The Future of Primary Care Is Independence And It’s More Lucrative Than You Think

“I think it is true that physicians are cogs in that big machine when you're part of an employed system, and you got to ask yourself what is the machine's goals?”

Dr. Farzad Mostashari is a physician, health policy leader, and the CEO of Aledade—a company helping independent primary care practices thrive in a system that often works against them. He’s also the former National Coordinator for Health IT, where he led one of the most ambitious digital infrastructure rollouts in healthcare history. But across every role, one mission has guided his work: fixing the machine of American healthcare by empowering the people closest to patients.

In this episode of How I Doctor, Dr. Graham Walker talks with Farzad about what really drives physician burnout, the perverse incentives behind hospital consolidation, and why doctors are too often treated as interchangeable cogs in a system built for billing—not healing. But it’s not all doom and gloom. Farzad offers real solutions, backed by data, and reveals why independent practices are starting to win big in a shifting payment landscape. If you’ve ever wondered whether it’s possible to practice medicine your way—and still get paid—this conversation proves the answer might finally be yes.

Here are four of the biggest takeaways from this powerful conversation with Farzad and Graham:

Why Primary Care Is Finally Getting Paid to Prevent Illness

“Many of our primary care practices this year are going to get more in one check...that came from keeping people healthy and out of the hospital than they did billing fee-for-service all year long for those patients. That's when you actually get a different business model.”

For decades, the system has paid doctors more to treat strokes than to prevent them. Farzad explains how that’s changing—slowly but surely—through value-based payment models. By keeping patients out of the hospital, independent primary care doctors are now generating real savings for the system and seeing those savings come back to them. It’s a rare win-win in healthcare—and a glimpse at what the future could look like.

The True Cause of Burnout? Moral Misalignment

“This is what I think leads to a fair amount of burnout is where individual physicians, clinicians know that what their day job demands of them. what their fealty to their organizations, what the CFO wants is different than what they know in an ideal system they'd be able to provide for their patients.”

Farzad argues that physician burnout isn’t just about long hours or documentation—it’s about being trapped in systems that ask you to compromise your values. When doctors work for organizations whose financial goals are misaligned with patient care, it creates a kind of moral injury. Independent practice, he says, can restore that alignment and give doctors the autonomy to do what they believe is right.

Independent Practices Have More Power Than You Think

“It's like 100 PCPs is a billion-dollar enterprise? That doesn't seem possible.”

It’s not about being small—it’s about being smart. Farzad breaks down the math behind how independent physicians can build serious leverage with payers and outperform large systems on both outcomes and cost. He also shares why so many doctors don’t realize their own power—and how that’s starting to change as new infrastructure and support networks emerge to help small practices succeed.

You Can Be Part of Something Bigger Without Selling Out

“Practices can be autonomous, but not atomic. The other thing we're seeing is how alone practices feel, where they just feel like there's nobody for them to support them. And I think being part of a community of like-minded practices is actually one of the powerful things we've found.”

One of the biggest myths about independence is that it’s isolating. Farzad challenges that idea with examples of how practices can retain full clinical control while still joining larger networks for data, tech, and contract support. It’s about building a new kind of community—one that respects physician autonomy, rewards quality care, and helps doctors build sustainable, satisfying careers.

Connect further with Farzad on LinkedIn and find out more about his work with Aledade at https://aledade.com/

To make sure you don’t miss an episode of How I Doctor, subscribe to the show wherever you listen to podcasts. You can also read the full transcript of the episode below.

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Transcript

Farzad Mostashari:
I think it is true that physicians are cogs in that big machine when you're part of an employed system, and you got to ask yourself what is the machine's goals, and in a very analytic way? Like let's call it spade a spade. What is this machine that I've agreed to become a cog in? What is the machine's goals?

Graham Walker:
Welcome to How I Doctor, where we're bringing joy back to medicine.
Today I get to spend time with someone who spent his recent career asking a question that matters more than ever.

Why Primary Care Independence Matters More Than Ever

Can primary care stay independent? And if so, how?
Dr. Farzad Mostashari has had an incredible career, but I want to get back to his work today because more and more physicians are being pushed into becoming employees, not just by hospitals, but by private equity and insurance companies. And for a lot of physicians, especially in primary care, it can feel like the only options are to sell or to drown. Independence looks impossible.
But as the CEO of Aledade, he has a different perspective. He's been on the front lines of health policy, health tech and practice transformation for decades. His work is grounded in a belief that independent primary care isn't just worth saving, but it may be the key to fixing so much of what is broken in American health care. Farzad doesn't just talk systems. He talks solutions. And in full disclosure, he is one of our angel investors with Offcall.
Farzad, welcome to How I Doctor. Thanks for being here.

FM:
Really glad to be speaking to you and to the audience.

GW:
Farzad, let's just start with the big picture. What do you think is the most urgent challenge facing primary care physicians right now today?

FM:
It does seem like I've done a bunch of different things in my career, but in actuality, it's been trying to answer the same question seven different ways, which is how do we change the healthcare system into being one that truly tries to answer the question, how do we save the most lives?
And the answer to that obviously is through more prevention, more primary care, better chronic disease management.
And then the question then is like, well, why don't we do it? And fundamentally, I used to think that there's this three-part problem. You got to have data and technology, you got to have new workflows, and you got to have a payment system.
And I was like, look, let's start with the technology parts, and then we can use that to orient the workflows and the payment system.
And I was wrong. I think what we needed to do was to first focus on getting an aligned payment system that

From Fee-for-Service to Shared Savings: Flipping the Healthcare Incentive Model

makes it more profitable to prevent strokes than it is to treat strokes.
And that's where independent physicians come in from a very first principles sort of way. When we were starting Aledade 11, 12 years ago, I was like, okay, there's this window in American healthcare where the old rules don't hold, where the most powerful people are not the people who can negotiate because they're the biggest and baddest. It's the people who are in this position of strength because they are the trusted sources who can help actually do prevention and who don't get hurt when a patient doesn't get admitted to the hospital.
And those are independent primary care practices. The whole power structure in healthcare inverts when payment flips from negotiating fee schedules to keeping people healthy and out of the hospital.

GW:
It's really interesting you frame it that way because there's been a lot of discussion about prevention and making America healthy again.
I certainly feel like I'm an ER doctor, but I still feel kind of blamed that I'm part of like this system that's trying to keep people on medicines, and this belief that I'm doing the wrong thing.
But I think, too, all sorts of physicians, primary care and otherwise, so much of what we do feels like we're trying to do prevention and we're actually viewed entirely opposite, that we're all like complicit in this big system that's actually trying to make a bunch of money off of kind of keeping people sick.

FM:
And here's the thing, we are, we are, every one of us embedded in a larger organization with organizational incentives. And this is what I think leads to a fair amount of burnout is where individual physicians, clinicians know that what their day job demands of them, what their

The Moral Injury of Employed Medicine

fealty to their organizations, what the CFO wants is different than what they know in an ideal system they'd be able to provide for their patients.
It's that discordance, that kind of moral conflict that I think eats away at people and is one of the best reasons to be independent and be able to make decisions, just in the patient's best interest and hopefully in a way that's aligned.

GW:
It feels like there's two fundamental frictions that I don't know how to escape. One is the individual practice of medicine where each person you see is a unique biological entity and you have to take that. You have to take all of their situations and all their past medical surgery and what meds they take and come up with a unique plan for each person versus the system wants everybody to be treated the same way because you can scale things better that way.

FM:
Well, it's also, Graham, the system will spend enormous amounts of time, attention and money to do things that maximize its profits or its retained earnings if you are a non-profit hospital. It's like why is there always money for like this thing, but there is never money to do that thing?
Well, look to the organization's incentives, and I think it is true that physicians are cogs in that big machine when you're part of an employed system, and you got to ask yourself what is the machine's goals and in a very analytic way? Like, let's call a spade a spade. What is this machine that I've agreed to become a cog in? What is the machine's goals? What makes the machine happy, and is that what makes me happy?
And I think

Building a Business Model Around Physician Autonomy

the ability to define your own machine and to define a business model that is more aligned with what makes you happy and also the ability to set your own schedule. That's the other thing, the two big things that I think are arguments for dealing with all the undoubtedly like pain-in-the-butt things that go along with being in an independent practice.

GW:
Who's responsible for the current machine, from your perspective? I mean, you've worked in so many different organizations, the federal government, public health, you're now in a private company. Is it the payers? Is it Congress? How do you think about why this machine is driving in a certain direction that it is?

FM:
Who made the machine? Good intentions.

GW:
I love that. Oh, I love that. Yes.

FM:
You know, it's like we're dealing with all of the efforts to patch over all the problems. Let's put in these modifiers, and let's make sure that we have integrity, payment integrity and, well, there's overuse of this thing, so let's do UN, and let's have denials, and let's have prior off and let's have this incredibly Byzantine system from Mipsylandia for determining whether you get a 1.2% raise or not.
Like it's insane, but all of it came from trying to put one patch on top of another for fundamentally a system that rewards volume and like the things that you can bill more for versus outcomes.
And I think finally we have a window for changing the game, changing the game so that many of our primary care practices this year are going to get more in one check, one shared savings check, that came from keeping people healthy and out of the hospital than they did billing fee-for-service all year long for those patients. That's when you actually get a different business model.

GW:
Now you've got me interested. That's a pretty incredible thing you just said. I'm sure every doctor will be interested in, well, how do I get on that train? So tell me where that's coming from.

FM:
And they should.

How Independent Practices Can Compete—and Win

Every primary care practice, every independent primary care practice should get on that train. And the reality is that we have virtually all the large practices in the country in the Medicare Shared Savings Program, and the vast majority of smaller and independent practices not yet in the program because of the complexity. And that's what we set out to do.
In New York City when I was with the City Health Department, we did the Primary Care Information Project, which was giving small independent practices the supports they needed to transition from paper and pen to electronic health records. In the federal government, we set up the regional extension centers, the health IT extension centers, doing that nationwide, and at Aledade we are doing the same thing. We have our local boots on the ground that helps these small practices be able to get the contracts, the workflows, the data, the software, all that you need in order to succeed in these models.
Because it really is the way to get primary care paid like specialists is focus, focus on the thing that's plays our strength, which is primary care and prevention in a shared savings model.

GW:
Where are those dollars coming from?

FM:
Basically saving the system from cost and saving the patient from suffering. In between being national coordinator for health IT and starting Aledade, I was at the Brookings Institute studying physician-led ACOs. And we did a toolkit and conference and all that, and I kept writing this, scribbling this on every surface. I would be like, okay, but does this make sense?
Like you get one accountable care organization with 100 primary care docs, each doc, do the math, Graham. We got 100 primary care physicians. Each primary care physician cares for a panel of, I don't know, 2,000 patients. If you could get all of those patients in a total cost-of-care contract, each patient has $5,000 a year in total medical cost per year.
So what's 100 PCPs times 2,000 patients per PCP times $5,000 per patient per year? How many dollars a year is that? It's a billion. It's like 100 PCPs is a billion-dollar enterprise? What? Doesn't seem possible.

GW:
Yeah, that does not seem possible. Wow.

FM:
Right? But it is. That kind of leverage is the whole thing. Primary care is like 5% of the total cost of care, and we're getting 10, 12, 14, 16% savings on total cost of care by reducing hospitalizations. That's it. More access to primary care, better chronic disease management, better follow-up.
And every primary care doc knows that they could. Like give me the tools, give me the resources, and, of course, I could prevent more hospitalizations. And now it's like, let's do it. And we are doing it, and it's like 2% a year slower trend in total cost of care, 2%, but it builds, it compounds.
So the net of that is last year we distributed about $350 million to community primary care practices.

GW:
Wow.

FM:
This year is going to be north of $500 million.

GW:
That's incredible. I mean, it also just goes to show you just how massive the healthcare system is. It's really hard for humans to fully comprehend just numbers of, I think we may hit 4.8 trillion in 2025 spending for the whole system and just how large that number is, it actually makes a billion dollars for 100 PCPs not even that big anymore.

FM:
Crazy, yeah.

GW:
Yeah. Does this make the work of documenting that prevention more palatable to these primary care practices that you work with?
I mean, I think that's the other piece that people get frustrated with is just the carrots and sticks, the requirements that these physicians have to go through. But maybe those are way easier to handle because they're getting paid, like you said, they're playing to their strengths, and they're being paid to prove how good of a preventionist they are.

FM:
I think documentation is the bane of every physician's life. It used to be like we wrote notes for ourselves, and then we're writing notes for ourselves and our colleagues and the malpractice lawyer and the billing department and the... It's like these notes are expanding more and more.
People just get used to the idea that for their fee-for-service billing to justify the 99214, they have to do, put all this crap in on every visit, like 20 times a day you're doing that, but once a year you got to document the burden of illness for the number of chronic conditions the patient has.
Otherwise, the rest of it is just doing the right thing and focusing on keeping the patient out of the hospital and healthy and managing their chronic conditions and thinking about like what's going to get this person in trouble over the next year. And if they go to the ER, having a system in the practice where the patient gets a phone call and says, how are you doing? Those are the fundamentals of kind of value-based care.
And then, yeah, then there's wraparound supports that we offer so that practices can be autonomous, but not atomic. The other thing we're seeing is how alone practices feel, where they just feel like there's nobody, nobody for them to support them.
And I think being part of a community of like-minded practices is actually one of the powerful things we've found. And to the extent that we can during the change healthcare things, Aledade made available $100 million of credit for practices. During COVID we helped them get up on telehealth and found PPE for them and so forth.
So being part of something bigger, but without giving up your ability to control your own life, I think, is the best of both worlds.

GW:
What do you find are the advantages of independent practice for physicians and then for patients as well?

FM:
You know, it's interesting when you talk to people who are not in healthcare, there's a little bit of a sense of like, "Well, what are you talking about? We don't have 10,000 car-makers anymore, like it's not efficient."
That's the exact opposite in healthcare. In healthcare, when you create these behemoths, the patient doesn't get higher quality care. That's proven. All the research in the world shows that.
My dad, he got a healthcare scare, and he put on his suit and tie and drove to the hospital and parked in the parking lot and paid for which he hates. He hates paying for parking, and walked to the primary care practice and said, "I have this thing that I'm scared about and can I see somebody?" And they said, "Oh, sir, we can't help you. Call the 1-800 number." That's what we're getting in the name of scale efficiency is call the 1-800 customer's support line.
That would never happen at an independent practice. They would find a way to see you. So what are we getting?

GW:
Are you seeing this trend accelerating on your end of people moving back to independence, or reforming their own independent groups? It does feel like there is starting to be a sense of like, hey, we should or we need to take this back?

FM:
It's still too hard. I remember a great quote. It's something like, "You can't judge whether people want to cross the river based on how many people are swimming across." And I think right now,

What It Takes to Start (or Restart) an Independent Practice

setting up your independent practice, leaving the hospital or whatever, is like swimming across a river. There's not an easy bridge.
And so that's one of the things that I hope we and others can help provide is that the easy button of saying, "Hey, you want to start your own practice, so here's some contracts, here's some software, here's a way to SEO and get some patients in the door, here's how you set up your revenue cycle," I think that would be awesome. I would love, and I'm sure after this podcast airs, there's going to be a bunch of people who say like, "We do that."

GW:
Yeah.

FM:
And I think we need more of that.

GW:
Do you guys have plans to expand to specialty care, or do you think you'll stick to primary care?

FM:
I think the opportunity is pretty big. You know this concept of crossing the chasm-

GW:
Oh, of course. Yeah, yeah.

FM:
... option? Jeffrey Moore wrote that seminal marketing book.
He and I wrote a piece in the New England Journal Catalyst around how do you cross the chasm for value-based care? We're kind of stuck at like 35% adoption and we were like, look, let's focus on primary care. Like this is where it makes the most sense, and let's drive complete adoption in primary care first, and then we can look to the specialists.
Because the specialists, let's face it, are facing a lot of the same frustrations, but from a compensation point of view, fee-for-service has been pretty good to them.

GW:
You hit a point earlier, the ability to control your schedule and just kind of control how your day looks or how your day works-

FM:
Totally.

GW:
... I think is so huge. Otherwise, it really feels like you're doing stuff that is not the right way to do things, or someone else is telling you to some degree kind of how to practice medicine. That the way things work here is you get seven minutes per patient and make sure that you've updated the problem list and make sure you've refilled all the meds.
So much of the practice of medicine is like mixed in with our personalities and the way that we view the world and the way that some people are like a more is less physician and other people or other physicians are like less is more type of physician, too.

FM:
Well, I was talking to a group of independent practice physician from Oklahoma and he said, I was like, "Well, what does this mean to you?" And he said, "Well, there was a bunch of us buddies that we've grown up together and there was a Van Halen concert in Kansas City."

GW:
Hey, I'm from Kansas City. Perfect.

FM:
And we were like, "Rock on. We're going to go, we're going to go see Van Halen. Yeah."
And then Mitch on the group chat is like, "Um, I can't get the day off." Because he sold his practice to the hospital, and there's some mid-level bean counter, who's his boss now, on his schedule. He can't tell Marcy, like, "Hey, Marcy, I'm taking Wednesday afternoon off. Let's move the schedule."
Control over the schedule is huge to satisfaction and to the feeling of kind of locus of control. Am I in control, or is somebody else in control of me?

GW:
I always tie it back to the autonomy of practice because ultimately I think I feel ultimately I am responsible for my patients and, in the same way, it feels like if you're going to give me the responsibility, give me the control at the same time to... Yeah, yeah. Yeah, maybe that is what respect is, is like, okay, you're going to give me the piece where I'm responsible. Well, give me the respect that I'm going to do this correctly. I took an oath to do it correctly. I'm responsible to do it correctly, so allow me to have some control over it as well.
It feels like I just kind of looked up from my desk and these statistics of most physicians are now employees just kind of happened while I was just not really paying attention because I was just busy seeing patients. Where did this all come from? Where were the seeds of this all starting?

FM:
I think if you just think first principles, if productivity goes down, choice goes down, quality doesn't go up, cost goes up.
Then why is it a better system? It's entirely because you get more leverage and leverage, this concept of... We looked at the price transparency data that the payers have to publish, and it's just shameful. The variance in how much a payer pays, how many dollars, United or Blue Cross or whatever, pays for the same thing depending on how much leverage you have is just crazy.

GW:
And leverage would just, I mean, leverage is how big your practice is so you can negotiate better?

FM:
Yeah. It's how many other things you can connect to it. You can say if you have one thing that the payer really needs and you have a certificate of need for that, then you can charge, literally, two or three or four times what an independent practice would charge, and the payer's not allowed to tell members that they should go to the lower cost place. These contracted provisions are crazy, and we'd let them get away with it, and we have facility fees that double down on that in Medicare.
So I think the root of it is what makes you financially successful in fee-for-service is how many expensive things can you tack on. And this is the private equity play. When they roll up practices, it's like, "Oh, you're a dermatologist. How many more Mohs surgeries can you do on people's backs? Like, let's rack that up."
I remember one doc in Kansas was like, he had tears in his eyes when we shared the contract we'd gotten from a big insurer and we were negotiating with them. And he got tears in his eyes and he said, "I've never negotiated with a health plan before. They just hand me the thing and it's like, and I sign it because I don't have any other options."

GW:
Because he's independent.

FM:
Because he's independent. And when we were talking about respect, that's to me is the fractal image of how we treat primary care and how we treat independent practices is just lack of respect.

GW:
It all feels like that gets back to our earlier reference about the patchwork nature of everything. Well, if the payers aren't going to pay us enough, then we'll create hospital outpatient department. So you can be nowhere near a hospital, but if it's an urgent care, they'll just bill that extra thing to get money back from the-

FM:
Patient.

GW:
... payers and yeah, from yeah, yeah.

FM:
Right?

GW:
And round and round we go.

FM:
Yeah, and honestly, it's our patients are caught in the middle, too.

GW:
Farzad, let me ask you a little bit more specifically about Aledade.

FM:
Yeah.

GW:
You mentioned a little bit the idea kind of started at the Brookings Institute. Where did this initial concept come to you?

FM:
I was the US National Coordinator for Health IT. We went from 9 to 90% of hospitals having EHRs, and during the time I was there and from like 20 to 80% of physician practices using an electronic health record.
That was the goal, but that wasn't my goal. My goal was improving blood pressure control and reducing strokes, and we didn't make any progress on that. I helped start this Million Hearts campaign, and it was so frustrating, and I felt like such a dissonance between, on the one hand, like, oh, hey, you're winning. You're getting EHR adoption and, quote, meaningful use of it, and they have decision support and they collect blood pressure and you have medications and you have quality measurement-

GW:
And it's in a flow sheet where it's all documented, yeah.

FM:
Yeah. Everyone's attesting and no one's-

GW:
I do a lot of attestation in the EHR, for sure.

FM:
Yeah, and no one's actually improving blood pressure control, and I just felt so discouraged.
And then, I was in the principals meeting at HHS and I saw the first draft of the ACO regulations and I was like this is it. You don't have to be a hospital to create an ACO. And I was like someone's got to start a business helping independent practices form ACOs because they're going to crush it, and no one did. And I was like, oh, all right. I guess I got to-

GW:
That's me. I'm kind of speechless. The digitization of American healthcare didn't really have an impact on outcomes or blood pressures, or... I mean, that was a lot of work we all did to implement.

FM:
It was a lot of work. It was a lot of work.
Look, some things did get better. Hospital safety undoubtedly improved from the time when you and I were scrawling in the charts, and people were trying to interpret what we wrote. So that definitely improved.
And none of what we are doing today would've been possible if we hadn't digitized. I just wish we had been able to tie it more to outcomes from the beginning.

GW:
What role does data play in Aledade?

FM:

The Power of Data, AI, and RCTs in Value-Based Care

We have a pyramid of what is the Aledade way, and at the top of the pyramid, like the highest form of the Aledade way is when we can automate a way to work, when we can pull the data from all the different sources and from the pharmacies and the labs and the EHRs and the payer claims and the hospital ADT and make sense of it and just fill the thing out for you, fill out the quality report so you don't have to go through and fill out the spreadsheet and attest and all that stuff, when we can send the text message to the patient to remind them to fill up the prescription, and we just do that when machines do the work. That's the best.
Second best is when we can enable our practices to do the work smarter, not just harder. But of all your patients, 5% of them are at risk of crashing into dialysis. The tough part is knowing which 5%. So we use data and machine learning algorithms and all the vast, now we have like tens of millions of patient years of experience, to be able to make better predictions and focus your efforts on the small number of patients who need this particular thing.
And then the third part of the Aledade way is centralizing. I don't think practices have a team of pharmacists, so we do. You don't have necessarily people who are experts in end-of-life counseling for very complex patients at the end of life. We do that, and data plays a key, data and technology and software in general plays like, literally, you could not do this at scale. Like we added 500 practices last year. There's no way you could onboard that many practices with just dropping care managers into every-

GW:
Can you share an example with me of a practice that kind of turned things around?

FM:
One of our practices in Delaware, I saw him recently and I was reminded of how 10 years ago, with one of our first set of practices, and honestly we didn't know what we were doing, but we knew that if primary care and prevention did actually reduce total cost of care and hospitalizations, then I knew that it would work.
But our first year we didn't get savings, and we reduced hospitalizations, but the hospitals jacked up their coding so that they had more sepsis cases that were highly paid and our costs went the wrong way. You were probably on the other end of that coding. Everyone has sepsis.

GW:
Yeah.

FM:
And this doc called me to say, he is like, "I'm pulling up, I'm pulling out of this." And I was like, "Doc, just hang in there with me. You're not paying anything. I'm paying for the cost of all the things that we're doing. Keep the faith because I believe."
And he was like, "You're not getting paid under the table?" And I was like, "No, no. I only get paid if you get paid." And he was like, "All right. I think you're crazy, but all right." And last year he made over half a million dollars in one check-

GW:
Wow.

FM:
... from shared savings from Medicare.

GW:
Aledade is you guys are the shared savings, shared savings program. How do you guys decide what new services to provide to your members? Are you asking, you're polling your member organizations? You looking at data?

FM:
We're really crazy data people. And one of the things we actually do is we actually do randomized trials because there's so much hopium in this work, line of business, there's so much stuff that makes sense. Like, "Oh, you know what we should do? We should do whatever. Food is medicine."
And then you do a randomized trial and you see that there's reversion to the mean, and you picked the people who had the biggest problem, and then you do anything to them, you do nothing to them, and they get better. And then you've ended up wasting a lot of time, precious, precious, precious time and attention on things that don't actually make a difference.
So we're constantly testing what we think is true, but you can't necessarily go by what you think is true in this work.

GW:
Yeah. I mean, it almost sounds like other health tech companies, startups, whatever, should be partnering with you or doing the same thing. I mean, doing RCTs of, did their food as medicine health tech thing have an actual impact on patients, or is it a great idea, but, unfortunately, not effective?
I mean, just like many pharmaceuticals. There are drugs that should work based on our understanding of the human body and biology and pharmacology. And then you get them into a trial, sorry, yeah, that didn't do anything.

FM:
The incentives in fee-for-service for any point solution is to try to apply it to as many people as possible, particularly the ones who are cheapest to deliver it to. So you could have something that works for the right population and even has a return on investment for the right population.
But if you pay for it fee-for-service, like end-of-life counseling, there was this great, great, great company, Iris Healthcare, that was doing six hours of conversation with patients around end-of-life scenarios. And they were trying to get health plans to pay a thousand dollars. And the health plan's like, "Well, no, because if I just pay for six hours of conversation, you'll have many hours of conversation, but I don't know if that makes sense."
And we did a randomized trial and on the right patients, it was amazing, and the patients had a net promoter score of +92.

GW:
Wow.

FM:
I mean, I've never seen anything like that, right?

GW:
Yeah, yeah.

FM:
Patients loved having the opportunity to talk about like what would you do in various scenarios and these empathetic, caring people. And if you apply it to the right people, then it produces end-of-days in the ICU at the end-of-life.

GW:
Sure.

FM:
But there are a lot of startups who I talked to who aren't willing to subject themselves to that RCT.

GW:
Farzad, in our last few minutes here, if you could say one thing to every medical student or medical resident about their future and the future of primary care, what do you think you would tell them?

FM:
I would say don't be afraid that primary care, oh, it's like low pay or hard, or even independent practice is hard. I think approach it with an open mind and seek out the people.
We have a residency training program pilot called Aledade First, where we give a subsidy to residents who learn about value-based care, and also they have a chance to rotate with one of our practices. And many of them end up choosing to work in an independent practice-

GW:
Oh, I'm sure.

FM:
... because they see that it actually... It can be a great life.
And that, I think, is focusing on the autonomy and the value of that above all, and being able to do what you believe is right for you and right for the patient is a great blessing.

GW:
What's one myth about independent practice that you love debunking?

FM:

The Myth That Independent Primary Care Is Dead

The idea that it doesn't exist anymore. And if you look at the data, every health plan is like, "Ugh, we don't have any more independent practice."
I'm like, really? Because we work with, like 40% of your primary care is actually in this long tail of independent practices. But what looms large in your mind is the big health system.

GW:
The big accounts, yeah.

FM:
Yeah.

GW:
You know, if Medicare understands this to some degree, and CMS and HHS, do any of the commercial payers, the BUCAs, do they look at you guys and think, oh, if these guys are able to generate better outcomes, should we be rewarding them more than the larger systems, or giving them perks like no prior off for independent practices that are meeting metrics?

FM:
Yeah, we do have that. Yeah, we do have that with Elevance, kind of a gold carding program.

What Commercial Payers Can Learn from Medicare’s Progress

We have a 10-year deal with Humana now, and in particularly for community health centers, which is a whole other topic. And I love our federally qualified health centers that are always going to be independent.
We're making progress. It's most clear right now on the Medicare and Medicare Advantage side. And I think the challenge will be bringing... That I think employers are going to need to basically be the ones to demand it. And if there are any, I mean, employers out there listening, let's talk.

GW:
As a fellow policy guy, what do you think is one policy change that would instantly kind of shift the power, the leverage back toward physicians?

FM:
10 years ago, we did this white paper for like pro-competition policies, and I think the thing that at that time I thought was the most improbable and also most powerful would be creating site-neutral payments or

Policy Fixes That Could Reshape Physician Power

eliminating the facility fees and the discrepancy there.
And it's interesting that that is now almost like bipartisan consensus that that should happen, and I think it will. But on the other hand, in the intervening 10 years, a lot of practices did already get rolled up.
The other thing that I'm actually kind of keen on is non-competes, getting rid of the five-year or 50-mile type non-competes for physicians. It's ridiculous. I would love to see the sort of non-compete reform that was proposed under the previous administration actually be taken up by very pro-market, a Republican pro-market kind of move. So I hope we see some of that reinforced.

GW:
Well, Farzad, thank you so much. I loved that your focus really has been on the same goal. I mean, I thought it was multiple separate goals, but it's so clear to me how laser-focused you've been the entire time on improving outcomes, saving lives and doing that through primary care. Thank you very much for joining us today.

FM:
Thanks so much.

GW:
Thanks for joining me today. For interviews with physicians creating meaningful change, check out offcall.com/podcast. Make an account on Offcall to confidentially share your details about your work, and sign up for our newsletter where you can hear more about the latest trends we're seeing in physician pay.
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This has been and continues to be Dr. Graham Walker. Stay well, stay inspired and practice with purpose.