FHC #226: Peptides, primary care & the false choices in American medicine

0:11Dr. Robert Pearl: Hello and welcome to Diving Deep, part of the Fixing Healthcare podcast series. I'm one of your hosts, Jeremy Corr, also host of the Pop Unit Books and Medicine podcast and CEO of Executive Podcast Solutions. With me is Dr. Robert Pearl. For 18 years, Robert was the CEO of the Permanente Group, the nation's largest physician group. He is currently a Forbes contributor, a professor at both the Stanford University School of Medicine and Business, and author of the best-selling books, Mistreated, Why We Think We're Getting Good Healthcare and Why We're Usually Wrong, and Uncaring, How the Culture of Medicine Kills Doctors and Patients.

0:39Dr. Robert Pearl: His new book, ChatGPTMD, How AI-Empowered Patients and Doctors Can Take Back Control of American Medicine, remains a bestseller. If you want information on a broad range of medical topics, you can visit his website, robertperlmd.com. Robbie, the interest in peptides is growing rapidly on social media. Influencers are increasingly promoting their use. Moreover, it's one of the most common topics that listeners ask questions about. We discussed them on the recent Medicine the Truth episode, but that just what our listeners appetite. Let's take a deeper dive today and start with what they are.

1:10Jeremy Corr: Jeremy, peptides are short chains of amino acids that are connected through what are called peptide bonds. Unlike proteins, which are also made up of amino acids, peptides are relatively short in length. They have between two and maybe 50 amino acids in total. That's different. The proteins, well, they can have hundreds and sometimes over a thousand amino acids. Peptides occur naturally with thousands of different ones serving as messengers and regulate in the myriads of biological functions that are required for life and health and physiological homeostasis. As you know, peptides are the newest obsession of online clinics and wellness influencers for improved health and fitness.

1:51Jeremy Corr: With minimal scientific evidence of their efficacy and safety, they are promoted for speeding exercise recovery, improving sleep, reducing inflammation, and extending longevity. Today, these substances are part of a growing gray market available through the Internet. A recent Forbes report estimates millions of Americans are injecting unapproved peptides, often purchased for suppliers in China, whose manufacturing quality, purity and contents are difficult to verify. Why are they everywhere in the news right now? One reason is the conflict, the growing conflict between the proponents and the critics of their use.

2:34Each side, it's convinced it is right.

2:38Jeremy Corr: Often what we see relative to medicine is that there's an inverse relationship between the amount of scientific evidence on a topic and the intensity of tone with which it is debated. And that's what's happening here. Despite the promotion of these experimental peptides, there's a dearth of conclusive research on whether they're beneficial and whether they're safe for people to use. A second reason for recent attention is that the Federal Drug Administration, the FDA, is in the process of deciding whether to restrict or expand access to these drugs. Currently, federal regulators face a milestone decision where the six popular but experimental peptides should be made available from suppliers to licensed compounding pharmacies, which would then use the raw materials to create customized medications for patients based on prescriptions written by physicians.

3:32Jeremy Corr: The financial stakes of this decision, they're substantial. If this approach to experimental peptides is authorized by the FDA, analysts at Leering Partners estimate that telehealth sales of these peptides could approach$2.2 billion in 2027. What's happened so far? Jeremy, last month, the Food and Drug Administration's Pharmacy Compounding Advisory Committee narrowly recommended adding six of the seven experimental peptides to what's called the Section 503A bulks list. This identifies ingredients that pharmacists and pharmacies can use to prepare compounded medications. As I mentioned, there are thousands of natural and synthetic peptides, ones that influence metabolism, inflammation, reproduction, and other physiological processes.

4:25Jeremy Corr: These six are the ones that commonly are being promoted. To date, more than 100 peptide drugs are currently FDA approved in the United States, and many are lifesaving medications. Insulin, for example, has revolutionized diabetes treatment and saved millions of lives. And similarly, GLP-1 drugs have helped people with obesity and diabetes lose substantial weight and improve their health. But just because two substances belong to the same chemical family, that doesn't mean they're equally safe or effective. Peer-reviewed scientific studies are needed to establish both. For the six peptides now under final consideration by FDA leadership, public enthusiasm has advanced much faster than the science.

5:13The first peptide being considered is BPC-157.

5:21Jeremy Corr: It's recommended for the treatment of ulcerative colitis and other GI inflammatory diseases. Three studies have indicated a positive impact, but in two of them, there was no control group, and the third, no peer review of the data. In addition, there are multiple FDA reports of allergic reactions with several of the patients who receive the peptides having to obtain ER treatment. The next is KPV. This is derived from a hormone made by the pituitary gland, and it's usually applied as a cream or a gel to the skin to promote wound healing and treat inflammatory skin conditions. Proponents recommend it as a means to strengthen the immune system.

6:02Jeremy Corr: Most of the evidence on its anti-inflammatory properties, however, it's based on studies in mice. However, in one recent study, this peptide wasn't found to even be effective at penetrating the skin, which would imply that it would never reach its target and as a result be completely ineffective if people applied it to their bodies. The third, TB500, this is a peptide that's used by people to improve healing. So far, one mass study supports juice, with another study showing no improvement. To date, there's no safety or efficacy scientific research on this peptide relative to humans. The fourth, MOTS-C.

6:46Jeremy Corr: This is a peptide derived from what's called mitochondrial DNA, distinct from the more commonly studied nuclear DNA that's responsible for our genetic inheritance. This peptide is promoted for obesity and treatment of osteoporosis, but as with TB500, there have been no published research studies on humans relative either to efficacy or safety. The fifth peptide that the advisory committee recommended was epitalon, a substance extracted from the pineal glands of cattle to help patients with insomnia. It's hypothesized that for patients with this problem, improvement results from better regulation of the individual's circadian rhythms.

7:28Jeremy Corr: However, the most common reason that this experimental peptide is recommended isn't for sleep, but it's recommended as a means to increase longevity. And the basis for this indication is that the peptide is thought to lengthen telomeres. This is the part of the DNA chromosome that shortens as we age. So it would make sense that that if this peptide reverses that pattern, it could also increase life expectancy. Although there is some data from animal studies that show this may happen with long-term use, there are clinical concerns in the literature about the association of telomere lengthening and higher cancer risks.

8:07Jeremy Corr: As such, researchers worry that the peptide could be carcinogenic if taken long-term. They just don't know. The sixth and final peptide that the advisory community recommended was C-MAX. It can be used for impaired blood flow, treatment of migraine headaches, and reduction of facial pain. However, nearly all the information on this experimental peptide comes from studies in the Russian literature with incomplete data. The one U.S. study showed a potential improvement for migraine sufferers, but it had a total of 12 subjects and no control group.

8:41Dr. Robert Pearl: How do people react to the advisory community's recommendations?

8:45Jeremy Corr: As you might expect, many supporters of making these experimental peptides readily available were pleased. But the committee's recommendations also drew broad criticism for two reasons. First, critics of the decision, they pointed out that the FDA staff and the scientists actually recommended against approval. These staff members cited insufficient evidence about the safety and effectiveness of the six peptides. Second, as the Washington Post reported, at least six of the eight new committee members that RFK Jr. appointed have close ties to peptide-related businesses or medical practices that promote them.

9:26Jeremy Corr: For obvious reasons, these individuals would have a potential conflict of interest, as they and their friends would benefit financially from easier access for millions of people. In response to these concerns, the FDA said that all committee members, all the advisory committee members, had undergone standard ethics review. And supporters of the committee's recommendations also argued that clinicians and pharmacists with direct peptide experience bring valuable expertise to the FDA's discussion.

9:58Dr. Robert Pearl: Where does the decision process stand today?

10:02Jeremy Corr: No decision date is set. It could be days or months before a final ruling is provided. However, we can expect approval for two reasons. The first is that only with a rare exception is the leadership of the FDA not approve an advisory committee's recommendation. And second, RFK Jr. is a big proponent of broader peptide use by people. And in his role of Secretary of Health and Human Services, he oversees the FDA. But with the recent departure of Marty McCary as head of the FDA, the final decision is likely to be delayed until his successor is formally nominated by the president and approved by Congress.

10:41Jeremy Corr: One thing the listeners need to understand, this recommendation differs from the usual FDA approval. It is specific to the chemical supplies available to compounding pharmacies and doesn't opine on the safety of what patients ultimately receive. As such, even if FDA leaders accept the committee's recommendations, the compounded medications could not be labeled FDA approved. Obtaining that designation, that's a much more complex, demanding process. Requires high-quality research data on both efficacy and safety of what is sold to patients. And neither exists. Currently, it's a scientific rigor that's required for these six experimental peptides.

11:27Jeremy Corr: At the same time, for patients obtaining access to them through physician prescriptions at licensed pharmacies, this, I'll call it a technical distinction. would not necessarily be evident, and they might easily assume that they were obtaining a drug that had been proven safe and efficacious.

11:48Dr. Robert Pearl: What would you decide if you were on the committee?

11:52Jeremy Corr: Jeremy, let me begin by pointing out that I haven't been privy to the totality of data on each peptide. That's what the FDA scientists and staff do, and how the advisory board is expected to make its decisions. But based on what I've read, if I had to vote, I would be reluctant to vote either yes or no. The reason is that when it comes to these experimental peptides, what we need is either scientific proof that they work, along with strong evidence that they are beneficial without major risks, or we need data that says there are safety concerns. And that information, either pro or con, doesn't yet exist.

12:33Jeremy Corr: At least it's not present in academically approved peer-reviewed journals. The central problem in either the FDA saying yes or no is that either way, doctors and patients are unlikely to know if these experimental peptides are effective and safe. Scientific research is needed to answer both questions, and I'm doubtful at companies or current providers who would have much interest in completing this type of study if they weren't required to do so. The reality is that it's easier to promote products through marketing and advertising than by scientific proof through well-controlled clinical trials.

13:14Jeremy Corr: Even without approval, promoters would still be able to recommend the six peptides through the gray market. After all, over a million people are currently following that path.

13:26Dr. Robert Pearl: Why do you think it's so important that we have these answers?

13:29Jeremy Corr: If these experimental peptides improve health and more patients who would benefit from using them, then doctors should be prescribing more of them than they do today. But if they're ineffective or dangerous, then patients, both those currently using them and ones considering starting, need to be warned so that they can make an informed decision. As such, both the restrictions of the past and the possibilities of approval in the future aren't sufficient to provide the clarity required for people who are using them or considering starting one. Under the Biden administration, regulators effectively barred these peptides from being sold in the United States after raising concerns about potential safety risks and gaps in human evidence.

14:15Jeremy Corr: This meant that people who might benefit would be unlikely to obtain these drugs safely. Moreover, the policy, along with stepped up enforcement against suppliers and pharmacies that might be providing them, it didn't eliminate the demand. Large numbers of Americans continue, over a million, to obtain the peptides online from overseas sources. As I noted, the Trump administration, with HHS Secretary Robert F. Kennedy Jr. among the most prominent supporters of peptides, it's likely to move in the opposite direction by permitting broader access through licensed compounding pharmacies. And if they do that, then we would have a dearth of information.

14:57Jeremy Corr: Since, as I mentioned, the proponents are unlikely to do the scientific studies needed. As such, Jeremy, either a yes or a no would leave doctors and patients and payers unclear whether these peptides should be used more widely or restricted far more aggressively. Across all six, high-quality human evidence remains limited. Much of the available research is the animal studies, mainly on mice. All of the research suffers from insufficient data to establish the efficacy or the safety. The lack of evidence does not prove that these peptides are dangerous. It just means that researchers cannot yet say with scientific confidence whether their claim benefits outweigh their risks.

15:43Dr. Robert Pearl: Robbie, what would you do if you were the head of the FDA?

15:47Jeremy Corr: Jeremy, let me start by pointing out that supporters of broader peptide access make a reasonable argument for approving advisory committee recommendations. Americans are already using these substances and obtaining them through physicians and regulated U.S. compounding pharmacies would likely be safer than relying on gray market suppliers in China. Critics make an equally valid point for rejecting the committee's recommendation. Expanded access would encourage far more Americans to use these products, despite lingering uncertainty about the benefits and long-term risks. I fear that either approach won't optimize the health of our nation, and as such, I favor a third one, one that's different from the other two.

16:33If either a yes or a no alone will establish whether people should be using more or less

16:40Jeremy Corr: of these products, then if the agency authorizes these substances for use to be provided through qualifying compounded pharmacies, it should pair that decision with a federally coordinated research program. As an example, the National Institute of Health, the NIH, could lead a one-year research effort in collaboration with the FDA and Centers for Disease Control and Prevention. To maximize safety, the people already using the peptide, they could continue to receive them, but now through the regulated pharmacy under a physician's prescription. This would protect the people who currently use them from the risks through the gray market.

17:21Jeremy Corr: New patients would also be able to gain access under scientific double-blind research protocol. Researchers would conduct controlled clinical trials of individual peptides for specific medical uses and evaluate both the efficacy and short-term safety. At the end of one year, the FDA would review the findings. The information obviously would be incomplete because the long-term data would not be available, but it would be exponentially better than what currently exists. And then they could decide whether to continue the approach, expand access through compounding pharmacies more easily or restrict access more aggressively.

18:03Jeremy Corr: Although a one-year program would not answer every question, it would generate the evidence that we need for doctors and patients to make a more informed decision about what they should do next.

18:18Dr. Robert Pearl: Robert, this seems pretty radical. Is there any precedent for it?

18:21Jeremy Corr: Jeremy, this type of approach has precedent. The federal government has previously linked access or coverage for certain experimental treatments to participation in research when important questions remained unanswered. Medicare, for example, used coverage with evidence development for certain Alzheimer's treatments, ones we've talked about on our various Fixing Healthcare podcasts, and have required patients to participate in improved studies to be able to get access to the drugs. Let me add one more piece to the approach. I believe that the companies that stand to profit for expanded peptide access, they should help finance the research.

18:59And this

19:00Jeremy Corr: principle also has precedent. Pharmaceutical and medical device companies already pay the FDA a user fee that support product review and certain post-market safety activities. The only difference is that rather than a single manufacturing company bearing the financial burden, it would be spread among a much larger group of entities who promote and recommend these six peptides. When I look at why we still have so little evidence about whether these peptides make a difference and whether they're safe to use, I think that both Democrats and Republicans have failed to resolve basic questions in a way that would be optimal for the health of our nation.

19:41Jeremy Corr: The Biden administration's absolute restriction on peptides resulted in Americans turning to the gray market without being given the information they needed to make an informed decision. And assuming the FDA, under the Trump administration, authorizes the sale of these six experimental peptides through compounding pharmacies without requiring additional research, we're likely never to know whether these substances work or create potential harm to their users. If our goal is to maximize the health of all Americans, I believe the best path is to pair regulated access with scientific research.

20:21Dr. Robert Pearl: Robbie, while the FDA is debating whether to make six experimental peptides available through compounding pharmacies, primary care seems to be in major trouble. Can you update listeners on the status of the specialty and what you recommend for the future?

20:34Jeremy Corr: Jeremy, I agree that primary care is in trouble. Across the country, there's a massive shortage of physicians in the specialty. with diminishing interest among medical students in pursuing it. However, the problem isn't new, and yet rather than anyone taking effective action to reverse the slide, the decline is accelerating. I'm glad you raised this important problem. And I'd add that the failures to solve primary care's issues reflect a pattern that I've seen when it comes to a variety of issues in health care and care delivery overall. What I've seen is that academic and policy experts, they're really good at identifying the reasons why American medicine performs so poorly, even when we compare it to other pure nations.

21:18Jeremy Corr: But they do a poor job of implementing improvements to rectify the situation. What we see are costs continuing to rise at twice overall inflation and three times wages and GDP. Burnout remains rampant with minimal relief in sight. And less than half of all insured Americans, they say they would not be able to afford the cost of their medical care if they suffered a severe injury or a medical problem. So let's dive deep into primary care because it is so vital to people's health. But also, let's use it as a means to analyze health care's growing problems overall. Reby, where do you suggest we begin?

22:00Jeremy Corr: Jeremy, let's start by noting how payers and providers view the same issue very differently. Ask primary care leaders what needs to change. They'll say the United States needs to provide primary care doctors with greater autonomy for clinical decisions, fewer patients to see every day, increased office support, and much higher salaries. They point to salaries and note that according to Medscape's 2026 compensation report, that primary care doctors earn an average$298 ,000, while specialists, they earn$417 ,000. In their minds, all of the issues relative to primary care, including both the fading interest in the specialty and the lack of respect, they believe that these stem from these lower salaries.

22:49Jeremy Corr: But through the eyes of payers, the administrative salatries are secondary to the reduced value that they perceive primary care providing. In fact, if you think about it, the failure of payers to invest more in primary care seems illogical. Wouldn't insurers, the government, self-funded businesses benefit financially if primary care could keep people healthier and minimize serious medical illness? And yet, the current reality is that despite repeated pleas by primary care physicians and their national societies to obtain more resources and promises that with the added dollars that patients would require less medical care, payers continue to resist making these investments year after year.

23:37Jeremy Corr: Through the lens of the primary care physician and the primary care national societies, making these investments is not only the right thing to do, but that doing so will generate a positive return to the payers of that investment. They argue that especially these problems and the larger failures of American medicine are just simply two sides of the same coin. Invest more in primary care and physicians will have the time and the resources to keep patients healthier, to better control chronic disease, coordinate fragmented medical care, and reduce expensive with downstream treatment. Of course, those outcomes would be enormously valuable.

24:17Jeremy Corr: They would save payers a huge amount of money, and they would improve people's health and lives. You know, what we've seen in the United States is over the past 15 years, despite spending a lot more on medicine, longevity has been stagnant. Chronic diseases remain epidemic and poorly controlled. Access is declining as waits for not just primary care, but specialty care as well, average weeks to months, depending upon the service and the location. And meanwhile, as I said earlier, national health care spending will increase by almost$4 trillion over the next eight years. When you look at the problems that exist, not investing seems illogical.

24:57Jeremy Corr: The return on the investment seems massive, and yet payers, The people whom we think of as the ones that would benefit the most, they don't appear interested. Psychological research and incentives indicate that people rarely fail to follow their own self-interest. But at first glance, that's what seems to be happening. Robbie, this is intriguing. How do you explain it? Jeremy, when a seemingly logical solution fails to advance year after year, the most common reason is that the root cause hasn't been diagnosed correctly. Toyota popularized one way to discern the actual root cause of an issue when there are seemingly illogical outcomes.

25:42Jeremy Corr: The technique is called the five whys. It repeatedly asks why through multiple rounds until the truest, most accurate, most logical answer surfaces. We can apply it to primary care. In fact, we can do so by compressing it into three steps. Why is primary care struggling? Because the work is under-resourced and undervalued. Why is the investment inadequate? Because payers aren't convinced that spending substantially more on primary care will raise quality and lower total costs. Why are payers unconvinced? because they lack sufficient evidence that paying primary care doctors will produce the promised improvements.

26:30Jeremy Corr: Assuming this root cause analysis is accurate, then the next step is to find ways for primary care doctors and the national societies to demonstrate success.

26:40Dr. Robert Pearl: Robbie, let's backtrack a little bit. Please elaborate on why the evidence to date is insufficient.

26:46Jeremy Corr: Jeremy, this hesitancy to spend more in primary care, it's understandable. As an example, although CDC data demonstrate that effective control of chronic diseases could reduce the number of heart attacks, strokes, and kidney failures up to 50%, primary care's success at controlling these common chronic conditions like hypertension, diabetes, it's been poor. Payers know that excellent control is possible with current medications and evidence-based guidelines, but given this performance, they don't believe that achieving success through primary care is likely to happen if all they do is pay more dollars.

27:26Jeremy Corr: And the pessimism extends beyond current performance. Now, is it the first time that payers have tried to improve clinical performance through financial incentives? In fact, they've tried multiple times to increase quality and lower costs by investing in primary care through various forms of pay for value. And nearly all have fallen short of producing the transformation that proponents hoped and promised to achieve.

27:54Dr. Robert Pearl: Robbie, why do you believe this is the case?

27:57Jeremy Corr: Jeremy, the two biggest problems with these traditional, and I want to label them transactional, pay-for-value approaches are that, one, they incentivize only a small percentage of what clinicians do, and two, they reward specific process steps in care delivery rather than measuring and paying clinicians based on total clinical impact. As an example, an insurer may decide to pay a few extra dollars every time a doctor checks the blood pressure and prescribes the medication. But if they don't provide that same payment for checking and managing blood lipids, doctors will do a better job with hypertension, but when rushed, they'll skip over an equally valuable preventive service, which they won't receive added income.

28:43Jeremy Corr: Similarly, when doctors are awarded for writing a prescription to treat hypertension, even if the patient never fills it, or if the elevated blood pressure doesn't come down, they still get paid. The result of this transactional approach to medical practice may be higher income for doctors, but little improvement in clinical outcomes for the patient and no reduction in total cost for the payer. This disappointing outcome was documented in a 2025 British Medical Journal review of a primary care pay-for-performance program. The researchers found the financial incentives initially improved the measures that were being rewarded.

29:23Jeremy Corr: By three years, however, those gains had largely diminished with deterioration in unincentivized care across that time. The reality is there's too many parts to excellent medical care for payers to incentivize each, and just adding dollars fails to provide the return that payers want and expect. For primary care to convince insurers and other payers to raise salaries, the primary care physicians will need to accept risk for the outcome of their actions and the financial impact it has, not simply be paid for additional steps along the way.

30:00Dr. Robert Pearl: Robbie, how can you envision this happening?

30:03Jeremy Corr: Jeremy, let's start with what currently exists. Fee-for-service, which accounts for 95 % of all medical payments to clinicians represents a broader version of the transactional problem. The more services clinicians provide, the more they're paid, regardless of whether more care produces better health. See the patient twice for a problem that can be treated in one visit, and the physicians earn twice as much, while the patient is inconvenienced and the care is delayed. Under fever service interventions like angioplasty or kidney transplantation, ones which reverse life-threatening medical problems, they're highly compensated.

30:43Jeremy Corr: While the actions that could prevent the heart attack, strokes, and kidney failures in the first place, they are not. If primary care wants both added revenue and greater autonomy, the only way I can see that happening is if the physicians receiving these dollars are willing to accept risk, and that will require them to embrace capitation. Under capitation, rather than an insurer paying separately for each visit or service, they provide a prospective payment to deliver all the medical care needed for a defined population of patients. When chronic diseases are well-controlled and the number of heart attack, strokes, and kidney failures decline, both primary care doctors and patients benefit.

31:25Jeremy Corr: When convenient access is provided and patients don't have to go to ERs for medical problems that can be treated at a fracture of the cost by primary care, both the providers and the recipients of medical care benefit. And when care is coordinated and patients don't fall through cracks, resulting in a major complication, the collaboration benefits everyone. Moving to capitation and demonstrating a primary care can achieve higher quality at lower cost. That's the only way I can see for primary care doctors to earn the confidence of payers and convince them to provide the resources they seek. Phrased differently, pairs are unlikely to invest more in primary care because clinicians and national organizations demand it.

32:06Jeremy Corr: If they would, these programs would already be in place. Instead, they'll spend the added dollars as an opportunity to transfer risk. They would argue that if primary care physicians are so certain that the investment would reduce overall cost, they should be open to taking the financial risk.

32:26Dr. Robert Pearl: Is added income the only advantage for primary care in shifting to capitation? No.

32:33Jeremy Corr: Capitation would also provide doctors with the practice control that's lacking in medicine currently. Direct payment for the totality of medical care to clinicians would eliminate many of the challenges that primary care doctors face today, including the frustrations of trying to obtain prior authorization and the time wasted on billing and claims. However, although capitation solves one part of the problem for primary care doctors, it simultaneously creates financial risk for them. As an example, there's the unpredictability of medical problems, which makes accepting financial risk too great for an individual doctor or a small practice to accept.

33:13Jeremy Corr: A handful of patients requiring organ transplants or advanced cancer treatments would quickly overwhelm each. To spread the risk, doctors therefore need to organize into groups large enough to protect everyone from these unexpected events, purchase stop loss of protection, and build the operational capabilities required to manage a population of patients. Furthermore, to protect all the members of the group, the participating doctors will have to surrender some individual autonomy inside their own organizations to maximize group excellence. The good news is that unlike today, they won't be under the thumb of the insurer.

33:51Jeremy Corr: However, succeed, they'll need to create agreements and adopt common approaches to chronic disease management, coordination of medical care for complex patients, appointment access to performance measurements. This is the only way to predictably improve quality and lower cost, but some individuals will find abiding by consensus decisions challenging. In the end, success will demand skilled medical leaders who are empowered to implement them and capable of doing so. Robby, if this is so positive, why haven't primary care doctors done this in the past? Jeremy, first payers haven't been interested.

34:27Jeremy Corr: They thought they could do better financially by limiting utilization and reducing payments to providers rather than paying more and granting autonomy. In addition, doctors haven't wanted to take the risk since they worry that doing so could negatively impact their income. But most importantly, primary care physicians haven't had the tools needed to achieve success with a high enough probability to justify taking the financial risk. I believe that the growing potential of generative AI applications like ChatGPT, Claude and Gemini are capable of empowering patients, providing care on a continuous basis, and identifying medical problems sooner, and that has shifted the landscape.

35:09Jeremy Corr: Can you give a few examples of what might be possible? Combined with home monitoring devices, telemedicine, and patient-generated health information, Genitive AI would allow continuous chronic disease management between episodic office visits. These large language models would be able to identify when blood pressure and blood glucose weren't controlled, and it would make it easy for doctors to adjust medications quickly. These same tools would allow physicians to identify when chronic heart failure was becoming acute, and they could intervene, preventing an ER visit and admission to the ICU. The technology would be able to evaluate people 24 by 7.

35:48Jeremy Corr: It would help patients know when they should go to the ER versus waiting until the doctor's office opens the next day. Moreover, with greater resources devoted to capitated payments, primary care groups could hire additional staff. This would give doctors the time they need to manage complex patients, who today, they just refer to specialists, not because they don't have the expertise required to take care of them, but simply because their schedules are overflowing. By doing so, they'd be able to narrow the enormous compensation gap that we talked about earlier between primary care and specialty medicine.

36:25Dr. Robert Pearl: Robbie, I follow so far, but the risk still seems great. What else can be done to reduce it?

36:31Jeremy Corr: Jeremy, you're correct. For individual physicians, the risks can still seem daunting. This is where I see national medical societies that support primary care today need to provide assistance. They could help primary care physicians to join together and to form medical groups. They'd help them take the financial accountability and figure out the best way for them to collaborate with colleagues. They can organize demonstration programs, provide expertise for negotiating capitated contracts, and assist with purchasing stop-loss protection, implementing generative AI technology, building clinical infrastructure, and establishing common measures for quality access, patient experience, and cost.

37:13Jeremy Corr: And using learnings from the success of the initial groups, they would then be able to spread the best practices and help new groups learn successfully.

37:21Dr. Robert Pearl: We could spend an entire Diving Deep episode on the improvements that this approach would have had on overall medical outcomes and longevity. But in the remaining time, Pam, why don't you offer listeners an overview of where American medicine is and where primary care needs to go if it wants to improve what's currently happening today?

37:38Jeremy Corr: Primary care physicians are right. They're carrying an unsustainable burden. They deserve higher salaries, more support, and greater respect. But the reality is that until they can demonstrate success in improving clinical outcomes and lowering costs, payers aren't going to listen. That may be unfair. But it's today's reality. To earn the confidence of payers, primary care doctors will need to take bold steps, not small incremental ones. Capitation aligns payment with the outcomes primary care physicians believe they can achieve, and it improves the odds of clinical success. Organized groups of clinicians can spread the financial risk, and they can create the operational excellence required to succeed.

38:26Jeremy Corr: Genitive AI offers new capabilities for closing care gaps that episodic primary care has struggled to address. And national societies can make the seemingly overwhelming transition achievable. Chairman, I believe that primary care physicians in national societies can accomplish what the specialty promises and what they need to demonstrate. And for the sake of our nation's health, I hope they will.

38:53Dr. Robert Pearl: We hope you enjoyed this podcast and will tell your friends and colleagues about it. Please follow Fixing Healthcare on Apple Podcasts, Spotify, or your favorite podcast app. If you like the show, please rate it five stars and leave a review. Visit our website at FixingHealthcarePodcast.com and follow us on LinkedIn, Facebook, and Twitter at FixingHCPodcast. Thank you for listening and have a great day.