Primary care is in trouble. Doctors are banding together to increase market power

Karen Brown/New England Public Media

Western Massachusetts, a patchwork of rural communities and low-income cities, is a difficult place to find a primary care doctor, if you don't already have one.

Frustrated patients often take to online forums asking for leads or advice on how to find a practice that is accepting new patients.

One name repeatedly crops up in these discussions: Valley Medical Group.

With four locations in the Connecticut River valley, the practice has been a mainstay of family medicine since the 1990s. Valley Medical's flagship office in Northampton can be found right off Main street, next door to a pizza restaurant and a Friendly's.

Valley has 90 medical providers — including doctors, nurse practitioners and physician assistants — and on-site labs, x-rays, and vision care. With tens of thousands of patients, it's become one of the largest independent practices in western Massachusetts.

It forms a key part of the region's health care infrastructure — yet Valley Medical has rarely been under more strain than it is now.

In January, the practice laid off 40 employees – 10 percent of its 400-person staff – mostly in support positions.

Despite patient demand for care — there are waiting lists to be seen — primary care providers take on more clinical responsibilities, and for less pay, than most medical specialists, said the group's CEO, Dr. Paul Carlan.

"It has to do with the fact that our [insurance] contracts don't pay as well as we think they should," Carlan said. "The cost of everything is going up."

Valley Medical Group is far from alone in this predicament. Thousands of primary care practices, a key gateway to the medical system, are fighting to remain financially viable — and independent.

In response, many of them are banding together to form Independent Physician Associations, or IPAs. The goal is to increase their market power, change the way they get paid, and remain in control of how they treat patients.

Threats to physician autonomy 

Primary care practices in the U.S. are in serious trouble, according to multiple workforce surveys. The American Association of Medical Colleges (AAMC) estimates a deficit of 86,000 primary care doctors by 2036, as more primary care doctors retire, and fewer ones enter the field.

The number of people who can't find a primary care doctor has grown by 20 percent in the last decade, according to a recent JAMA report.

Lower relative salaries, and higher professional stress, are disincentives when medical students consider a career in primary care. Newly-minted doctors can earn more in specialties such as cardiology or surgery.

Financial stresses in U.S. health care – exacerbated by the COVID pandemic — have led to the closure of many primary care practices, according to the AAMC.

The Massachusetts Health Policy Group released a report in 2025 blaming the crisis, in part, on the relatively low insurance reimbursement rates for primary care. The revenue problem for primary care is projected to get even worse, when the Republican-backed cuts to Medicaid start to go into effect later this year.

As they seek financial security, many primary care practices have merged with large hospital systems, with the doctors becoming employees of that system.

But the doctors at Valley Medical Group were determined to avoid that fate. Joining a health system takes away the autonomy doctors need to make the best clinical decisions for their patients, Carlan said. It also siphons off income into the larger hospital system.

"Our priorities get muddled up," he said. "And I think when you're part of a health system, you're constantly being asked to bend for the needs of the organization. Hospitals get paid when their beds are full."

Karen Brown/New England Public Media

In contrast, primary care providers need time and money to manage or prevent illness, Carlan said, and their insurance reimbursement rates should take that into account.

In December, Valley Medical Group decided to join an Independent Physician Association. Like a union, an IPA combines individual primary care offices, giving them power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies.

"It's a moment of transition," said Dr. Lisa Bielamowicz, chief clinical officer of TrustWorks Collective, an independent healthcare consultancy that works with health systems and physician groups.

IPAs are gaining momentum as older doctors retire, especially following the challenging years of the COVID pandemic, Bielamowicz said. "As the baby boomers move out and younger physicians take leadership roles, these kinds of models become more attractive."

The American Association of Family Physicians, a trade group, is hearing from practice owners who joined hospital systems but now want to break off and return to being a smaller practice.

"So if independent IPAs can create the infrastructure support to make independent practice viable, then that's a good thing," said AAFP Vice President Karen Johnson.

IPAs can bring more clout to the table when negotiating rates with insurance companies. Nevertheless, some insurers say they like working with these partnerships, because they help stabilize primary care practices, maintaining access and options for insured patients.

Otherwise, some doctors shift their business model to "direct primary care," which bypasses insurance altogether.

"We're looking at independent practices that aren't buoyed by …. these large health systems and can support members in the community in the ways that they want to be supported," said Lisa Glenn, a vice president with Blue Cross Blue Shield of Massachusetts.

Can a different payment model save primary care? 

When those independent practices band together, Glenn said, Blue Cross can offer what are called "value-based contracts." Instead of getting a payment for each visit or procedure, the medical practice is given a budgeted amount for each patient's care, which provides an incentive to keep them healthy so they need fewer treatments.

"[Medical providers] make different kinds of choices than they would if they're paid for every procedure, every visit, every widget," said Bielamowicz from TrustWorks Collective.

If there is money left over at the end of the year, it's split between the practice and the insurer.

The catch, Glenn said, is that a value-based contract only works if there's a big enough pool of patients to spread out the risk, in case a few get really sick. Otherwise, she said, "the risk of ending up above or below the budget becomes somewhat subject to random variation rather than performance."

Karen Brown/New England Public Media

Value-based contracts were supposed to be the next big thing when the Affordable Care Act passed in 2010, an innovative way to bring costs down for the health system as a whole.

But they were slow to catch on; the traditional fee-for-service payment model was too entrenched. Experts say that could still change, if enough primary care providers work together to build market power through IPAs.

"If we keep people out of the ER, keep them out of unnecessary hospitalizations, we save money for the system," said Chris Kryder, CEO of Arches Medical IPA in Cambridge, Mass., an IPA specializing in value-based contracts. "And we create more income for the PCPs [primary care providers], which is dreadfully needed."

These contracts also allow more flexibility in staffing, Kryder said, because nurses, physical therapists and medical assistants can take on some of the less complex medical tasks,, saving the practice money.

IPAs can help — but it depends on who's in charge 

But IPAs are not a panacea for primary care's problems, according to some health care leaders. There are hundreds of IPAs across the country, but not all offer the independence and autonomy that many doctors crave. Some IPAs are actually owned by hospital systems, or even private equity companies, and they're less focused on preventative care.

The American Association of Family Physicians advises its members to seek out IPAs with "integrity," that give doctors a strong role in decision-making.

"Who's calling the shots, who's making the decisions, and is it really focused on the best interests and long term benefit of physicians in practice and their patients?" said AAFP's Karen Johnson.

The IPA that Kryder leads, Arches Medical, is owned entirely by physicians and focused specifically on primary care, he said. But to be more effective, Arches needs to recruit more practices that want value-based contracts.

That can be a hard sell, said Lisa Glenn of Blue Cross. Under that payment model, doctors might see a lag of more than a year, from the time they provide care to the moment they realize the savings.

"It doesn't happen overnight, and it does take an investment," she said.

That lag is one reason Valley Medical Group had to lay off staff after joining the Arches IPA, said CEO Paul Carlan. But he has faith that, after some time, the practice will become more financially stable, be able to offer higher salaries, and most importantly, keep the doctors in charge.

This story comes from NPR's health reporting partnership with New England Public Media and KFF Health News.