This newsletter was sponsored by apree health, which are big fans of Advanced Primary Care. The company has a footprint of APC centers that extend to 12 states, across employers and health plans. They also do digital navigation and advocacy nationally to steer people to high-value primary care, with a goal of avoiding unnecessary emergency room visits and closing care gaps — and they do it all in a value-based way.

So… What is Advanced Primary Care? That’s a harder question to answer than you might think. When I posted about it on LinkedIn with a video, I got more than 100 comments and dozens of messages from people sharing their take. While there were some similarities in the responses (more below) there were also real differences. The lack of a clear definition speaks to something fundamental: Primary care in the U.S. is not functioning as it should be, particularly given growing patient needs, provider shortages, and unsustainable cost trends. What most of us crave is that trusted family doctor who can address most problems in an empathetic manner, see us quickly when needed, and refer us to trusted specialists. Instead we face months long wait lists to even see a primary care doctor followed by an eight-minute visit, and we’re lucky to see the first available provider let alone develop a long-term relationship. 

Hence the movement towards ‘advanced primary care’ - which harkens to a prior era in which patients had a trusted, long-term relationship with their PCP but with a few “upgrades”: 

(1) a team based approach to provide a richer set of services like behavioral health and care management

(2) some basic technology like the ability to chat with your provider and do a telehealth visit;

(3) that the care is paid for in a way that incentivizes better quality and outcomes.  

This post will address what advanced primary care is, where it makes sense (Medicare Advantage and Medicaid? Probably. How about the commercial markets? Possibly.) And how can it get paid for? Lastly, will there be changes on the horizon that may help us all agree on a common definition? Let’s dive in.

When I asked Dr. Kevin Wang, an internist and the chief medical officer at apree health, to share a definition, he put it this way. It addresses “80 percent of problems.” What that means in practice is that if a patient shows up to the clinic, in theory the care team should be able to take care of most of the patients’ needs. That might include everything from dermatology to behavioral health, and the team may be inclusive of doctors, nurses, coaches and a range of other allied health professionals.

“I define it as thinking about it as communities, or populations if you prefer that term, to design effective primary care for that group,” said Rebecca Mitchell, managing partner at Scrub Capital and a physician-by-training. “It’s not generic primary care that’s designed for everyone – a 22-year-old I might work with has different needs, than say a grandparent with five or more chronic conditions – and they don’t want to engage with their health and medical care in the same way, but we lump them in the same spaces.”

You might be wondering if we can simply turn back the clock to get back to this kind of primary care. Well, yes and no (this research is a great place if you’re interested in the origins of primary care, and how it’s changed in the past few decades). The crux of it is that some GPs did used to serve as the backbone of their communities, often operating with their own practice or as part of a small group. Nowadays the primary care physician is more often part of a larger organization, employed by a health plan or system. But let’s not forget that things weren’t perfect 50 years ago. The solo GP was usually male; biases ran rampant; care was not integrated across specialties; and quality measurement was virtually non-existent. The idea behind Advanced Primary Care is to revitalize the parts of primary care that we’re all nostalgic for while making it relevant to the time we live in today. Instead of one doctor, there’s a care team. Instead of everything happening in a clinic, it happens in a hybrid manner. Instead of paying for volume we pay for value. 

That’s the ideal state for Advanced Primary Care, but it’s not so easy in practice. So I invited Jared Augenstein, who closely follows developments in Advanced Primary Care, to co-author this piece with me with a particular focus on the regulatory challenges. As with all things in health care, we need to understand how the incentives are aligned. 

How do you know it’s Advanced Primary Care and not Primary Care?

When I surveyed my LinkedIn network, one of the most succinct responses I received came from Omada Health’s Chief Medical Officer Carolyn Jasik. As she put it: “It’s just primary care extension… It’s filling gaps that primary care can’t accomplish for a host of reasons.” Others spoke to more clinical aspects of primary care, noting that it’s ideal for people with complex medical needs because it addresses patients’ mental health, social needs and their physical health. There’s also a link to the concept of the “Patient-Centered Medical Home,” which is grounded in the idea that patients should receive evidence-based, research-backed primary care from a centralized location. 

Wang, from apree health, shared his “essential questions” for Advanced Primary Care. Think of it as a checklist of sorts for, although there are exceptions to the rule. 

• Are there same day or next day appointments?

• A combination of services that can handle up to 80% of a patient’s needs that extends into specialties like dermatology, behavioral health? 

• Is there an integrated care team?

• Is there an ability to manage acute conditions and prescribe medications?

• Can this form of primary care bring down cost, and therefore be offered as part of or as a value-based construct? It doesn’t need to be 100% value-based, because we’re told by experts in the space that most Advanced Primary Care still includes some fee for service payments. 

If the answer to all of the above is “yes,” then it’s likely Advanced Primary Care. 

Other companies we spoke to, like Premise Health, spoke more to a set of services. That includes: Primary care, behavioral health, care management, care navigation and pharmacy. 

When asked about the business model, Patrick Nelli from Aligned Marketplace, an expert on the topic, said there’s usually some balance of fee for service and capitation – “most don’t have all payments tied to risk,” he said. He’s also seen a broad spectrum when it comes to risk: shared savings agreements; upside/downside; and full cap risk. Nelli said most Advanced Primary Care can be found within Medicare, and there are pockets in commercial and Medicaid markets. 

During our conversation, I asked Wang if One Medical counts as Advanced Primary Care. One of the reasons I’m curious is because the company does own Iora Health, which specializes in vulnerable patients and team-based care. The Amazon-owned primary care chain has for years offered same day appointments, and it has expanded into some other areas like pediatrics and women’s health. Wang notes that it’s a complex question. But he doesn’t think it fits, namely because of the cost issue. One Medical primarily operates with a fee-for-service model.

Nelli agrees: “One Medical has the capability; but I don’t think it’s there yet,” he said. Nelli stressed he doesn’t have inside knowledge, but said One Medical is only operating advanced primary care in “subsets.”

Taking on Risk

The concept that advanced primary care involves taking on risk seems to be generally agreed upon by industry experts. Per research from New York State, advanced primary care is outcomes based, meaning it is measured, assessed and ultimately paid for based on quality. That care is typically delivered in a team-based way, not just via a physician, and there may also be opportunities for shared savings. 

As we touched upon in this piece, there are a variety of ways to think about taking on risk, which we’ll discuss in this piece. One of my earlier posts - “In defense of tech-enabled services” has a good summary. Outside of fee-for-service, there’s everything from:

• Bundled/enhanced rates: Getting paid for a swath of services to solve a clinical problem. Oftentimes that rate is higher than what the company would make as a traditional provider.

• Shared savings: The opportunity to share in any potential upside. This is based on an actuarial calculation of what the cost would have represented without the intervention, so in theory there’s savings to be generated if the provider can take steps to prevent expensive outcomes, like a hospital stay. 

• Partial capitation: Companies take on full risk (upside and downside) for part of the patient’s costs, for instance just the behavioral health component. 

• Full risk: That means what you might think – taking on the full risk for the cost of care for that patient. Oak Street is a good example of that with its focus on older adults with chronic conditions. The company has said that by investing in primary care, as well as behavioral health, it is seeing 51% reductions in emergency department visits for its population. 

I asked Nelli if there’s the potential for healthy patients to be covered, because it’s challenging to prove and demonstrate a real cost savings. He noted that it’s nuanced. He does believe that starting primary care in a persons’ twenties does certainly improve their health over time and drive down the cost of care. But proving that in the immediate term can be tricky. Therefore he estimates that within commercial populations, taking the 30 percent deemed the highest risk – meaning the most medically complex – only equates to the average Medicare risk. So from that perspective “higher touch, advanced primary care that drives savings” is possible, if targeted to those who are higher risk. 

How about the other 70 percent? Should advanced primary care companies leave them out of the equation? According to Nelli, that means a different type of care. It might be “heavily virtual,” he said, and it doesn’t require 4 or 5 interactions per year. A focus might be in helping those patients avoid emergency room visits, an enormous source of cost, or driving them to the most high value specialists. Within commercial, there is an opportunity for big savings there because the government sets the price for the same site of service while commercial is individually negotiated. 

There’s now a small number of companies doing advanced primary care in the commercial space ranging from apree health to Premise Health, targeted to employers. Most of the companies in the commercial space operate on a purely fee for service basis though some are beginning to tie payment to outcomes. Wang notes there are some challenges with shared savings, joking that three actuaries will give you five opinions. It is very difficult to prove that an expensive outcome that didn’t happen would have happened. We heard from one company in this space that their employer customers had little interest in pursuing a shared savings or risk-based arrangement given the administrative cost and complexity of monitoring and adjudicating these sorts of deals. They shared that their customers are happy to pay on a fee-for-service basis because they believe the service is valuable at the current price and the fee-for-service arrangement is much simpler to administer. 

Jared, my co-author, is also closely tracking the proposed new codes for Advanced Primary Care Management, as set forth by CMS, and will share some thoughts throughout this piece on what that means for the health-tech industry. 

What about the new codes?

In July, as part of the 2025 Physician Fee Schedule Proposed Rule, CMS proposed to improve how primary care providers are paid to care for Medicare beneficiaries - for simplicity we’ll call this the Advanced Primary Care Management bundle. If finalized later this month, this proposal will create new reimbursement opportunities for the delivery of advanced primary care for all Traditional Medicare beneficiaries (the codes will also be adopted in Medicare Advantage). 

These codes are best understood in the arc of evolving payment for advanced primary care services in Medicare. Over the past 10 years, providers have invested in infrastructure to bill CMS’s various existing standalone codes—chronic care management (CCM), transitional care management (TCM), principal care management (PCM), eConsult, eVisit and virtual check-in code sets. All of these codes require time-based tracking which can be technically challenging and administratively burdensome. Most critically, the new proposed codes de-emphasize the need for minute-by-minute activity tracking and re-emphasize the need for capability development and practice transformation to deliver advanced primary care. 

There will be three codes - one for lower-risk patients, one for moderate-risk patients, and one for high-risk patients which will pay at $10 per month, $50 per month, and $110 per month respectively. Providers will be able to bill for one of these codes per Medicare beneficiary per month so long as the practice has in place the capabilities to provide advanced primary care.

The capabilities include things like 24/7 access, comprehensive care management, transitions of care, and a care plan. Notably, services like remote physiologic monitoring are not currently contemplated as part of the Advanced Primary Care Management bundle. 

In short, the proposal shifts focus for providers and tech-enabled services companies from tracking time to developing capabilities that underpin advanced primary care. For companies in the space, it’s definitely worth paying attention.

Where are the opportunities in Advanced Primary Care?

The proposed codes, if finalized, should create a significant opportunity for providers and tech-enabled services companies serving the Medicare population to invest in tools and capabilities which enable the practice to provide advanced primary care. This should in turn create opportunities for health-tech companies providing tools in this space - some of the capabilities that practices will look to invest in include risk stratification and population health management, night/weekend telehealth coverage to meet the 24/7 access requirement, chat and other secure messaging capabilities between patients and the care team, and performance measurement tools.

Companies in the enablement space - Aledade, Privia, Agilon, Pearl, Vitalize - should also benefit from the Advanced Primary Care Codes as they provide a potential new revenue stream for practices (beyond Medicare Advantage, the Medicare Shared Savings Program, and other CMMI programs) to invest in infrastructure development which these companies provide. 

Another area with potential involves finding new ways to reach national employers, according to apree’s CEO Don Trigg. That’s probably not going to work with an employer like Google, which is known to have an employee base that skews healthy and young. 

But Trigg mentioned on a call that many companies have a complex mix of both salaried and contract-based workers, and are seeing rising rates of cancer. These employers may also be concerned about the rising costs associated with weight loss drugs like the GLP-1s. 

“The AT&Ts, the Boeings, the Comcast’s of the world, which all have a vested interest in more primary care.” He may have a point. 

As we have spent more time of late with employers at various forums, many have described rising rates of cancer diagnoses and dropping rates of preventative health screenings, including flu and Covid vaccines (that has also been backed up by employer associations like Business Group on Health). It would not be surprising to see a subset of large employers whittling down their health offerings to a small subset, and determining that primary care should be at the top of the list.

This post was co-written with Jared Augenstein, a managing director at Manatt.

Plus something fun…!

I’ve been spending time with the team at In Women’s Health, which is a great resource for anyone looking for a role in the industry, as well as education about how it works. I often send them to people starting out who are looking to get into the space.

The team is launching their second cohort of the Women’s Health Mini-MBA next week. It’s designed for professionals in women’s health and is six-weeks long, explaining all the nuances (PBMs, strategy and financing, regulatory, reimbursement codes, payers, revenue cycle). Speakers include Jill Angelo from Gennev, Trish Costello from Portfolia, and Michelle DeBenedictis, and SVP Payor Relations from Kindbody. If you want to attend, use SECONDOPINION at checkout for 10% off.

Or want a free overview? Join the webinar tomorrow at 1pm EST / 10 am PST.  Register here.