To explore practical pathways for implementing primary care transformation, the Hopkins Business of Health Initiative convened an expert panel featuring leaders who bridge research, policy, and practice. 

Rather than revisiting what is broken, this discussion focused on what it would take to realize a new primary care vision, and who is positioned to lead it.

The panelists included Sherry Glied, Dean of NYU Wagner Graduate School of Public Service and a leading health economist; Emily Maxson, a partner at Spirited VC, a primary care physician, and former CMO at Aledade; and Zirui Song, Associate Professor at Harvard Medical School and a primary care physician at Massachusetts General Hospital.

"What we all hope for is a trustworthy system with well-functioning teams that triage patients to the right people at the right time, and help everyone stay healthy and prevent serious illness," posited the panel’s moderator and HBHI director Dan Polsky. "But how do we actually get there?"

The Economic and Structural Pressures Shaping Primary Care

Payment incentives still run counter to primary care’s role

To reform primary care is largely to reform American health care, which brings its own challenges and complexity. Our current conditions have collectively created a fragmented, inefficient, and costly health care system that struggles to provide comprehensive, patient-centered care.

That’s because the fee-for-service system that we currently operate under creates perverse incentives that fundamentally undervalue primary care. 

"If you spend 15 minutes taking out somebody's cataract, that's 10 relative value units," explained Song. "The classic 15–20-minute office visit with your primary care doctor is worth one relative value unit—essentially a ten-to-one ratio. That is really at the root of all of this." 

Song explained that transitioning to value-based care involves extraordinary complexity on the ground. After Massachusetts General Hospital implemented a sophisticated risk-adjusted capitation model, "volume dropped by about 10% and primary care lost $10 million in the first year," forcing the organization to re-implement some fee-for-service incentives. 

Maxson added an important perspective: "Primary care revenue is not the problem. Until we address the reimbursement disparity in specialties and the fact that you can overspend in specialty care without getting desirable results for your patients, I would like to see more payment reform efforts in that category as well."

Data gaps limit policymakers’ ability to design reform

Together, these payment distortions are compounded by limited visibility into what primary care actually looks like today, which leaves policymakers trying to redesign a system they cannot fully see. Glied emphasized this gap: "We haven't done enough recent research on what primary care actually is today, how these different payment mechanisms are rolling out. We need to understand what this animal is. We should stop thinking that it is what it was 30 years ago." 

“Value-based care assumes that you pay by outcome, but we have never really done a great job of measuring those outcomes,” said Glied. “We might even think that we could just pay fee-for-service, measure and display the outcomes, and let patients go where they will.”

A shrinking workforce threatens system capacity

Panelists noted that workforce shortages magnify the impact of poor incentives and limited measurement. Song painted a stark picture: "Currently, not only do we have the retirement crisis of PCPs getting older. Indeed, PCPs are, on average, older than non-PCPs in this country, and we have a drying pipeline of students coming into primary care. Less than a third of residents in primary care tracks stay in primary care by the time of graduation. But those two long-standing facts are now joined by a third free market reality, which is that many primary care doctors are leaving for concierge and direct primary care practices." 

This exodus is already having profound spillover effects. "The rest of society is now battling over fewer and fewer available slots. It is readily understandable why medical students choose not to go into primary care, given the other opportunities. There are big opportunity costs of choosing primary care."

The Human Foundations of Primary Care Are Eroding

Trust is collapsing, and prevention is collapsing with it

The erosion of trust shapes how patients use or avoid the system. Panelists described trust not as a soft concept but as a foundational condition for prevention and continuity. Maxson emphasized the existential nature of the trust crisis: "Trust undergirds all of health care, and if you can't take as a given that vaccines are a good thing that should be promulgated across populations, the vision is impossible without empowering primary care. If we don't empower and encourage and raise up evidence-based leadership in health care policy, we regress, and we cannot achieve the health outcomes that we desire." 

She pointed to concrete consequences already visible: "Employers are spending a ton of money on benefits for their employees, and their employees are not leveraging those benefits. They're not getting their preventive screenings. They're not necessarily even getting their vaccinations at the same rates as they used to. They've gone through the river and fallen off the waterfall—that's where the costs are incurred, because now they have a cancer that was caught at a later stage." 

Her call to action was clear: "We need a just-in-time intervention to reinforce the importance of evidence-based prevention and primary care in the eyes of patients and policymakers."

Clinicians are being tasked with solving non-clinical problems that they alone cannot fix 

The panel wrestled with a fundamental difference between the U.S. and peer nations. "Unlike other countries, the US has placed all manner of social issues in health care's basket of issues to solve," the moderator, Dan Polsky, noted. 

Glied reinforced this point: “In other countries, they don't do social determinants of health in physician practice.” This puts primary care providers and practices in a nearly impossible position. "Today, there are some payment models for screening of social determinants of health. So you screen your patient population, and you find out that there's housing insecurity. But what can you do about that?” said Maxson. “It's incredibly demoralizing as a PCP to find out that you have this need that you just can't care for." 

New Models and Leaders Will Shape What Comes Next 

AI and team-based models could extend primary care’s reach

To shift medicine's focus from treatment to prevention, a new system should incorporate the unique assets of unlicensed or alternative supports, such as community health workers, who are already integrated into communities that trust them. Panelists noted that expanding the care team will be necessary to manage rising complexity. 

Maxson proposed an innovative approach to building primary care teams that leverages technology that has never existed before. "How could we use AI, not just to work on the efficiencies, but to help unlicensed individuals in the community to deliver high-quality, protocol-based, evidence-supported care? We have the workforce—it's a trusted workforce. How do we make sure they're delivering the best complementary care possible?" 

By combining their community connections with AI-supported clinical protocols, primary care practices could dramatically expand their capacity to meet patient needs while maintaining quality and evidence-based approaches.

Licensing frameworks need modernization to support the next generation of care teams

To reform payments and build effective teams, the licensure of various professionals will require uniformity that currently does not exist. "If you're going to have licenses, they should be standardized. There is no sense in having a system of licensure in which you can't be sure what exactly it is that people do,” said Glied. “It makes it really hard to build anything. Having standards is a function of government, and we should have standards." 

However, there’s an important way in which primary care differs from other practices of medicine and defies easy categorization. "By nature, primary care has to handle anything that comes through the door. Anything that comes down the lane, you've got to scan it, or figure out a way to scan it,” said Song. “Somebody walking in with abdominal pain could have anything from they ate something bad last night to stomach cancer. The expertise is really more about an approach and a thought process. It's very different from procedural-oriented care."

States and employers can lead the way until national reforms take root

Song highlighted Rhode Island's proven model: "Rhode Island is a leader in state investments in primary care. In 2007, before they required increases in primary care spending, Rhode Island spent $48 million on primary care, of which $3 million was non-fee-for-service. By 2023, Rhode Island spent $86 million on primary care, and $52 million of that was now for non-fee-for-service payments." 

Several states have begun to test what a more deliberate investment strategy could look like. Following Rhode Island's lead, "other states like Colorado, Oregon, Delaware, Virginia, Pennsylvania, Maine, Massachusetts, and California have taken this lead to try to essentially legislate this increase in primary care spending." 

On the employer side, Maxson emphasized their unique leverage: "Work with employers to improve utilization of health care benefits, develop programs encouraging preventive screenings, and create incentives for employees to engage in preventive care." Employers have both the financial motivation and the direct relationships with covered populations to drive meaningful behavior change.

The panel's message was ultimately one of cautious optimism tempered by realism. As Glied noted, looking back 30 years: "We would have been talking about how what we need is a staff model, integrated delivery with value-based purchasing—all of that stuff. It didn't happen. That organizational form did not triumph in the marketplace."

Together, these experiments suggest that the most durable reforms may come from entities that control spending directly (states and employers) rather than from federal policy shifts. 

If a new primary care vision is achievable, panelists argued, it will require leadership rooted in aligned incentives, trusted relationships, and investment models that support the work clinicians are actually asked to do. Doing so will require sustained action across policy, industry, and practice. This work extends well beyond the walls of any individual clinic. 

About the convening 

Primary Care Reform: Aligning Payment, Policy, and Innovation

This conversation was co-hosted by The Hopkins Business of Health Initiative and the Center for Health Systems and Policy Modeling at the Hopkins Bloomberg Center in Washington, DC, bringing together experts from the field to discuss the future of primary care.

Featuring a total of nine guest experts, the day’s discussions explored the strategies needed to advance the state of primary care, ranging from innovative care delivery models to emerging workforce approaches and to the technologies and policies that shape its ability to function. 

As defined in the day’s first panel discussion, the overarching goal is to create a comprehensive ecosystem that financially, culturally, and systematically supports primary care providers in leading public health efforts and improving overall health outcomes. 

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