According to the Primary Care Collaborative, primary care accounts for roughly 5 percent of health care spending, yet it influences nearly 90 percent of downstream costs. That statistic is not a compliment. It is a diagnosis. And for a profession that has spent decades accepting influence as a substitute for economic ownership, it is long past time to read it that way. For decades, physicians have been told their value lies in prevention, coordination, and stewardship. That framing is accurate as far as it goes. What it obscures is the economic consequence of acting on it inside a financial architecture that has never been designed to reward those things. Fee-for-service payment models compensate activity, not stabilization. Conversations are reimbursed modestly. Procedures are reimbursed generously. The system monetizes intervention, not the clinical judgment that prevents intervention from becoming necessary. Primary care influences decisions. Specialty care captures revenue. That is not a coincidence. It is structural design.
The spending data makes the imbalance concrete. According to the 2026 Milbank Primary Care Scorecard, national primary care spending under the narrow physician-only definition dropped from 4.6 percent of total health expenditure in 2022 to 4.5 percent in 2023. Commercial spending fell from 5.5 percent to 4.9 percent in the same period. Medicare allocates 3.7 percent. For context, OECD nations average approximately 8 percent of total health expenditure directed to primary care, roughly double what the U.S. commits to the physicians who carry the largest share of patient contact. The U.S. spent $5.3 trillion on health care in 2024, and less than five cents of every dollar in that figure reached a primary care physician. The reimbursement spread is where the structural logic becomes undeniable. The 2025 Milbank Scorecard reported that in 2022, primary care physicians averaged $259 per visit in reimbursement. Gastroenterologists averaged $1,092. The work of a colonoscopy is reimbursed at more than four times the rate of the comprehensive office visit that may make the colonoscopy unnecessary. The payment system does not undervalue primary care by accident or oversight. It undervalues primary care because a model designed to monetize intervention has no economic incentive to compensate the physician who prevents the intervention from occurring.
While the profession has been debating documentation burden and burnout rates, something more consequential has happened quietly in the background: Physicians have largely surrendered the ownership of their own practices. The economic consequences of that transfer are rarely framed clearly enough. According to the AMA’s 2024 Physician Practice Benchmark Survey, only 35.4 percent of physicians held an ownership stake in their practice in 2024, down from 53.2 percent in 2012 and from approximately 76 percent in the early 1980s. As of January 2024, a PAI-Avalere analysis found that 77.6 percent of all U.S. physicians are employed by hospitals, health systems, or corporate entities. Private practice now accounts for less than half of physicians in most specialties. In cardiology, a specialty whose downstream revenue is directly shaped by primary care referral patterns, private practice representation has fallen to 30.7 percent. This is the financial architecture in motion. Hospitals own the infrastructure. Insurers own the premium flow. Private equity owns the consolidation strategy. And increasingly, they also own the physicians whose referral decisions route patient volume, and therefore revenue, to the same consolidated entities that write the paychecks. The physician carries the influence. The system captures the return.
What is rarely stated plainly enough is what a referral actually is inside this structure. Every referral is a routing decision. Every routing decision moves capital. Primary care physicians are not simply clinicians managing panels; they are the front door of capital flow in a $5.3 trillion industry. The difference between a practice that understands that and one that does not is increasingly the difference between independence and employment. The conventional response to the primary care revenue gap has been to advocate for higher evaluation and management rates, expanded coding complexity, and incremental adjustments to the Medicare physician fee schedule. These are not without value at the margin. They are not structural remedies. Negotiating for better codes is negotiating inside a system built on misalignment. It accepts the premise that the fee-for-service architecture is the appropriate frame for primary care’s economic future. Some states have begun to move differently. Oregon currently leads the nation, directing 7.1 percent of total health expenditure to primary care, the highest in the country, well above the national average of 4.6 percent. State-level primary care spending targets represent a more structural intervention than code adjustments, but they recalibrate what flows through existing insurance channels. They do not address the ownership and contract architecture that determines who ultimately captures the economic value of primary care’s influence. Even well-designed mandates can see increased primary care spending absorbed upstream by health systems or insurers before it reaches the practice, as the Milbank Fund has noted in its chronic disease investment report.
Primary care is not without leverage. It simply has not organized around the leverage it holds. Referral patterns are capital allocation decisions. Network participation determines which entities receive downstream revenue. Employer contracts, particularly in direct primary care and direct care models structured outside of traditional insurance, represent one of the few available mechanisms through which primary care can capture a meaningful share of the economic value it generates rather than routing that value to consolidated systems. Employer-sponsored direct primary care reframes the economic relationship fundamentally: Instead of primary care functioning as a loss leader within an insurance product, it becomes a contracted service with defined value-based economics. The employer captures downstream savings. The physician captures a recurring contract. The insurer is partially disintermediated. This is not theoretical; it is an observable and growing market structure that a number of independent and concierge practices are beginning to operationalize, particularly as mid-sized employers grow more sophisticated about the relationship between primary care access and total health spend.
The future of the profession will not be determined by expanding panel sizes or improving documentation efficiency. It will be determined by whether primary care can structurally reposition itself closer to the health care dollar, not by waiting for the system to revalue it, but by building contract structures that do not depend on the system’s cooperation. The practices that close in the next decade will not fail because of burnout or documentation burden. They will fail because they kept accepting influence as a substitute for ownership. The ones that survive will have done something different: They will have stopped negotiating their value inside a system designed to extract it, and started structuring deals outside of it. 90 percent influence. 5 percent revenue. That is not a gap waiting to be closed by policy. It is an arbitrage waiting to be captured by someone.
Dana Y. Lujan is a health care strategist and operator with more than twenty years of experience across payers, providers, and health systems. She is the founder of Wellthlinks, a consulting firm that helps employers and providers redesign care models through concierge and direct primary care, and author of The CEO Physician: Strategic Blueprint for Independent Medicine. Dana has led multi-state network development, payer contracting, financial modeling, and compliance initiatives that strengthen provider sustainability and employer value. She previously served as president of the Nevada chapter of HFMA and is pursuing a JD to expand her expertise in health care law and compliance. She has been featured in Authority Magazine and publishes on KevinMD, MedCity News, and Medium, where she writes on health care innovation, direct primary care, concierge medicine, employer contracting, and compliance. She has forthcoming BenefitsPRO. Additional professional updates can be found on LinkedIn and Instagram.
