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Healthcare's Cost Crisis: How Primary Care Can Deliver The Savings We Need

Whereas all healthcare providers play a part in addressing chronic disease, primary care focuses ... [+] mainly on preventing and managing these serious health issues.

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In the months leading up to the 2024 presidential election, Americans voiced concerns over the unaffordability of healthcare. In a Kaiser Family Foundation survey, voters said they worried most about the cost of medical care—more than groceries, gas, rent or any other expense.

With tens of millions of U.S. Patients and thousands of employers struggling to afford rising premiums and drug prices newly elected officials now face increasing pressure to address the medical spending crisis without compromising the nation's health.

But what's driving the relentless surge in healthcare spending, and how can we contain it?

How Chronic Disease Created A Spending Frenzy

While many factors contribute to rising medical costs, the biggest driver—by far—is the explosion in chronic disease.

Long-term illnesses like diabetes, high blood pressure and heart failure now affect six in 10 American adults—double the proportion from just two decades ago. These ailments are the primary culprits behind heart attacks, strokes and kidney failure, and they are estimated to account for 70% to 90% of all healthcare spending.

It doesn't have to be this way. According to the CDC, better prevention and management of chronic disease could reduce life-threatening complications by 30-50%. Even with conservative estimates, cutting these events in half could save the United States $1.5 trillion annually—more than a quarter of the nation's total healthcare expenditures.

Where Should We Begin?

Whereas all healthcare providers play a part in addressing chronic disease, primary care focuses mainly on preventing and managing these serious health issues.

Studies conclude that effective primary care reduces hospitalizations, improves patient health and extends life expectancy more than other specialties. And yet, the U.S. Allocates just 5 cents of every healthcare dollar to primary care. The rest goes toward costly interventions, efforts to reverse medical problems that could have been avoided in the first place.

At first glance, the easiest solution would be to increase primary care dollars. But here's the surprising truth: multiple recent studies show that simply allocating more money to primary care fails to reduce overall healthcare costs or improve clinical outcomes.

Contrary to what we might assume, communities with higher primary care spending report only modest gains in patient satisfaction and no significant reduction in total costs, emergency visits or hospitalizations. The reason? Most primary care providers still operate in a fee-for-service system that rewards them for treating medical problems, not preventing them. Seeing a patient twice as often after a heart attack, for instance, does little to improve health outcomes or save lives. True impact comes from managing blood lipids, glucose and blood pressure long before an acute event occurs.

A New Model: Enhanced Primary Care

To combat healthcare's rising costs, we need a new plan—one that ensures additional funding for primary care is used effectively. The following two-step approach to enhanced primary care enables doctors in both large healthcare systems and independent practices to more effectively manage chronic disease and lower medical spending.

Step One: Reward Better Health Outcomes

Nearly half of Americans with hypertension—a major risk factor for stroke—do not have their condition under control. Diabetes and prediabetes, affecting one in three Americans, are managed even less effectively. These numbers reveal a critical failure in U.S. Healthcare: poor management of chronic diseases. Enhanced primary care aims to address this by preventing these medical conditions and rewarding improvements in specific clinical measures.

This plan's financial approach builds on the success of the Medicare Shared Savings Program, which incentivizes large healthcare groups—known as accountable care organizations (ACOs)—to achieve superior clinical outcomes at a lower cost. Last year alone, ACOs saved Medicare $1.8 billion while achieving better patient outcomes than doctors in traditional Medicare programs. Patients enrolled in these MSSPs experienced improved diabetes and blood pressure control, fewer emergency room visits and reduced hospital readmissions. These results demonstrate that well-designed incentives can effectively drive meaningful improvements in healthcare performance.

Applying the ACO model, universally, would require a large number of doctors to form a group, appoint skilled leaders and accept the financial risk that their income would decrease if costs increase. For small or solo practices without substantial financial reserves, this risk is prohibitive.

Here's how it would work:

Clear Patient Identification. At the start of each year, patients enrolled in Medicare, Medicaid or a private insurance plan would select their primary care physician. By designating a specific physician, patients establish a clear line of responsibility, and doctors know precisely who they're accountable for. Therefore, they can plan for each patient's chronic disease needs. With a defined patient group, clinicians can set measurable health goals and track progress over time, similar to how a teacher might be tasked with raising test scores for a specific set of students. This approach aligns financial incentives with improved health outcomes.

Outcome Based Evaluation. Today, most "pay for performance" programs measure and reward physicians based on dozens of process-related metrics, from ordering laboratory tests to administering vaccines. Although well-intentioned, these payment models (a) don't focus on clinical outcomes and (b) overwhelm doctors with too many tasks. In fact, a Johns Hopkins study found that primary care physicians would need 27 hours a day to complete the 57 daily tasks measured by these types of pay-for-performance programs. Instead, the new program will focus solely on improving outcomes related to chronic disease and give doctors the autonomy to find the best way to accomplish that. For example, successful management of hypertension would be lowering blood pressure to normal. For patients with diabetes, did daily glucose determinations improve? For heart disease, were hospitalizations avoided?

Reward Calculation. Each year, financial rewards for primary care doctors would be tied to the number and severity of chronic conditions they manage, alongside improved control of each medical problem. The added incentive payments would represent about 2% of total healthcare spending (about $90 billion), distributed across practices. For each of the nation's 527,000 primary care doctors, this would amount to as much as a 50% increase in average take-home pay ($130,000 annually), provided they achieved the health outcome goals. This structure would allow primary care doctors who effectively control patients' chronic conditions to obtain income parity with specialists.

Step Two: Turn Potential Into Practice

With a sound financial plan in place, the next step is to help clinicians successfully implement it. Today's technologies can help physicians more effectively manage chronic diseases than ever before.

Patients who choose to participate in the program will receive wearable monitors connected to generative AI tools. These devices will allow patients to track their health in real time and receive immediate feedback on managing their conditions. They will know, for instance, when a medication adjustment is needed. Free educational programs would also help patients learn to use these tools and make lifestyle changes—such as improving diet, exercise, and stress management—that can significantly impact their health.

For clinicians, this approach will transform healthcare from episodic to continuous care. Instead of only assessing patients during office visits four or five times a year—leaving over 360 days with minimal oversight—doctors could continuously monitor their patients' health using technology.

Consider this scenario: When a doctor prescribes blood pressure medication to a patient with hypertension, the patient's wearable device would collect ongoing data while a GenAI tool uses that information to determine by the end of a month if the drug is having the intended effect. If not, the clinician would be notified and could alter the dosage or prescribe a different medication. Similarly, analysis of daily blood glucose levels would help physicians know when insulin doses need to be adjusted. Generative AI tools would monitor the weight and degree of ankle swelling in patients with heart failure to detect early signs of trouble, allowing doctors to intervene sooner, preventing the need for hospitalization that otherwise would ensue.

The Future Of Enhanced Primary Care

The U.S. Healthcare system is at a crossroads. We can keep spending more and more to treat medical problems after they arise, or we can invest in a model of enhanced primary care that empowers doctors to prevent chronic diseases and their complications in the first place, improving patient health and lowering costs.

If, over the next six years, this program simply cuts the rate of healthcare inflation in half, it would save the nation over $2 trillion compared to current predictions.

Preventing chronic diseases (and avoiding 30-50% of avoidable heart attacks, strokes, cancers and kidney failures) would bring about real, measurable improvements in people's health and national financial stability—a two-part prescription for success.

This program is structured so that, if it does not achieve the intended improvements, the government and private insurers would pay little. However, if the program succeeds, the benefits will be tremendous for patients, payers and primary care providers alike.

Nearly 400 Primary Care Doctors At Mass General, Brigham And Women's Hospitals File To Unionize

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Citing a "crisis" in healthcare, nearly 400 primary care physicians at Massachusetts General Hospital and Brigham and Women's Hospital are taking steps to unionize, a move that medical professionals are calling "historic."

The doctors on Friday filed a union election petition with the National Labor Relations Board, Attorney Marisa Powell, lead organizer for the Doctors Council, said in a statement on Monday. The council describes itself as the country's oldest and largest union of attending physicians.

A vote to unionize is expected within two months, Powell said. If the vote passes, the physicians would be members of Doctors Council of the Service Employees International Union, Local 10MD.

The move comes as Boston doctors are facing "the growing corporatization of healthcare, collapsing primary care patient access, and the moral injury caused by systemic challenges," officials said in their statement. The doctors are uniting as members of the Doctors Council "to protect the future of primary care and provide the care that patients deserve."

"I decided to become a doctor because I hoped to fix our broken healthcare system from the inside," Dr. Elsa Imbimbo, a physician at Massachusetts General Hospital's Internal Medical Associates, said in a statement.

"I chose primary care because it placed me at the foundation of healthcare where I can best understand and advocate for my patients. It is clear to me that by unionizing, we will have the influence we need to make meaningful changes to this professional work and improve our care for patients," Imbimbo said.

Boston 25 reached out to Mass General Brigham for comment on the filing.

"Primary Care physicians are critical to the health of our patients and community," a Mass General Brigham spokesperson said in a statement on Monday. "We know that PCPs across the Commonwealth are facing unprecedented volume and stress as a result of a confluence of factors that are not unique to our organization."

"We share the common goal of offering world-class, comprehensive care for our patients and believe we can achieve this best by working together in direct partnership, rather than through representatives in a process that can lead to conflict and potentially risk the continuity of patient care," the Mass General Brigham spokesperson said. "We are committed to continuing our dialogue with our PCPs, supporting them and their practices through this challenging time and investing in ways to reduce burden."

The filing represents a "pivotal moment" for the field of primary care, which is "under increasing strain as administrative and financial pressures jeopardize the ability of physicians to provide comprehensive and equitable patient treatment," officials said.

By forming a union, the primary care physicians said they "aim to collectively address these challenges, advocating for the necessary resources, staffing, and support systems that will allow them to deliver high-quality care for their patients."

Dr. Kristen Gunning, practicing at Massachusetts General Hospital Bulfinch Medical Group, said that the institution must lead by example.

"Primary care is in crisis in Massachusetts and nationwide," Gunning said. Mass General and Brigham Women's Hospitals are world leaders in medicine. We are excited to collaborate with hospital leadership in leading the way to save primary care."

By organizing with Doctors Council, the physicians "will advance the national conversation around primary care and demand a seat at the table to advocate for their practices and patients," officials said.

"Their efforts address the urgent need to reform how health care systems operate, prioritizing patient well-being and physician support over administrative profit margins," officials said.

"We as primary care doctors have allowed ourselves to be slowly stripped of our voice in the critical health care decision making process," Dr. Jiani Guo, of Brigham & Women's Faulkner Community Physicians at Hyde Park, said in a statement.

"Only with the power of collective bargaining can we push back against the rising tide of corporate interests," Guo said. "Only through unionizing can we help to restore the soul of our profession and improve patient outcomes. Only then will our health care system move away from the destructive trajectory of profit-driven models and rise up as truly the leader in health care."

This is a developing story. Check back for updates as more information becomes available.

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Champions Of Health Care: Lane Relies On Old-school Relationship Building To Serve Patients

In another life, Madeline Lane would be a school teacher. In this life, she's a nurse practitioner at UMass Memorial Health – Harrington Hospital in Charlton, but that doesn't mean her love for education has fallen by the wayside.

It's quite the opposite.

"I felt like nursing was the best marriage of both education and medical science, because nurses are educators by trade," said Lane.

Her commitment to teaching is at the forefront of her work in primary care; education paired with connection.

Lane sees many patients who miss the relationships they used to have with their doctor: that once-standard familiarity from decades prior when patients saw their primary care providers for a wider range of needs before the creation of more specialized fields.

A bio box for Madeline Lane

"A lot of people mourn the loss of that feeling when you come in and see your doctor, or your nurse practitioner in my instance," she said.

This sentiment rings particularly true for Mike Stowe, one of Lane's patients and co-founder and senior partner at Westborough accounting firm Stowe & Degon. Stowe first met Lane when she substituted for his PCP, who was out on vacation.

"It was like the doctor that used to make house calls [that] you don't see anymore. She does that," he said. "When she filled in, the level of service, professional care, it was a whole new level that I had never experienced before."

Stowe, who never thought he would choose a nurse practitioner as his primary provider, switched to Lane as his PCP within three visits.

Lane keeps detailed notes on not only her patients' health, but also the little anecdotes that come up in a visit. If a patient's son plays ice hockey or their partner also sees her, she'll make a note.

Stowe said during his first appointment with Lane she insisted on knowing everything about his medical history for the past 20 years. She made sure to run a plethora of tests in the office, have him self-test at home, and followed up through email on nights and weekends.

When patients have a good relationship with their provider, they're more likely to return and receive treatment to mitigate more acute health conditions, helping keep patients out of the hospital and lowering the chances of readmission, said Lane.

And for Lane, putting in the work to form connections with her patients doesn't mean they have to be the same person or even have similar values. Instead, it's about cultivating an environment where patients feel heard and respected.

"It's nice to feel like you at least showed them that you're in their corner before they leave," she said.

An integral part of fostering a strong and informed provider-patient relationship is providing anticipatory guidance, said Lane. She actively puts in the forethought as to what patients can expect from their lab results, ultrasounds, or new medications in an effort to mitigate future issues.

"I'm not just going to say 'Hey, we're going to start you on this, and I'll see you when you come back,'" said Lane. "I try to anticipate what questions they might have when they go home, because they're there and they should be afforded that time."

Preemptively giving patients information saves the patient time and energy by reducing the need to reach out later with questions, if they end up reaching out at all. If a patient isn't informed about a temporary uncomfortable side effect to a treatment before starting, they won't know it's temporary and may discontinue use and subsequently care altogether. Putting in that extra time beforehand helps Lane practice preventative healthcare.

The times when patients do follow through with their treatments and have tangible positive outcomes are the most rewarding for Lane. Primary care providers don't often experience instant gratification, so seeing her patients' long-term efforts pay off is especially gratifying, she said.

"I get the most satisfaction when the work I do to educate and convince a patient to try something pays out … and then we reap the benefit of it," she said.

Mica Kanner-Mascolo is a staff writer at Worcester Business Journal, who primarily covers the healthcare and diversity, equity, and inclusion industries.

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