Dr Sachin Jain on the Changing Doctor-Patient Relationship and Middlemen in Health Care


Sachin Jain, MD, MBA, president and CEO at SCAN Group and SCAN Health Plan, discussed the growing roles of middlemen between physicians and their patients in an increasingly complex system.

Sachin Jain, MD, MBA, president and CEO at SCAN Group and SCAN Health Plan, discussed the growing roles of middlemen between physicians and their patients in an increasingly complex system.


You recently authored a Forbes piece highlighting the implications of a growing number of middlemen operating between health care providers and their patients. Can you discuss the timeliness of this topic?

Well, I think over the past decade or so, there's been an explosion in the number of companies that are aiming to solve what we perceive as gaps in the care of patients—oftentimes, specific populations, specific types of patients. And what I see is that we have a number of entities now that are trying to wrap around the care of patients, and wrap around their traditional care settings, whether it’s primary care or specialty care. And that wraparound comes in the form of care management programs from managed care companies, comes in the form of disease-specific programs from startups—and I think all of these folks are incredibly well intentioned. But at the same time, I find that in many cases, they're creating more complexity for patients, as opposed to the promised simplicity.

I think it's important for us to pause and reflect on what this is doing for people and the effect that it's actually having on patients, as well as clinicians, and whether anything is actually truly getting better. I think we can point to specific examples, always anecdotal cases of individual patients who benefited from the so-called middlemen. But at the same time, I think if you look at how much we've invested in middlemen, both from a private capital perspective, as well as in customer relationships with the variety of health care entities, I think there's a lot of questions to be answered and that these questions extend to health plans, they extend to pharmacy benefit manager companies. They also extend to the growing number of startups that I think create a lot of hope, but then also leave, oftentimes, a significant amount of of disenchantment.

What are some of the main challenges posed by the increasing number of middlemen in health care, and how do they affect patients and providers?

Well, I think the middlemen start out with the best of intentions. They're trying to solve for an unmet need. Take, for example, the growing number of companies that try to aim to address the needs of high-cost, high-need patients in a health plan cohort or in a medical group cohort. They'll implement programs like sending clinicians to a patient's home, they will provide high-risk case management. But oftentimes what happens is they don't necessarily connect into the other settings where patients receive care. And so, they'll have a wraparound physician who will be prescribing medicines, but without actually communicating to that patient's primary care doctor or specialty network. As a result, there's more confusion for patients, more confusion for clinicians.

What I'm not doing is defending the status quo. I think there's obviously a problem that's trying to be addressed or be solved. But I'm asking an earnest question, an honest question, and an authentic question, which is: Is the right answer for us to introduce new layers of care, or should we be doing more to empower the patient's existing care provider network, whether it's the health systems where they receive care, the primary care doctors, or their specialists, to be able to do more instead of implementing these arms and legs?

Now, the truth is that oftentimes, those entities have been invited to do more, but they don't actually want to do it, in which case, I think the need for the so-called middlemen is created. But at the same time, I often think that we're not empowering primary care physicians, specialists, and health systems to do those things [and] we're not paying them to do those things. As a result, we're now having to pay others to do it. Think about health plan care management—I call health plan care management, in many instances, strangers calling strangers. These are well-intentioned strangers calling patients that they don't know particularly well, trying to lend a helping hand. And the question should be asked: Would that helping hand better come from an extension of the person's primary care practice? And I think in many instances, it would.

And so, we have to take a hard look at all the things we're doing for all the people we're doing it for, and just ask, "How do we best meet the needs of this patient population?" And I think what we have is this mushrooming, Frankenstein health care system where patients are not necessarily sure where to go for what, because there are so many different people. And I think back to the time when someone had a strong, confident generalist primary care physician to actually address their needs. Dr Balu Gadhe and I wrote a piece in Health Affairs years ago called "The Competent Generalist." And the point of that piece was, rather than disaggregating care in the hands of a number of different specialists, we would better serve patients by having a number of competent generalists who could be the true quarterbacks of patient care. Those people are few and far between, however.

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