Here's a puzzle that affects nearly everyone: the doctors we need most—the ones who know our history, catch problems early, and keep us out of hospitals—are disappearing. Primary care physicians are increasingly rare, and medical students are avoiding the field entirely. It's not because the work isn't meaningful. It's because the math doesn't work.

The healthcare system we've built pays handsomely for procedures and specialists while leaving primary care financially starved. Understanding why this happens reveals something important about how healthcare systems shape the care we receive—and why fixing it requires more than just training more doctors.

Imagine two doctors. One spends forty-five minutes with a patient managing their diabetes, adjusting medications, counseling on diet, and coordinating with other specialists. Another spends the same time performing a colonoscopy. The proceduralist might earn three to four times as much for that identical chunk of time.

This isn't arbitrary—it's baked into how Medicare values medical services. A committee called the RUC (Relative Value Scale Update Committee) recommends payment rates, and it's dominated by specialists. They consistently value technical procedures over the cognitive work of diagnosis, prevention, and chronic disease management. Private insurers typically follow Medicare's lead.

The result is predictable. A cardiologist might earn $500,000 annually while a family physician earns $230,000—despite similar training lengths. Medical students graduate with $200,000 or more in debt. They're not greedy for choosing cardiology over family medicine. They're rational. The system literally pays them to avoid primary care.

Takeaway

Healthcare payment systems don't reward what keeps people healthy—they reward what's done after people get sick.

Even when primary care doctors do see patients, much of that revenue vanishes into overhead. The average primary care practice spends 27% of revenue just on billing and insurance-related activities. Add rent, staff salaries, electronic health records, and malpractice insurance, and overhead can consume 60-70% of what comes in.

Here's what makes it worse: primary care relies on volume of patient visits, not high-value procedures. When each visit pays relatively little, you need to see more patients to survive financially. This creates the dreaded fifteen-minute appointment where your doctor seems rushed—because they are. They need to see 25-30 patients daily to keep the practice solvent.

Compare this to a dermatologist who can schedule cosmetic procedures that insurance doesn't cover. Or an orthopedic surgeon whose single joint replacement generates more revenue than a primary care doctor sees in a week. Primary care practices operate on razor-thin margins while drowning in paperwork. Many simply close.

Takeaway

Primary care's business model forces doctors to choose between financial survival and the time patients actually need.

Some healthcare systems have figured this out. Kaiser Permanente employs doctors on salary and measures success by keeping patients healthy, not by billing for visits. The Veterans Administration provides primary care without fee-for-service pressure. These systems consistently achieve better outcomes at lower costs.

The key insight is paying for value rather than volume. Models like capitation give primary care practices a fixed monthly amount per patient regardless of how many visits occur. This creates incentive to invest in prevention, manage chronic conditions proactively, and actually spend time with patients. Direct primary care practices, where patients pay a monthly fee directly, operate similarly.

Policy reforms are emerging. Medicare now offers some value-based payment options. Some states are experimenting with primary care spending targets. But change is slow, and the specialist-dominated committees still control most payment decisions. The solution exists—we just haven't committed to implementing it broadly.

Takeaway

Paying doctors to keep people healthy instead of paying per sick visit would transform primary care from a failing business into a sustainable one.

Your difficulty getting a timely appointment with a primary care doctor isn't a personal inconvenience—it's a system failure. We've built payment structures that systematically underfund the care that prevents expensive downstream problems. Then we wonder why healthcare costs keep rising.

Understanding this helps you navigate the current system and advocate for change. Primary care access isn't just about individual health—it's about how we've chosen to value different kinds of medical work. That choice can be made differently.