I ran into my friend Bert last night and we got to talking.
“I hear you guys talking about medical care, about how it is for-profit and lots of people are using it to make too much money on the backs of communities,” he said. “But my care is great. I go to Oak Street. I see a nurse practitioner. She’s great. She takes all the time I need with me. She explains things. And you know me. I have lots of questions. If I need to see a specialist, they set it up. Seamless.”
Oak Street Health is a medical practice for people with Medicare. It was started in 2012 by three entrepreneurs who had worked together at the Boston Consulting Group, who realized they could make money by providing really good primary care, using doctors and nurse practitioners and other health professionals and services. Oak Street Health keeps each doctor’s or NP’s workload reasonable, making sure they have no more than about 500 patients. (The typical doctor or NP cares for 1000-2300 patients.) This way of doing primary care saves money – and keeps people out of the hospital, as it keeps people healthier.
Oak Street employs its clinicians, and they have created a network of practices across the country that function in this way. They made a deal with Medicare that lets Oak Street keep some of the money they save Medicare. An number of other medical businesses do this: ChenMed, Iora (which was bought by an organization called One Medical (which was bought by Amazon) and PACE, which is a non-profit. (Disclosure: my wife works for PACE.) Oak Street got sold to CVS for $10 Billion in 2023, so now CVS runs it, which makes it a Rhode Island company, more or less.
There are two take-home messages from the Oak Street story.
The first and most important message is that we know how to provide really good medical care in the US. Really good medical care starts by providing robust primary care with doctors and nurse practitioners who have the time to listen and are backed-up by a multidisciplinary team. Not part of the Oak Street story: there’s plenty of evidence showing that if we provided this kind of really good health care to all Americans, we’d drop the cost of health care significantly, maybe in half, and we’d actually improve the public’s health by eliminating HIV and Hepatitis C, colon and cervical cancer – and significantly reducing the impact of heart disease and stroke, using the science we have today. (I’m a believer in the weird and dangerous idea that we should stop all medical research until we have figured out a way to get primary care like Oak Street provides to all Americans, because the public health impact of providing primary care like Oak Street provides to all Americans far out-strips the public health benefit of any and all research coming out of NIH.)
The second message from Oak Street, unfortunately, is that there is money to be made off public funds in health care, to paraphrase my friend Samuel Shem. Big money. A bunch of guys, some of whom I know and count as friends, made billions of dollars by figuring out a way to provide decent health care to some of us. All those billions came from Medicare. Public funds. Every single dollar. And all those guys did was take a process that everyone knew about – really good primary care – that itself had been developed and refined in our medical and nursing schools and universities and was thus also mostly paid for by public money, and make that primary care available to a thin slice of the population that had a public funder. So kudos to them for figuring out this hustle and making a big fortuna for themselves off it. But shame on us for not doing it ourselves, as a nation. For everyone.
We could have a health care system that works for everyone. Oak Steet Health, One Medical Chenmed and PACE prove that it is possible – and they prove that it works every single day, for hundreds of thousands of people.
But it’s crazy that we don’t provide the same kind of primary care Oak Street provides, to everyone, in every neighborhood and community. Crazy and sad.
You can find Michael Fine’s commentaries and short stories on
https://michaelfinemd.substack.com/and on http://www.michaelfinemd.com
