Rethinking Reform: Ken Terry on Primary Care, Cost, and the Future of U.S. Healthcare

In this episode of SoundPractice, host Mike Sacopulos talks with veteran healthcare journalist Ken Terry about his new book, Beyond Medicare for All: Cracking the Code of the Healthcare Affordability Crisis, published by the American Association for Physician Leadership.

Mr. Terry, a former senior editor at Medical Economics has written for publications including Medscape Medical News, WebMD, cio.com, InformationWeek, and Fierce Healthcare. He is the author of two previous books on healthcare reform: Rx for Health Care Reform (Vanderbilt University Press, 2007) and Physician-Led Healthcare Reform: A New Approach to Medicare For All (AAPL, 2020). He also contributed to Stephen K. Klasko's 2023 book, Feelin' Alright: How the Message in The Music Can Make Healthcare Healthier.

Mr. Terry explains why he abandoned the assumption that Medicare for All will ever become reality — and lays out an alternative model built around empowered, salaried primary care groups, all-payer hospital rates, and a new “consumer council” to help guide difficult coverage decisions.

This transcript of the discussion has been edited for clarity and length.

Mike Sacopulos: Before we jump into the new book, I'm interested to know how you came to the healthcare field.

Ken Terry: I came to the healthcare field through a friend of mine who worked at Medical Economics. At the time, I was looking for a journalism job, and he gave me some freelance opportunities. They liked my writing and hired me. At that point, I was thrown into the fire — I had a lot to learn.

Sacopulos: I'm excited to talk about your new book, Beyond Medicare for All: Cracking the Code of the Healthcare Affordability Crisis . Why did you write it?

Terry: This is actually the third book I've written on healthcare reform. I've been building this model for more than 20 years, based on things I've observed in the field and studies I've read. I felt we needed a different approach to reform — one that emphasizes primary care and provides universal healthcare that's high quality and affordable for everyone. My earlier books assumed we would someday have Medicare for All as the overarching financing mechanism for the system. But I came to realize that will probably never happen, so we need an approach to restructuring the system that meets the needs of the major industry players.

Sacopulos: Why should primary care physicians be in charge of basic care, including lower-level specialty services? And how would that help save primary care?

Terry: Going up one level — physicians generally should have a greater role in running healthcare, since they're the ones who diagnose and treat patients and know where the waste is. Primary care doctors specifically should oversee basic care because they're trained to deliver preventive and chronic care and to coordinate with specialists. If PCPs deliver all the care they're capable of, they won't have to refer out to specialists as often as they do now. But primary care has been declining as fewer young doctors enter the field and more older doctors retire — in the past decade, the share of U.S. doctors in primary care has dropped from about a third to a quarter. Over the same period, the majority of PCPs became employed by health systems and corporations. If they could be freed from that employment and form groups large enough to be financially responsible for basic care, primary care physicians could help save healthcare while earning more and restoring prestige to their field.

Sacopulos: What are your thoughts on physician assistants and nurse practitioners? How do they fit into this model?

Terry: They're essential, because right now we don't have enough primary care doctors, and PAs and NPs are delivering a great deal of the primary care in this country. But they're not substitutes for primary care physicians. It's said they can provide 85 to 90 percent of the care a primary care doctor does — but that remaining 10 to 15 percent can be critical. Some primary care doctors have told me that PAs and NPs can't always determine what's wrong with a patient who comes in with ambiguous symptoms.

Sacopulos: Your model involves a system of competing primary care groups. But most physicians today are employed. How would you address that?

Terry: To create this model, the federal government would need to restructure the healthcare system through an act of Congress. But states could implement changes to the employment status of primary care doctors on their own. Today, 33 states and the District of Columbia have corporate practice of medicine laws designed to prevent corporate employment of doctors. Those laws don't currently stop health systems, insurers, or private equity firms from employing primary care doctors — but they could be strengthened to do so, and other states could adopt similar laws.

Sacopulos: Would that be done through the legislature, through boards of medicine, or all of the above?

Terry: It would be done through the legislature. States would need to pass laws strengthening their existing corporate practice of medicine laws in the ways I describe in the book — but applying specifically to primary care doctors.

Sacopulos: A lot of this comes down to money, which brings me to third-party payers. How do you believe insurance companies would respond to your model?

Terry: I think insurers — along with the majority of corporations that self-insure today — realize the system is headed for collapse and that it's unsustainable. Insurers oppose Medicare for All because it would cut them out, and they don't support a public option because they know it would lead there. But in the model I'm proposing, insurers would still have an important role. They would cover everything outside basic care — inpatient care, post-acute care, and more expensive ambulatory care such as cancer care and outpatient surgery. They would cover everyone, including all Medicare and Medicaid beneficiaries, for those types of care, including Medicare beneficiaries not currently enrolled in Medicare Advantage. Overall, their business model would remain strong.

Sacopulos: Under your model, hospitals would charge every payer the same for the same service and operate under global budgets, as in Maryland. Why wouldn't hospitals fight this change?

Terry: The first part of the answer is the same as for insurers — the current system is unsustainable, and eventually there won't be enough money to cover hospital costs if most people can't afford healthcare. Maryland's system of all-payer hospital rates and global budgets has worked well for both insurers and hospitals, and it could work elsewhere, as Ezekiel Emanuel and colleagues have pointed out in Health Affairs. Under global budgets, hospitals also wouldn't be subject to prior authorization rules — their physicians would determine how best to deliver high-quality care within a budget negotiated with the state.

Sacopulos: What happens in rural areas?

Terry: Rural healthcare differs from suburban and urban healthcare in many ways — most importantly, the scarcity of hospitals and clinics. Because there aren't many doctors in some rural areas, you couldn't form the kind of competing groups that would exist in more populated areas. I talked with a number of rural doctors and experts and developed a modified version of the model for rural healthcare. The financing would still be split in two, as in the mainstream model, but whether care is covered by a basic care subscription or by insurance would depend on where the care is delivered rather than what kind of care it is. Care delivered at a rural hospital, primary care clinic, or federally qualified health center would fall under a state-negotiated global budget for the local healthcare system. Care delivered at a metropolitan hospital or outpatient center would be covered by major medical insurance.

Sacopulos: With competing primary care groups in an urban or suburban area, could different members of the same family belong to different groups?

Terry: That would create some real problems. I didn't consider that scenario directly in the book, but clearly you'd want family or individual premiums, and a family premium for a family of four would likely be much less expensive than four individual premiums — so cost would probably discourage that kind of splitting. In any case, the distinguishing feature of primary care is that it covers people from birth to death, so all members of a family could receive appropriate care, differentiated by whether it's pediatric care, family medicine, or internal medicine.

Sacopulos: Would the day-to-day experience of a primary care physician be different under your model than it is today?

Terry: Yes, very different. Physicians in these primary care groups would be paid salaries, so what they did day to day would have no bearing on how much they earned — bonuses would be based only on quality and stewardship of resources. They would also work in care teams designed to manage population health, where the health of the individual patient and the broader population would both be paramount, including in-between-visit care needed to keep people healthy or prevent chronic illness from worsening. I think of the primary care physician as more like the quarterback of the team — maintaining an individual relationship with each patient while also directing the team in ways that benefit the patient's long-term health and the health of the population.

Sacopulos: We're experiencing the aging of the baby boomer generation, who require more healthcare. Would your model accommodate that better than what we're seeing today?

Terry: Yes and no. On the positive side, better chronic disease care would definitely help older patients, many of whom have multiple chronic conditions, and doctors would be able to spend more time with each patient. On the other side, I considered the challenge of long-term care and couldn't come up with a financing approach that would work better than what we have now — a limited amount of Medicare coverage, mainly for dual-eligible patients and only for professional services, with the rest falling to Medicaid and whatever resources families have. It's a very challenging subject, and one other countries haven't found good answers for either.

Sacopulos: You write in the book about new technologies and a consumer council. Can you tell me what that is and why you'd advocate for one?

Terry: Right now, Medicare isn't allowed to consider cost in its coverage determinations. Other countries do consider cost, and we need to start doing the same — because if there's no limit on what new medical technologies can be covered, no matter how expensive, the health system loses resources that could otherwise provide basic care that most people need. Society has to weigh, for example, whether an exorbitantly expensive drug that benefits relatively few people, or extends life by a relatively short amount of time, is a better use of resources than chronic care for people with diabetes, hypertension, or heart failure, or prenatal and maternity care. That decision has to be made democratically rather than left to the free market. This idea builds on a conversation I had years ago — described at the end of my first book — with David Eddy, a population health advisor to Kaiser Permanente and an expert in clinical guidelines. Eddy's idea was that if we want to apportion healthcare resources fairly and democratically, we should have a consumer council made up of people who pay for their own insurance, and show them how much their premiums would likely rise if a given technology were adopted. His insight was that people would weigh that cost differently than they'd weigh the small likelihood of someday needing the treatment themselves. It gets more complicated with something like GLP-1 drugs, which aren't extremely expensive individually but are used by millions of people. The UK has had a citizens' council along these lines that once had a real impact on National Health Service coverage decisions, though its influence has declined over the past decade. It's just one idea, but I do think we need some way to determine what's worth covering — otherwise there's no way to limit healthcare spending.

Sacopulos: Any ideas on how many people would be on such a council, or how it would operate? I like the concept, but I also think about who I'd encounter on a given night at the store — I'm not sure I'd want those people making decisions about my healthcare.

Terry: It is difficult. I'd guess somewhere between several hundred and several thousand people. We'd look for people with some college education and some knowledge of healthcare, who would be given consumer-friendly descriptions of a technology and its likely results, and who would serve limited terms. They'd also be anonymous, so no one could pressure or reach them. They'd need to be somewhat public-spirited, since they'd be devoting time to considering these questions. I'm not sure exactly how members would be chosen, but I don't think it would be at random.

Sacopulos: Do you believe your model could be implemented on a statewide basis, or would it need to be national?

Terry: It would need to be a national restructuring, because people receive care across state lines and businesses operate across state lines. Some states have tried versions of reform on their own — Massachusetts famously enacted the precursor to the Affordable Care Act — and that had some good effects, but it was limited to financing. I think the federal government has to establish the framework and set certain rules. States would still have an important role, particularly in regulating hospital markets — negotiating with hospitals and likely producing statewide hospital report cards. There would also be a role for a new regional health authority, similar in some ways to bodies in the UK, made up of representatives from consumers, businesses, and physicians. These authorities would regulate competition among the basic care groups, hire third-party “health utilities” to help administer the system, reassign physicians if a group fell apart, produce report cards on quality and patient experience, and process claims for services from specialists and labs.

Listen to this episode of SoundPractice .