A growing number of employers are now turning to Advanced Primary Care (APC) — a preventive, holistic care model that combines onsite and virtual access with real-time clinician availability — as well as more one-on-one time between patients and clinicians.

Organizations like Marathon Health report that APC closes care gaps, improves outcomes, and cuts total healthcare spending by over 40 percent.

Nirav Vakharia, M.D., COO of Marathon Health, discussed further with Healthcare Innovation.

Could you provide an overview of Marathon Health?

Marathon Health’s purpose or mission is to enable millions of people to lead their healthiest lives, one member or one patient at a time. What the company has been doing for 25 years is really listening to the voices of the healthcare purchaser and the healthcare consumer and trying to figure out a model to bring the right type of access to high-quality primary care services to as many people in the population who need it as possible. How that shows up is that we work directly with employers who are self-funded, meaning they are covering the entire healthcare expense for their population, and offer them an alternative to what they may normally have access to, which is a hospital system or medical group in the community.

At this point, we serve over 600 clients, 600 self-funded employers or unions. They, in total, have about 3 million lives that they entrust to us.

We provide on-site or near-site health centers, or virtual options if preferred, including primary care, behavioral health, physical therapy, health coaches, nutritionists, and care management to help that population navigate the healthcare system, become more engaged in their own health, improve population-level outcomes, and ultimately assist the employer in managing costs.

So, we are talking about the concept of Advanced Primary Care (APC). What led your organization to explore this?

The opportunity we saw was that the usual state of care was insufficient. People are unhappy with the access that they have today.

About 28 percent of Americans say they don't have access to primary care. It's almost 90 to 100 million people today. And when you look at the numbers out there, it takes three or four months to get your first appointment. The average appointment is 11 minutes.

That has led to low experience. Poor experience led to worse outcomes as a country, and importantly, it's led to a reduction in people wanting to go into this field because it's just structured incorrectly.

We saw the opening to address all of the above: highly accessible, longer appointment times, more team-based and holistic care, great experience for providers. It has a positive ROI for an employer because your overall healthcare expenditure goes down. You're saving emergency room visits, you're saving hospitalizations, you're preventing cancers, you're preventing heart attacks, all those sorts of things, which we all know are possible. It's just that our current system isn't designed to do it. This is for employers who want to still achieve those goals, but through a different mechanism.

How do you achieve longer appointment times?

The model is purpose-built to deliver on same or next-day accessibility, and in many of our centers, people just walk in. We build our schedules to make sure we can maintain access to those standards, and then we make sure that the number of appointments per day that a provider can deliver is appropriately load-balanced to ensure people have enough time.

I'm a primary care provider (PCP), physician. I still see patients. I used to do it in the old way. Now I do it in this new way. I'll just tell you both my experience, as well as what our data shows, is that if you just give the patient and physician more time together, we see less need to refer out to specialists. Because in the old world, when I had 11 minutes, I had no ability to ask all the questions and explore this new symptom. Now I have the time — let's talk about what's going on, let's explore your symptoms, let's do some testing right here in the health center. Let's take care of it ourselves, versus having to send you out.

That longer time, which we kind of built this whole model around, automatically drops down by 25 percent the need to send people out into the community for specialty care, because you're managing it in primary care, where most of these things belong.

The last piece is that we keep panel sizes smaller. The number of people I'm responsible for is smaller, so that I can spend more time with each one.

Could you tell me more about the financial aspect?

The clinical model is not hard to imagine. It’s fee-for-service. The more visits I generate, the more income I bring in. Our model is different. We are paid for outcomes for that panel. I'm generating income based on the results: do you meet your goals around cancer screening, diabetes control, depression diagnosis and management, prevention of emergency room visits, and total cost of care? These are the things we are paid for, true outcomes, not just the delivery of a service.

Do you contract with providers?

We have about 700 health centers. We have about 1700 providers, and those exist across about 42 states. How we contract is direct to the employer. And we know that for every dollar they invest, they're getting more than $1 back. Our data shows that in the first year, you get $1.20 back for every dollar you put into this model. By the fifth year, you're getting $3.70 back because you're preventing more, meaning less is going out to hospitals, urgent cares, and specialties.

If you look at U.S. healthcare today, we all know we spend too much. We don't get the outcomes we want. It's because we're too focused on the end of the road, right after bad things have happened, rather than prevention.

What were some of the challenges you faced when setting this up?

The entire system is designed not to work in this model. And it is designed to go through insurance, which is fee-for-service, which then just drives that sort of behavior around more patients every day, more volume, more throughput, resulting in shorter times with those patients, and less focus on outcomes.

That newness created problems and challenges. The primary one was just around, do patients understand the difference? There are so many doors to walk through in healthcare. What we've figured out over time is that both the employer and Marathon Health have to work together to build trust with those patients.

What are some outcomes you have seen?

What we have done is not just for one employer, but across all of our employers. Access is better, and appointment times are longer.

The NPS (Net Promoter Score) for any healthcare organization is typically 30 or below. NPS for Marathon Health is 89. That just means we're delighting patients, because they can get in. That's the first, most important thing: do people like it?

The second is….are we driving results clinically? When we look at quality outcomes, we are consistently across all the common quality measures out there: prevention, chronic disease, and mental health. When we rank ourselves, where we look at national benchmarks, we are consistently above the 75th percentile, and in many we're above the 80th percentile.

The next thing we look at is whether we are actually saving that employer money. Is this investment having a positive ROI for them? For those 3 million people who came through, did their healthcare trends look different from the general public's? The answer is yes; we see that the trend flattens versus the trend continuing to rise year over year. On a five-year basis, our compound average annual growth rate is about 2.3 percent versus about 6.5 percent in the community. You're creating that difference in the slope of those two lines, whether they use us versus they don't, which, over time, compounds and creates massive savings and leverage on this investment.

For those who use us more, their emergency room utilization goes down by 15 percent, their hospitalizations go down by 42 percent, and their specialty spend goes down by about 9 percent.

We can build that trust with the workforce to actually engage in health; if other barriers sometimes prevent it, it keeps people on the job longer.

Are participating health centers using this model exclusively?

Out of the 700 health centers, we have over 300 that have some sort of shared access, and then we have 100 that are pure open access.

What are your thoughts on this model reducing healthcare spending?

Year over year, over 95 percent of clients choose to keep this in place because they see on their end that it is reducing their healthcare costs.

Do you have any initiatives or improvements you're considering for the future?

What we're really excited about right now is what's the right way to bring technology into care. We have, as a country, done a lot of experimentation over the last few years around apps, AI, and digital health, and I'd say, for the most part, been pretty surprised at how much people still want a relationship as the foundation of their engagement and health. The core of our company is that relationship between the provider and the patient. We never want to do anything to disrupt that.

But how do we strengthen that relationship? Sometimes with technology. How might we, for example, bring texting, AI, or self-service, if they don't necessarily always need to talk to their doctor through the app or other technologies, just to make that relationship stronger? So that's a lot of what we're doing today.

In addition…we want to make sure this is the best place to work in healthcare. How do we make their experience better? And that's where we're thinking a lot about technology as well. How does AI make their day smoother, more efficient, get them the information they need faster, help them make decisions faster, et cetera

Do you have any advice for healthcare leaders who are exploring this concept?

Try to make sure you're not responding to the shiny object that's rolling across your path. I get that this is not the most glamorous space right now, advanced primary care, but it is the most credible thing I've ever seen in terms of checking all those boxes we've been trying to check for so many years in this country.

Avoid the hype, or at least be skeptical, trust but verify, if you will, but really get into the data and get into the experience and the credibility of whatever it is you choose to do next, and not just follow the masses and just adopt the latest technology.