There is near-universal agreement in U.S. medicine that primary care is in trouble. Our nation faces a massive shortage of these doctors , with diminishing interest among medical students in pursuing the specialty. Unless something alters this trajectory, access to primary care will continue to decline nationwide.

Ask primary care physicians what must change, and they will point to greater autonomy, fewer patients per day, increased office support and much higher salaries.

They have a point about payment. According to Medscape’s 2026 Physician Compensation Report , primary care physicians now earn an average of $298,000, compared with $417,000 for specialists.

National primary care leaders assert that if the nation invested more in the specialty, physicians would keep patients healthier, better control chronic disease and reduce the need for hospitalization and expensive downstream medical treatments.

Logically, payers — including insurers, the government and self-funded businesses — would find those outcomes enormously valuable. Chronic diseases remain epidemic and poorly controlled. Access is declining, with waits for both primary and specialty care averaging weeks to months depending on the service and location. Most concerning, national healthcare spending is projected to soar from $5.7 trillion today to $9 trillion by 2034, according to CMS projections .

And yet, despite the pleas and promises of primary care, payers have not made the investment. Why?

Why Primary Care Remains Stuck

When an apparently logical solution fails to advance year after year, the reason is usually that the source of the problem hasn’t been diagnosed correctly. Decades ago, carmaker Toyota popularized a way to identify the root cause. The technique, known as the “Five Whys,” repeatedly asks why until the underlying cause becomes clear.

Applied to primary care, the chain can be compressed into three queries:

  • Why is primary care struggling? Because the work is under-resourced and undervalued.
  • Why is the investment inadequate? Because payers aren’t convinced that spending substantially more on primary care will raise quality and lower total costs.
  • Why are payers unconvinced? Because they lack sufficient evidence that paying primary care doctors more will produce the promised improvements.

In other words, payers aren’t going to spend the dollars until they see clear proof that they will receive a return on their investment.

Consider hypertension. CDC data show that nearly half of American adults (124 million) have the condition, yet only 21% of patients with hypertension have it under control. That means that approximately 95 million people have uncontrolled hypertension. The CDC also reports that elevated blood pressure contributes to approximately 680,000 deaths annually. Using the average per-person costs from hypertension treatment, bringing the condition under control for 80% of Americans — a rate of success that leading healthcare systems currently achieve — could save as much as $262 billion.

Payers know better results are possible with existing medications and evidence-based guidelines. But past efforts to incentivize the desired outcomes have failed.

Transactional Payments Rarely Produce Intended Change

For two decades, payers have relied on pay-for-performance programs in hopes of getting primary care physicians to better control chronic disease, improve clinical outcomes and reduce costs.

Under this payment model, physicians might receive an additional payment each time they check a patient’s blood pressure or modify a medication. The experience has been that with the incentive in place; clinicians routinely perform the steps needed to earn the added dollars. But when they become busy, they often skip other preventive services that carry no financial reward. The result is more dollars paid without equivalent improvement in overall health.

This failed outcome was documented in a 2025 BMJ review of a large primary-care pay-for-performance program . Researchers found that financial incentives initially improved the measures being rewarded. However, by three years, those gains had largely diminished, with deterioration in unincentivized care over time.

This is the problem with paying doctors on a transactional basis. There are too many components of excellent medical care to incentivize each one individually. For primary care to convince payers to invest significantly more in the specialty, physicians will need to accept financial accountability for all the results of their care, not simply receive more money for completing some of the individual steps along the way.

Fee-for-service, which accounts for 95% of all medical payments to clinicians, represents a broader version of the same transactional problem. The more services clinicians provide, the more they are paid, regardless of whether the additional care produces better health. See a patient twice for a problem that could have been resolved in one visit, and the physician earns more while the patient is inconvenienced and care is delayed.

Why Capitation Is Best For Payers And Primary Care

If primary care wants both greater income and more autonomy, physicians will need to accept a form of payment called “capitation.” Rather than paying doctors piecemeal for each visit or service, capitation provides a prospective payment for the totality of the medical care needed by a defined population of patients.

Payers are likely to welcome the change because it shifts financial accountability to the clinicians delivering the care. Providers are likely to experience ambivalence as they recognize the financial risk involved but also the equally great opportunity it offers.

By moving reimbursement from fee-for-service to capitation, primary care can demonstrate its ability to achieve higher-quality outcomes at lower total costs and obtain the added resources it seeks in exchange for the higher value it provides.

Furthermore, by accepting direct payment for the totality of medical care provided, clinicians would be able to avoid many of the frustrations they currently experience, including prior-authorization requirements and much of the fee-for-service billing and claims process.

The financial risk is real. The unpredictability of whether individual patients will experience an expensive, life-threatening medical problem in any year makes that risk too great for a single doctor or small practice to accept. A handful of patients requiring organ transplants, advanced cancer treatment or hospitalization after a stroke could overwhelm a small practice through no fault of its physicians.

To reduce the financial risk, doctors will need to organize into groups large enough to spread risk, purchase stop-loss protection and build the operational capabilities required to manage a population of patients.

That will require physicians to surrender some of their personal autonomy in order to achieve group excellence . Agreements will be required around common approaches to chronic-disease management, coordination of care for complex patients, appointment access and performance measurement.

Unlike today, however, these decisions would be made by practicing clinicians rather than insurance executives or health-system administrators. Success will require skilled medical leaders empowered to implement them.

Primary care physicians have understood the advantages of moving from fee-for-service to capitation for years. But they haven’t had the tools needed to reliably and effectively control chronic disease, avoid preventable hospitalizations and improve patient health.

Generative AI has begun to change that calculus.

GenAI Changes What Is Possible

Combined with home-monitoring devices, telemedicine and patient-generated health information, GenAI would allow primary care groups to manage chronic conditions including diabetes, chronic heart failure and hypertension continuously in patients’ homes rather than relying on episodic office visits.

Using GenAI, physicians could identify when blood pressure or blood glucose remained uncontrolled and adjust medications more quickly.

Moreover, with the added dollars capitation would provide, primary care groups could hire additional staff and give doctors more time to manage complex patients. Today, they frequently refer these individuals to a specialist. They don’t do this because they lack the expertise, but because their overflowing schedules don’t provide the time needed for them to complete the evaluation and provide ongoing treatment.

By expanding the scope of care that primary care physicians provide and allowing them to share in the financial value they create, this model offers a path toward narrowing the enormous compensation gap between what they and their specialty colleagues earn.

Primary-Care Societies Need To Make The Mountain Smaller

For an individual primary care physician, all of this may seem daunting: change payment models, join or form a larger medical group, accept financial accountability, collaborate with colleagues, adopt new technology and redesign how care is delivered.

That is precisely why national primary-care societies need to do more than lobby Congress for additional money. They will also have to lead and help facilitate the financial and operational transition.

These organizations can build demonstration programs, help physicians form appropriately sized groups, provide expertise for negotiating capitated contracts and purchasing stop-loss protection, assist with implementing the necessary technology and clinical infrastructure, and establish common measures for quality, access, patient experience and cost. They can then apply the lessons learned from the initial groups to new ones.

Already, Medicare is encouraging doctors to move in this direction through innovative, technology-supported care models .

Primary care physicians are right that they carry an unsustainable burden. They deserve higher salaries, more support and greater respect.

But until they demonstrate that greater investment will produce better clinical outcomes and lower costs, payers aren’t going to listen. To earn their confidence, primary care physicians will need to take bold steps rather than incremental ones. Anything less is destined to fail.