HJNO Mar/Apr 2026

WHAT’S WRONG WITH HEALTHCARE 24 MAR / APR 2026 I  HEALTHCARE JOURNAL OF NEW ORLEANS   differentiation: The best advanced primary care teams — those that innovate, integrate technology effectively, and truly improve health — should earn higher returns than average performers. That is how real markets function. When superior results are rewarded economically, innovation accelerates, fast followers emerge, and best practices spread — not by mandate, but by imitation. Over time, the market begins to self-correct around what works. Without this flexibility, advanced primary care risks becoming another underfunded mandate. With it, advanced primary care becomes the engine through which healthcare can finally compete on value, rewarding those who produce the most health per dollar spent. Aligning Incentives Around a Shared Customer Value Proposition A workable path forward requires payers and providers to align around a single customer value proposition: measurable improvements in health and health outcomes. One way to do that is through population-based payments set as a percentage of premium, where the payer takes a modest, transparent margin off the top — say 10% rather than the roughly 15% com- mon in Medicare Advantage today — while sharing additional upside when total costs fall as health improves. Unlike today’s shared-sav- ings models built on a fee-for-service chassis, this arrangement would be grounded in shared actuarial risk from the outset. In that model, the payer’s core value shifts from utilization con- trol to insight generation: providing advanced analytics that help providers understand risk, identify gaps in care, measure outcomes, and benchmark performance over time. Provid- ers, in turn, are incentivized to invest in bet- ter data capture and care processes because those insights directly improve their clinical performance and financial results. Success is no longer defined by coding intensity or visit volume, but by fewer emergency visits, fewer admissions, slower disease progression, fewer complications, and better functional outcomes. When both sides win only by improving health, the market finally has a reason to organize itself around producing it. This stands in stark con- trast to today’s utilization management arms race, where payers invest enormous resources in prior authorization and denials to control costs after the fact, and providers expend equally enormous effort trying to navigate, cir- cumvent, or document their way around those barriers — producing friction, burnout, and ad- ministrative waste without ever addressing the underlying drivers of poor health. Instead of fighting over who can say “no” more efficiently, this model rewards both sides for making the patient healthier in the first place. None of this is easy, and pretending otherwise only undermines credibility. Transitioning from a volume-driven system to one that produces health carries real risk for providers, health systems, and payers alike. Revenue streams change before cost structures fully adjust. Clinicians fear being held accountable for outcomes they do not fully control. Health systems worry about stranded assets built for a throughput-based model. And payers are understandably cautious about relinquishing familiar utilization controls in favor of outcomes- based accountability. These fears are rational — but they are also the cost of evolution. Every industry that has successfully transitioned to a higher-value model has had to cross a period of uncertainty where old incentives no longer work and new ones have not yet fully stabilized. Healthcare is no different, and delay only increases the eventual disruption. If policymakers want to play a constructive role, they should stop arguing about whether subsidies should flow through insurers or directly to consumers and instead focus on the far more consequential question: How do we build a delivery system that actually produces health? The most powerful lever available is not another subsidy redesign, but legislation that requires commercial payers to offer a true alternative to fee-for-service — namely, a risk-adjusted, population-based payment option priced as a percentage of premium. Participation should be voluntary, not mandatory. Primary care practices and health systems should be free to choose whether to remain in traditional contracts or opt into population-based arrangements. If these models are designed correctly — adequately funded, risk-adjusted, and flexible — many will choose to participate not because government forces them to, but because the economics finally make sense. Over time, the market would do what markets do best. Early adopters would innovate. High- performing advanced primary care teams would demonstrate superior outcomes and stronger financial performance. Fast followers would adapt and replicate what works. And gradually the system would shift — not through central planning, but through competitive learning and iterative cycles of improvement. This is how we overcome the fear of a government-run healthcare system: not by excluding government, but by limiting its role to that of market architect rather than market operator. Government should set the rules that allow providers to compete on improving health and health outcomes, while leaving room for innovation, differentiation, and choice. If we get that right, we do not need to choose between markets and medicine. We finally align them. Build the Engine, Not the Subsidy Path Arguing about whether healthcare dollars should flow through insurers or directly to consumers is like arguing about who should hold the gas card while ignoring the engine. You can reimburse gasoline however you want — through employers, insurers, or individuals — but if the vehicles remain heavy, inefficient, and designed to burn as much fuel as possible, total consumption will keep rising. The same is true in healthcare. We can reshuffle subsidies, redesign tax credits, and move money from one pocket to another, but as long as the delivery system is built to produce services that generate margin rather than health, spending will continue to climb. That is not a failure of consumer responsibility, or market theory; it is a failure of system design. Advanced primary care is the equivalent of redesigning the engine. It is the structural change that allows the system to run more efficiently because it is built to do something different: keep people healthy, catch problems early, and prevent avoidable downstream costs. If we want healthcare to behave like a real market, then we must first give it a product worth competing on. That product is health. Build a system that rewards producing it, and innovation will follow. Keep arguing about who holds the gas card, and we will keep driving the same inefficient vehicles down the same expensive road — wondering why nothing ever seems to change. n