What will it look like? – Healthcare Blog
What will it look like? – Healthcare Blog
By matthew holt | Published: 2025-10-20 14:33:00 | Source: The Health Care Blog
Written by Matthew Holt
A few weeks ago I wrote an article about what’s wrong with primary care and how we should fix them. The tl:dr version was to give every American primary care physician a concierge whose fees were paid by the government. We will give everyone a $2k voucher (on average, depending on age, medical condition, location, etc.) and have an average committee of 600 people per primary care provider.
My argument was that a) this would be cheaper than health care now – Due to reduced emergency department visits and inpatient admissions This b) will enable us to pay primary health care providers such as specialists (about $500,000 per year). This means that many current emergency physicians, internists, hospitalists, etc. will convert to primary care physicians. I also believe we can make better use of the nurse practitioners who now number 400,000 in the United States. We will only need about 600,000 primary health care providers to get this work done. Although it would double spending on primary care, it would lower health care costs overall. (Okay, there’s some debate about this but the Milliman study linked above and common sense suggest it will save money.)
Obviously there are two big problems with my proposal. First we have to go through the conversion process. Second, we have to do something big with the three major players who are currently soaking up health care dollars: the large hospital systems and their associated specialists, health insurance companies, and drug and device companies.
I don’t think there would be any problem selling this product to most doctors or to the American people.
Doctors know they are trapped in the current system. This would free them to practice what they want, and to remember why they got into medicine in the first place – to care for their patients holistically.
People know very well that access to primary care is good for them but it is also very difficult. The waiting lists are very long. In this system primary care would be abundant. I and many others have nothing but horror stories about how major hospital systems, insurance companies, and big pharmaceutical companies have treated them poorly. They prefer to have a capable PCP on their side.
The only concern about patients’ primary care is whether their primary care provider is incentivized not to refer them to needed specialty care. In my system there would be no universal surrender or danger to the Palestinian Communist Party, and thus no incentive not to signal. But there is no reason to point unnecessarily. They will do the right thing because it is the right thing. (It took Jeff Goldsmith 30 years to convince me of this.) So there will be no need for insurance companies to manage primary care at all. No claims, no bills, no usage management. Instead, we should have 600,000 well-paid primary care docs who are able to manage their practices to do the right thing.
This is likely to involve a lot of variation. There will be primary care providers working in groups. There will be a solo. There will be specialists in certain types of patients (thin children, people with serious illnesses, or geriatricians). They would all receive the same amount of salary but their practice revenues and patient numbers would be adjusted in a similar way to how we risk adjust for Medicare Advantage now, but without the games, and without the profit motive.
This system would create a lot of innovation. Primary care providers will be responsible for people with chronic conditions. They will have a budget starting at $2,000 per person (from which they will receive approximately $800 in income) to build remote monitoring software, to use artificial intelligence, to build teams of assistants and nurses, and so on.
Can this be done in the United States? Yes, that actually happened. I urge you to take some time to read this ChatGPT summary of Alaska’s innovative Nuka system. (I believe it was created by Steve Schutzer MD). Noka has gone from being an expensive, bureaucratic, stilted system – one that its patients hated – to one with culturally appropriate care that its “consumers” love today. Its costs are lower and its results are better. There are plenty of other examples of a similar approach across the United States. Just ask Dave Chase. They didn’t expand because the current incumbents killed them. (One great example Is this the case in Texas? It bought a hospital chain and killed off a large primary care group led by… Scott Conard Because it was costing them $100 million a year in low admission rates for hospital field schools).
What we need to do is create incentives, get doctors and patients to enter into these arrangements, and let American medical ingenuity and professionalism carry it forward.
The other side of the equation is the need to control the costs of specialty and hospital care. How this will happen is up for debate.
Personally, I would delay this over 2-3 years and identify which hospitals would be the “losers” – that is, those hospitals that currently use their primary care networks as loss leaders for expensive specialty care. I will gather a national group of them and gently persuade them to chart a course to transform them into a global budget. After all, there is no need for them to provide primary care in the emergency department, and their admissions for unsupervised chronic care will decline. Oh, and they won’t need those huge hedge funds – they can be reallocated to pay for primary care! Under this worldview, there would be no need to pay top executives like baseball players — as UPMC (for example) does with its top 117 executives!
America’s leading hospitals and specialists will continue to provide the most scientifically advanced, world-leading care. They won’t offer many of them at this high price. And of course they will develop very strong relationships with innovative primary care docs. In fact, I strongly suspect that there will be direct integration, but on the terms of the Palestinian Civil Police. See what’s happening in Alaska and Kaiser.
You may have noticed that in a world of basic global budgets for primary care providers and global budgets for hospitals, my system doesn’t seem to have room for health insurers. You will be right. Look, you just saved 15%! Well not really. Some of these administrative costs and some actuarial analysis have to be done somewhere. But in this system there are no claims, no UM, and no UnitedHealth Group corporate aircraft. There are services that technology and service companies sell to primary care providers. In fact, part of what now lives inside United, Elevance and others will continue as medical groups and technology companies. But the basic insurance function will no longer exist.
Which leaves the last of the big players in the healthcare ecosystem. Pharmaceutical and device companies are currently creating great products (generally). They are used incorrectly and cost a lot. I would add a function to the FDA that looks at cost-effectiveness or drug use, post-Phase III drug abuse management, and I would have a transparent global pricing system. Goodbye to PBMs. Hi Mark Cuban.
How to pay for it? For now that won’t change much. The government now pays 60% of health care costs, and employers and consumers pay the other 40%. I’m just going to take that money and move it around. (Well, I would run it through a rational tax system, extract reserves from insurance companies and hospitals that no longer need them, and add a wealth tax on billionaires for good measure. But those details can come later.)
Look, I know this is a massive system change. Maybe we need a king/dictator to accomplish this. But given the current mood in the country, we seem to like this idea. This is an area where radical change can do a lot of good.
Given a little policy marketing budget, I could easily position insurance companies, hospital systems, pharmaceuticals, etc. as the villains, and make underpaid health care providers the heroes.
Who wouldn’t want free concierge care?
Matthew Holt is the founder/publisher of THCB
ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ
