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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.

Cottage Health Opens New Primary Care Clinic In Goleta

Cottage Health has opened a new primary care clinic, Cottage Primary Care — Goleta at 334 S. Patterson Ave, Ste. 120. Open 8 a.M.-5 p.M. Monday through Friday, the clinic is now accepting new patients.

Physicians at Cottage Primary Care — Goleta specialize in the prevention, diagnosis and treatment of common illnesses and chronic conditions, ensuring patients receive comprehensive care for health issues ranging from minor ailments to more serious conditions.

Cottage Primary Care — Goleta's Team of Physicians includes:

Nastassia Sylvestre, MD, who is board-certified in internal medicine. She earned her Doctor of Medicine from the University of Michigan Medical School, where she also completed her internal medicine residency.

Dr. Sylvestre has previously served as a clinical assistant professor at the University of Michigan, with clinical interests in preventive health, women's health and health education.

Brett Trzcinski, MD, who is board-certified in internal medicine, earned his Doctor of Medicine from the University of Michigan Medical School and completed his residency at Wayne State University/Detroit Medical Center.

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He has served as an assistant professor of medicine at Northwestern University's Feinberg School of Medicine. Dr. Trzcinski's clinical interests include preventive health, longevity and men's health.

Jayson Wright, MD, is a Goleta local who is returning to his hometown after completing his education to become board-certified in internal medicine and board eligible in geriatrics.

He earned his Doctor of Medicine from the University of California Irvine School of Medicine and completed his primary care residency at Cedars-Sinai Medical Center, followed by a geriatrics fellowship at UCLA Medical Center.

Dr Wright's clinical interests include preventative health, dementia assessment and management, geriatric assessment, and weight loss management.

To schedule an appointment, visit cottagehealth.Org/gpc or call 805-681-6424.

RFK Jr. Eyes Overhaul Of Medicare Physician Pay: What To Know

Robert F. Kennedy Jr. Is exploring an overhaul of Medicare's physician payment model and looking to shift health incentives toward primary care and prevention, The Washington Post reported Nov. 21.

Here are six things to know:

1. The discussions are in the early stages, but involve a plan to review thousands of billing codes, according to four people who spoke anonymously with the Post.

2. Currently, the coding system is accused of rewarding providers for surgeries and costly procedures. It is also accused of pushing physicians toward becoming specialists, which pays more. Policymakers have highlighted the skewed incentives for years, but the issue has received little national attention due to its complexity and the financial interests of powerful industry groups, according to the report.

3. Medicare's billing codes are assessed by the American Medical Association and implemented by CMS. The AMA oversees the AMA/Specialty Society RVS Update Committee, made of several dozen physicians, who study the resources needed for each medical service and recommend reimbursements for those duties.

In 1991, prior to the establishment of the RUC, surgeons consumed 32% of Medicare payment charges. By 2023, it was down to 17.7%. Primary care went from 23.7% in 1991 to 28.8% in 2023, an AMA spokesperson told Becker's.

4. These recommendations have "historically been skewed by misleading estimates of how physicians spend their time," according to a 2013 Washington Post investigation of colonoscopies. For instance, The Post found that the RUC often inflated the amount of time a physician needed to perform a procedure, according to the report.

5. The AMA has collected millions of dollars in revenue from its work to develop and recommend billing codes. It also sells books and training around the codes. The AMA declined the Post's request for comment.

6. Mr. Kennedy is reportedly looking to work with the AMA on changes to billing codes that will promote primary care and reduce poor health outcomes in the nation.

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