Today, we’re thrilled to sit down with James Maitland, a renowned expert in robotics and IoT applications in medicine, who brings a unique perspective to the intersection of technology and healthcare policy. With a deep passion for advancing healthcare solutions, James has been at the forefront of discussions on how innovative approaches can address systemic challenges, including the critical issue of reforming Medicare’s physician fee schedule to prioritize primary care. In this interview, we’ll explore the disparities in physician payments, the shortcomings of current reimbursement models, the potential of value-based care, and the structural barriers that continue to hinder progress in strengthening primary care in the U.S. healthcare system.
Can you help us understand why primary care physicians often earn less than specialists, despite their central role in managing patient care?
Absolutely. Primary care physicians are essentially the backbone of healthcare, coordinating patient journeys and often preventing more costly interventions down the line. Yet, their compensation doesn’t reflect that importance due to how payment systems like Medicare are structured. The reimbursement model heavily favors procedures and specialized services over the ongoing, comprehensive care that primary care provides. This pay gap discourages medical students from choosing primary care as a career, leading to shortages. For patients, this means longer wait times, reduced access to preventive care, and often having to turn to more expensive emergency services for issues that could have been managed earlier.
What do you see as the core flaws in Medicare’s current physician payment system?
The biggest issue is that Medicare’s payment system is rooted in a fee-for-service model, which rewards the volume of services rather than the quality or outcome of care. This doesn’t incentivize doctors to focus on preventive measures or long-term health management, which are hallmarks of primary care. Instead, it prioritizes billable procedures, often performed by specialists. Since private insurers tend to mirror Medicare’s rates, this creates a ripple effect of underinvestment in primary care across the entire healthcare landscape, leaving it undervalued and underfunded compared to other areas.
Why do you think the U.S. spends so much less on primary care—under 5% of healthcare dollars—compared to other wealthy nations that spend around 13%?
It comes down to a fundamental difference in priorities and system design. In the U.S., our healthcare system has historically emphasized acute care and high-cost interventions over prevention and maintenance. Other countries invest more in primary care because they recognize it as a cost-effective way to keep populations healthy and reduce the need for expensive hospitalizations. Here, the low investment leads to a strained system—patients struggle to get timely care, costs spiral due to untreated conditions, and primary care doctors face burnout from overwhelming workloads with inadequate support or compensation.
Could you explain what value-based payment models are and why they’re considered a promising fix for primary care challenges?
Value-based payment models shift the focus from paying for each service to rewarding providers based on patient health outcomes. Unlike the traditional fee-for-service approach, which just counts visits or procedures, value-based care ties payments to metrics like reduced hospital readmissions or improved chronic disease management. CMS has rolled out several programs targeting primary care, aiming to give doctors financial incentives to prioritize prevention and coordination. It’s seen as a fix because it aligns the payment structure with the actual goals of healthcare—keeping people healthy rather than just treating illness after the fact.
Even with some progress in value-based care, why are so many primary care doctors still hesitant to adopt these models?
The hesitation often stems from practical barriers. Transitioning to value-based care requires upfront investments in technology, staff training, and data systems to track outcomes—resources many small practices just don’t have. There’s also a heavy administrative burden with documentation and reporting requirements. On top of that, Medicare’s payment unpredictability creates a risky financial environment. Doctors worry that if they shift to these models and the payments don’t materialize as expected, they won’t be able to sustain their practice. It’s a leap of faith many can’t afford to take without more stability.
Can you break down the concept of budget neutrality in Medicare’s physician fee schedule and its impact on primary care payments?
Budget neutrality is a rule that requires any increase in payments for one area of healthcare to be offset by cuts in another, keeping the overall budget unchanged. While this sounds fair in theory, it severely limits the ability to boost primary care reimbursements without slashing funds for specialties or other services. This zero-sum game makes meaningful reform tough. Often, Congress steps in with temporary pay hikes to bypass this, but relying on last-minute legislative fixes creates uncertainty for physicians. They can’t plan for the future or invest in their practices when they don’t know if the money will be there.
What are work relative value units, or RVUs, and how do they shape Medicare’s payment rates?
RVUs are a metric used by Medicare to quantify the effort, time, and resources involved in providing a specific medical service. They’re a key factor in determining payment rates for each service code. The problem is, RVUs don’t account for the broader value of a service to a patient’s health or to society. Critics argue they often overvalue procedural work done by specialists while undervaluing the cognitive, time-intensive work of primary care. Additionally, since these units are influenced by recommendations from a committee tied to the American Medical Association, there’s concern about bias toward higher payments for specialty services.
Looking ahead, what is your forecast for the future of primary care payment reform in the U.S. healthcare system?
I’m cautiously optimistic. There’s growing recognition across political and industry lines that primary care is the foundation of a sustainable healthcare system, and we’re seeing momentum with initiatives like value-based care models and proposed legislation to refine how we measure service value. However, the road ahead depends on overcoming entrenched structural barriers like budget neutrality and RVU biases. If we can align payments with outcomes, standardize metrics to reduce administrative burdens, and provide financial stability for providers, I believe we’ll see a stronger primary care sector within the next decade. But it will require sustained commitment from policymakers, payers, and providers alike to make that vision a reality.
