Health Affairs analysis calls for Medicare payment reform to better value primary care

In 2025, it’s harder than ever to access primary care in the United States, with patients now waiting an average of 31 days for an appointment — a 50% increase over the past two decades.

A new Health Affairs Forefront article points to income disparities as a key factor in this trend. Specialists earn about $394,000 annually, while primary care physicians average $277,000. The authors argue that this gap disincentivizes new physicians from choosing primary care, worsening shortages and straining patient access.

How the fee schedule shapes payment

The Centers for Medicare & Medicaid Services (CMS) pays physicians under the Physician Fee Schedule (MPFS), which is built on the Resource-Based Relative Value Scale (RBRVS). Payments are calculated using relative value units (RVUs) based on physician work, practice expense and malpractice costs. While designed to reflect resources required, the “work” RVU underrepresents the cognitive effort primary care demands — particularly for patients with chronic conditions requiring diagnosis, counseling and long-term care coordination.

Comparisons show that common procedures like colonoscopies or bronchoscopies receive RVUs 30% to 75% higher than a typical primary care visit, despite requiring similar or less time. The authors note that once procedural skills are acquired, many specialists can perform dozens of procedures in a day, while primary care involves sustained, individualized decision-making.

The RUC’s outsized role

The American Medical Association’s Relative Value Scale Update Committee (RUC) has significant influence in shaping payment values, yet primary care is underrepresented. Primary care physicians account for about a quarter of the workforce but hold just 19% of RUC seats.

In a system where increasing payment for one service often reduces it for another, this imbalance disadvantages primary care.

The RUC’s process is also criticized for opacity. Members sign non-disclosure agreements, vote by secret ballot and rely on surveys with small samples to estimate time and effort for procedures. Although CMS is not bound by RUC recommendations, it adopts roughly 90% of them.

Policy shifts and recommendations

CMS has acknowledged gaps in payment by introducing new codes in the 2025 fee schedule for chronic condition management, aiming to ease administrative burdens and compensate for complex patient care. Still, the Health Affairs authors argue more is needed.

They recommend CMS formally recognize that cognitive work in medicine has been undervalued and increase RVUs for evaluation and management services. They also propose a comprehensive reassessment of both physical and mental effort across services, potentially led by CMS or an independent third party. Budget neutrality, they argue, could be maintained by adjusting down RVUs for less cognitively demanding technical services.

Why it matters

Evidence consistently links strong primary care access with better health outcomes and lower spending. Yet without payment reform, the authors warn, the U.S. risks further eroding the foundation of its health care system.

“An adjustment to the work component of the RVUs to reflect this reality is much needed to arrest the decline of primary care in the U.S. health care system,” the analysis concludes.