even Cigna, they're all trying to take on integrated delivery systems through which they can affect the deliverance of care.
Troyen Brennan:So like one old practitioner told me, a guy who had organized a PPO in Western Colorado over forty years ago, he said the insurance companies have realized they've lost the game with regard to sort of reducing the amount they pay per service and I think they really have. But so now what they realize is that they have to control what services are being offered. And you know, there's a lot of inefficiency in The United States healthcare system. If you can cut that inefficiency in half, you can get 15% savings. And I think that's what the big companies have to be aimed at today.
Jeff Byers:In the book, have a lot of different examples of practices and organizations that were on the leading edge of primary care that you visited. So you visited a lot of practices and companies which have a lot of different arrangements utilizing primary care as a core element of care delivery. Was there any common through line that you noticed?
Troyen Brennan:Yeah, I'd say if you're looking for like a sign or a symptom that the practice is doing the right thing, the one that I found most compelling was every morning in the really good practices, the providers all get together and talk about their most difficult patients and they have good data that they show on a big board that shows what's been going on with their care population in terms of sort of utilization and costs. And there's a focus on keeping people out of the hospital and a focus on jumping on problems that could lead to hospitalization. And there's a real focus on the prevention steps that we take, whether they're vaccinations or appropriate care patterns for people with diabetes. So, you know, what that says is that they're looking prospectively, they're trying to anticipate problems that patients are going to have, and they're working as a team. These teams are the primary care providers, nurse practitioners, doctors, physician associates, social workers, care managers, pharmacists, and nurses, and they all meet as a team.
Troyen Brennan:So that's what you're looking for is a prospective approach, anticipation of problems, and team effort.
Jeff Byers:You end the book with 10 observations. So again, I don't wanna spoil the ending for listeners. You're gonna have to get your book, Wonderful and Broken, The Complex Reality of Primary Care in The United States. But you heated the perils of reliance solely on government intervention for the future of primary care to succeed. Why is that?
Jeff Byers:And how do you hope primary care moves forward?
Troyen Brennan:Well, I think it's often overlooked. Health policy experts have either been universities or the government, and that's kind of how they think about things. Sort of it's the government. But they have to realize that the people in large companies, insurers, big and small, for example, are looking at the same data and they're trying to sort of take the same steps and they understand sort of where they need to get to. And people are very suspicious of the profit motive in healthcare and I've written about that a lot over the years, but to put it sort of succinctly, if you can get a better product, healthier people whose care is carefully rendered by primary care doctors, and that leads to fewer poor outcomes and as a result, lower costs, that's what insurance companies are after with regard to their profit motive.
Troyen Brennan:So if they can bend the curve in terms of costs through better care, that's something that's really good for their shareholders. So in many ways, their interests are aligned with the people who are trying to guide the government when the government's thinking about care for, individuals.
Jeff Byers:Well, with that, Troy Brennan, thanks again for joining us today on Health Affairs This Week. And if you, the listener, enjoyed this, please send it to a friend. Leave a comment, publish a rating. It helps people find the show. Thanks, and we'll see you next week.