Undervalued to In-Demand: Rethinking Incentives in Primary Care

A consistent pattern in medical training is hard to ignore: many students enter wanting to work in primary care with underserved groups, yet later choose to pursue specialty careers. I’d like to think these intentions are sincere, but something during training redirects them. That pattern isn’t about greed or moral failure–it’s a signal that we need to rethink how we value and incentivize primary care in the United States.
Unsexy, but efficient and effective
“Student loans” by cafecredit is licensed under CC BY 2.0.
Despite primary care’s cost-effectiveness, the payment system is structured in reverse. It currently rewards costly, reactive specialist care rather than preventative medicine. For every health care dollar spent in the US, just four to six cents goes to primary care. One method to combat the rise in health care costs and poor health outcomes in the US is to increase the number of primary care providers. In order to do so, we must work to make primary care a more appealing specialty.
There are valid reasons why primary care gets a bad rep. Students see burnt-out primary care providers drown under loads of administrative tasks. They see primary care as the mundane, “unsexy” choice, as it typically doesn’t have the dramatic life-or-death moments more commonly seen in ER or surgical specialities. And the burden of student loans, coupled with predatory interest rates, can incentivize providers to pursue higher-paying specialties.
If you do primary care right, nothing obvious happens
Yet the value of primary care is well established. We know that primary care decreases costs and increases life expectancy. At the individual level, adults who have a primary care provider (rather than a specialist) spend 33% less on health care each year and are 19% less likely to die in the next 5 years. Another study found that each additional primary care provider per 10,000 people reduced ER visits by 11%, surgeries by 10%, and hospitalizations by 5%.
The true value of preventive care can be hard to quantify, because if done right, nothing obvious happens for patients. Few patients will think about the illness they didn’t catch, the emergency room visit they didn’t make, or the hospitalization that didn’t happen–all because of good primary care. That is the beauty of preventative medicine.
The reality of working in primary care 
However, our system fails to invest in primary care, or reward the providers doing the hard work. Instead, primary care providers are among the lowest paid of all specialties. Despite the low pay, primary care is a difficult skillset of its own. Beyond diagnosing and managing a vast range of conditions, providers must coordinate referrals and specialist care, manage paperwork and prior authorizations, and navigate community resources.
It’s not just a hard job—it’s structurally impossible. One study found that a primary care provider would need 26.7 hours in a day to complete all the tasks needed for the job. It’s gritty, emotionally taxing, and complex work. And yet our health care system under-appreciates and under-compensates our primary care heroes. When the demands are this high and the rewards are relatively low, it’s no surprise that trainees are steered elsewhere.
Reversing the decline in primary care interest doesn’t require reinventing the system—it requires realigning it. From clinic-level changes to national policy reforms, there are practical steps that can make primary care a more structurally viable and appealing path. Solutions exist at both the practice and policy levels—and many are well within reach.
Practice-level changes
Not all solutions require sweeping policy changes. At the practice level, clinics and health systems can take immediate steps to help reduce burnout and improve retention—making primary care more attractive in the near term.

Continue the shift toward value-based care, rewarding better patient outcomes rather than volume, and enabling a greater focus on prevention over reactive care.
Expand team-based care, including patient navigators and advanced practice providers (PAs and NPs), to expand capacity and improve care coordination.
Set sustainable patient volumes by capping daily visits, with incentives for additional work rather than uncompensated.
Lengthen visit times to 30 minutes to allow for more meaningful patient interactions, more fully meet patient needs, and reduce after-hours charting, referrals, etc.
Protect administrative time, such as a guaranteed half-day each week.
Offer flexible scheduling, including options like four-day workweeks (10 hours per day) or dedicated telehealth days.

Structural change strategies
While practice-level interventions can improve day-to-day conditions, they operate within a larger system. National and legislative bodies play a critical role in the incentives across the health care landscape, and they are an essential place for reform.

Rebalance reimbursement rates within Medicare, Medicaid and private insurance to align with health-producing preventative care and reduce procedure-heavy payments. Some of this may already be happening in Medicare.
Expand loan forgiveness programs for primary care physicians, building on models like the National Health Service Corps. This could be funded, in part, by any savings from rebalanced reimbursements.
Reduce or eliminate student loan interest for those entering primary care, a targeted and potentially more feasible reform. Temporary pauses during COVID-19 demonstrated that this approach is possible,  and could save borrowers over $100,000 in interest.
Develop accelerated primary care training pathways, such as three-year medical degree programs, to lower costs and bring primary care physicians and advanced practice providers who wish to work in primary care into the workforce sooner.

Many of these ideas have been around for a while. And some are initial musings to get the conversation started. If we want to improve health outcomes and reduce costs, we must be honest about why providers avoid primary care, and get real about strategies to incentivize it.  
Author informationMargaret ListerThird year PA (physician assistant) student at USC Keck School of Medicine. Passionate about health policy and primary care.
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