Amazon paid the NFL $1 billion dollars a year for over a decade for the rights to show the weekly Thursday night game exclusively on the Amazon Prime streaming service.

OK.

Sports-related money talk is officially ‘crazy land’ these days.  $250 million contracts for dudes who wear shorts to work are a dime a dozen.  18-year-olds who have not played a minute yet for their college get more in name/image/likeness deals from a booster than the kid with the engineering degree will make in a year.

Stupid money.

But the Amazon/NFL deal is interesting as we think about how value-based care will shift the dynamics in healthcare.  I love me some random parallel metaphors.

So, if you don’t get enough football on Saturday, Sunday and Monday and just have to have more on Thursday night, you now have to sign up for Amazon Prime.  The service costs about $140 a year and the company reported its ‘biggest three hours of US prime signups ever’ during its first game last week.

Clearly, that was part of the plan in Amazon’s fight against Netflix and Hulu and Disney and everyone else who has a streaming service, which seems to be everyone except you and me.

But that is not the biggest play for Amazon.  Not saying a $140 times a few million folks doesn’t add up to real money, even for Amazon.

Here is the real juice, though.  The average customer on the Amazon mothership buys about $500 a year worth of stuff that comes in cardboard boxes.  Prime members, however, spend four times as much.  Free shipping is catnip.

Spend money for streaming content…get more people to sign up for Prime…sell them more stuff.

Let’s connect the analogy with an example.

Let’s say there is a large primary care group in your market that is all in on taking full global risk with Medicare Advantage.  They are focused, wired, and dialed in to make money by better managing the care for this group, reducing unnecessary costs, and getting to keep the surplus they generate. That is the secret sauce of their economic engine.

And let’s say you are a decent sized surgical group (pick a specialty, most will do) that has a couple of ASCs, which are your real profit machines.

What if the primary care group approached you and asked you to take 95% of the normal Medicare rate in exchange for getting a priority position for their referrals into your specialty?  You might think about any incremental volume increase against the 5% haircut.  Maybe you like it, maybe you don’t.

But what if they said, ‘Whoever helps us make more money on our Medicare Advantage side also gets all of our commercial referrals as well.  And yes, please use your ASC instead of the hospital because that also lowers our Medicare cost.’  No brainer taking the discount on their Medicare patients because now they are feeding you more of what you want.

These are the types of deals that are coming.

Unspoken assumptions, so hidden from view and conscious thought that they are forgotten, are often the most important.

The cost of healthcare – regardless of how we pay for it – is unpredictable.

We 330 million humans and our 37 trillion cells each add up to…I can’t do that math before coffee, but it is a lot…a boatload of complexity.  And cost.

Someone has to pay the bill; someone has to carry the financial risk.  We don’t say that out loud when we debate policy, but it is still true.

In a single payer system, the government and taxpayers own the risk.  In the fee-for-service model, several someones have to pay the piper.

OK, we get it.

The move toward value-based care (VBC) is accompanied by all sorts of PR-driven, focus group-tested bumper stickers, but let’s be real for a minute.  This is ‘mostly’ about is changing who ends up holding the risk bag.

Who holds the bag matters a lot because it turns out that whoever is at the end of the line where the piper cashes the check has a lot of power over everyone else.

One way to assess healthcare economics over the past 50-80 years is to conclude the risk-holders were asleep at the wheel.  Cash was good (printing presses at the Fed helps); no one seemed to be the worse; everyone learned to play their part in order to get their share.  Right up until it didn’t work anymore.

So, now we are passing the risk bag downstream – from the government to health plans to providers.  But that sounds so callous, so financial, so untoward.  But hey, VBC is awesome.  It has ‘value’ and ‘care’ in it and who doesn’t like those?

Fortunately, ownership of the risk – and the power that goes with it – is moving the right direction, at least in my strong ‘preference for the market over central planning’ bias.  It is moving closer to where real decisions – actual care – occur a million times a day.

Take Medicare Advantage, a topic we’ve been discussing of late.

About 50% of Medicare beneficiaries now opt for an MA plan, a number that will pass 60% by the end of the decade. These folks are covered by a plan that shifts the risk from CMS to the insurer (United and Humana have about 50% of the MA market).  That is a step.

But increasingly, the MA plans turn around and delegate that risk to provider organizations like big health systems (mark me down as skeptical here) or primary care-centric provider organizations – the Bus Drivers we talked about last week (very bullish on this group).

Why?

Now those holding the bag – and wielding the power – are physicians, on the ground, in the community.

There is a lot that will go wrong, for sure. But since someone has to hold the bag, I’ll take this option all day.

During high school, I spent a lot of hours on a big yellow school bus – basketball road games, summer youth group trips.  It was always a good time, especially if you got to sit by that cute girl or got deep into a game of Spades.  But once on the bus, you were oblivious to where it was going.  Tell us when we get there.

Unless you happened to sit in the front row, looking out the windshield, talking to the bus driver.  Then you had a real sense of going somewhere.

Many physicians, particularly specialists, are in the back of the bus, rocking along, wondering if we’re ever going to get to this place called ‘value-based care.’  Deal the cards and pass the Cheetos.

This past week, in separate conversations, I got to sit up front and talk to two bus drivers and get a sense of where we are headed.

One is on the west coast; one on the east.

One has been at this almost four decades; the other is new to the gig.

One is with a small organization owned by a band of primary care physicians; the other is pretty large and is equity-backed.

One is purely focused on Medicare Advantage; the other does both MA and commercial plans.

One is in a mature managed care market; one is an early mover in their markets.

Both agree that ‘value-based care’ is just marketing lipstick on a pig attempting to dress up and rehab ‘managed care.’  They use them interchangeably.

Both are all about capitation, full risk.  They want it, that is what they are trying to do, that is how they make money.

Both conversations were fascinating.  I took away a few things…

It takes some time to get traction with the primary care physicians, even though they are holding the risk and have the incentive to make changes.  Even new docs, right out of school, were not trained to think about risk and really managing care. The one that has been doing this a while has the PCPs dialed in – they get it and behave accordingly.  The new organization, and others like them, are getting there quickly.

Once they get their own crew rowing in the right direction, the hospital relationships – far and away the biggest part of the spend they have to manage – are next.  First, they get aligned with them.  Then, they go after them.  ‘Site of service’ is the biggest needle mover.  That is code for moving surgeries and diagnostics out of the hospital to ASCs and other lower cost ambulatory sites.

Next up comes whatever are their biggest issues on the specialty physician side.  That is happening and gaining speed.  Those that cooperate on their big agenda will win, but those that don’t will lose.  The risk-bearing entities, with the power to direct patients, will decide.

After all, they are the bus driver.