Building a Better Backbone and the Role of Primary Care
- carbesman
- Dec 23, 2025
- 4 min read
Updated: Jan 6
Why primary care as a function, not a visit, is vital to a thriving healthcare system
Jared Johnson, Paul Schrimpf
The phrase “The U.S. healthcare system is broken” is common, but the core issue is structural. The system is privatized and built around a capitalist model. Within that framework, one flaw stands out: unlike nearly every other high-performing health system in the world, the United States lacks a true backbone. There is no layer that reliably guides people, connects decisions over time, or helps them confidently take the next step.
In most countries, primary care fills this role. In the U.S., it was never empowered as the system’s connective tissue. Fee-for-service payment compressed primary care into brief encounters, specialty care grew in both cost and influence, digital tools expanded without coordination, and patients were left to navigate the system on their own.
Dr. Marschall Runge, Chief Executive Officer of Michigan Medicine, put it simply: “Every country with better outcomes has a stronger front door than we do.” He added, “If we want better outcomes, we have to invest in the structures that give people direction instead of leaving them to fend for themselves.” Without a backbone, fragmentation becomes the norm. People don’t just need care. They need a system that keeps track of them.
People Don’t Just Need Care. They Need a System that Keeps Track of Them
The human cost of this architectural gap is clear. Dr. Georgia Gaveras, Chief Medical Officer at Talkiatry, explains: “Diagnosis is hard. But what patients really struggle with is what to do after the diagnosis.” Patients are overwhelmed not only by illness but by a system that is invisible between touchpoints.
“They are expected to navigate a system that even clinicians struggle to navigate,” Gaveras adds. Individuals must sequence referrals, understand insurance rules, interpret test results, manage follow-up, and maintain medications, tasks the system never provided support for.
Jessica Holton, Co-Founder of Ours Privacy, reframes this challenge as patient overload rather than disengagement: “People are willing to engage if someone can simply tell them, ‘Here’s what to pay attention to next.’” Navigation is not a convenience. It is a cognitive safety net.
Consumers do not need more portals or data. They need someone or something to hold continuity, provide sequence, and translate complexity into clarity. That “someone” is primary care, not as a person but as a function that understands context, anticipates needs, connects dots, and guides people through each next step.
Primary Care as the Glue and Conduit of a High-Performance System
When primary care works as intended, as it does in countries with better outcomes, it becomes the glue of the system. It is the conduit through which information, risk, continuity, and prioritization flow, absorbing complexity and returning coherence.
Dr. Runge highlights that the highest-performing systems are not defined by technology or specialist networks. They are strong at the front door because the spine behind it—the backbone—is strong. Care becomes a guided, predictable journey rather than a series of disconnected touchpoints.
Health economist Jane Sarasohn-Kahn adds: “Health happens where people live their lives. Not where the system sends them.” The current U.S. system is episodic; the system people need is continuous. “If you want outcomes, you have to design for the moments between visits,” she says.
Primary care, supported by modern platforms, is uniquely positioned to design for these moments. It builds the architecture for follow-through, behavioral health coordination, medication continuity, chronic disease stabilization, and consumer confidence. When primary care performs this integrative role, the ecosystem begins to function as a cohesive whole rather than a loose collection of services.
Digital infrastructure amplifies this effect. When paired with intelligent triage, contextual guidance, and unified data, primary care transforms healthcare from disconnected decisions into continuity. Patients experience a system that recognizes their place in the journey and supports them between steps.
Why Navigation and Primary Care are Now Economic Imperatives
Leaders from Piedmont, Tampa General, and other risk-bearing organizations agree: navigation and primary care are not just clinical necessities. They are the economic engine of modern healthcare.
Value-based arrangements reward early guidance, correct site-of-care decisions, medication adherence, reduced leakage, stabilized chronic disease, and continuity across touchpoints. Navigation ensures these mechanisms work reliably. Primary care makes them scalable. Holton’s insight that patients simply need clarity on “what to pay attention to next” becomes a financial lever. When people know what matters, they make better decisions, adhere more consistently, and use fewer avoidable services.
Dr. Gaveras’ point about the post-diagnosis void reinforces this. When patients don’t know how to proceed, conditions worsen. When they do, value-based models succeed. Dr. Runge’s global “front door” framing shows that coherent, navigable systems consistently outperform fragmented ones in both outcomes and cost.
Sarasohn-Kahn’s focus on “moments between visits” underscores a critical truth: navigation and primary care are infrastructure, not enhancements. Without the backbone, the system feels expensive, confusing, and reactive. With it, the system finally aligns with its goals.
Building the Backbone
The United States does not have a navigation problem alone. It has a navigation vacuum. The solution is to restore primary care to its role as the functional backbone of healthcare. When primary care, navigation, digital platforms, and value-based incentives are aligned, they create a truly coordinated system supporting patients across their journey.
When these elements work together, primary care provides the glue, navigation provides guidance, digital platforms provide scale, and value-based incentives provide alignment. Patients stop guessing, providers stop absorbing unnecessary burden, payers gain predictability, and the system becomes more humane, navigable, and economically sound. The solution is not more complexity. The solution is the backbone it never built, and that backbone is primary care.
References
Insights for this report were exclusively sourced from podcast interviews on Healthcare Rap
Gaveras, Dr. Georgia. The Healthcare Rap, Episode #409, “Improving Access and Continuity in Behavioral Health.” Shift Forward Health, 2024.
Runge, Dr. Marschall. The Healthcare Rap, Episode #418, “Reflections on Global Health System Structures.” Shift Forward Health, 2024.
Holton, Jessica. The Healthcare Rap, Episode #430, “Helping Consumers Navigate Complexity.” Shift Forward Health, 2024.
Sarasohn-Kahn, Jane. The Healthcare Rap, Episode #379, “The Long Arc of Consumer Health Behavior.” Shift Forward Health, 2024.