Primary care physicians (PCPs) typically earn significantly less (30 to 50 percent less than their specialist colleagues), creating a strong disincentive for medical students to choose this path, especially when average medical school debt exceeds $200,000. New physicians are drawn to higher-paying specialties to manage their loan repayments [9] . The fee-for-service payment model rewards procedures and tests rather than time spent with patients. PHC is particularly vulnerable among other specialties, as all primary care revenue is derived from in-person evaluation and management visits [10] .

Primary care doctors spend approximately 2 hours on paperwork and electronic health records (EHRs) documentation for every 1 hour of direct patient care, leading to significant and rapid burnout [ 1 1] . Navigating multiple payers with different rules and reimbursement rates also adds complexity to running a primary care practice [12] [13] . Primary care physicians report among the highest burnout rates in medicine, leading many to reduce their hours or retire early, which further decreases the pool of primary care physicians [14] [15] .

Independent practices are increasingly acquired by hospital systems and private equity firms, changing practice dynamics and reducing physician autonomy, causing many physicians to leave clinical practice [16] . When physicians practicing in any specialty are taken over by a hospital, charges invariably increase, while quality either stays the same or diminishes [17] .

These alternatives address immediate concerns but fragment care and do not provide comprehensive primary care services. These centers have not bridged the challenges in reducing access for patients in rural and underserved areas [18] .

A recent survey from the American Medical Association shows that the scope of practice tops the list of 2024 legislative priorities for state and specialty medical associations, with 86% ranking it as their top legislative priority. “Expanding nonphysician providers’ scope of practice can make patients less safe, especially when health professionals present themselves in a way that makes it difficult for patients to understand their role or training, experts said during a panel discussion at the 2024 AMA State Advocacy Summit” [19] . Generally, non-physician providers provide excellent care with well-defined problems, such as preventive care, acute minor illnesses, and management of defined problems such as hypertension and diabetes. The difference in education and training is apparent when patients have less well-defined problems and/or are more seriously ill. A recent study showed that in the Veterans Administration (VA) health system, Nurse Practitioners working without Physician supervision led to increased lengths of stay, higher costs, and more preventable hospital admissions [20] .

In a digital world, with constraints of time, high insurance deductibles, and difficulty accessing PHS, surveys have found more than one-third (probably more) of Americans self-diagnose when encountering a health concern, and over two-thirds of American adults consult the internet for medical information [21] .

Will artificial intelligence (AI)/large language models (LLMs) be the final nail in the coffin for primary care? The four tech giants, Google, Amazon, Microsoft, and Nvidia, are heavily invested in tackling healthcare issues through cloud computing and regenerative AI [22] . In the near future, AI will play a prominent role in primary healthcare delivery by improving clinical decisions, diagnosis accuracy, and disease surveillance [23] . The reduction of the administrative burden by AI may help with provider burnout. Healthcare providers should have input on the design, development, and deployment of AI in medicine to ensure it is more helpful than harmful to patients, while providing safeguards for accuracy and privacy breaches [24] [25] .

To improve access to primary care services and an equitable healthcare system, insurance coverage needs to extend to ALL people in the US. The reality for the US is that legislative authorities (Congress) lack the fortitude to defy the power of the various lobbyists (Insurers, Hospitals), making health insurance a privilege vs. a right [37] . Coverage needs to be financially regulated, ensuring out-of-pocket expenses are affordable. Transitioning from a fee-for-service (FFS) to a value-based payment (VBP) model for primary care, rewards preventive care, and offers care management fees for maintaining patient panels [38] . Reimbursing for care and case management (utilizing a team approach, telemedicine, and a robust electronic medical record) will increase both physician and patient satisfaction and provide overall better care [39] .

Value-based payment programs have not significantly increased the incomes of primary care physicians. Despite the potential benefits, such as improved patient care and reduced healthcare spending, participation in these models remains low. Financial barriers, workforce shortages, and imperfect performance measures are key factors preventing primary care practitioners from joining these programs [40] . Solutions to these challenges include increasing payments, boosting support for PCPs, and investing in primary care trainees. The success of any healthcare system is ensuring the quality, adequate financial compensation, and the number of primary care providers, which both the FFS and VBP have failed to address.

Reduce the paperwork burden on primary care practices by standardizing prior authorization processes across insurers, streamlining and reducing nonclinical documentation requirements, and creating unified quality metrics instead of multiple competing programs [41] .

Studies show the US could save over $81 billion with the implementation of a universal EMR [42] . Having an EMR improves healthcare delivery by decreasing administrative duties, standardizing data collection and chronic disease surveillance, reducing the risk of errors and duplication of work, and allowing primary care physicians to view notes, consultations, procedures, laboratory, and imaging studies without the burden of requesting medical records.

With the COVID-19 pandemic and closure of primary care offices, successful practices quickly transitioned to telehealth. Through secure video visits, health monitoring, and digital communication tools, healthcare providers deliver more responsive care that meets patient needs. This approach reduces travel time for patients, lowers healthcare costs, and helps doctors manage ongoing health conditions more effectively [43] . Insurers should ensure permanent coverage parity for virtual primary care services; support hybrid care models that combine virtual and in-person care to remove geographic disparities in telehealth coverage.

Insurance companies have significant leverage to address the primary care physician shortage and crisis through several impactful strategies. Health insurance companies have developed sophisticated algorithms for patient utilization, clinical outcomes, and chronic disease management. Sharing claims data to identify care gaps, investing in health information exchanges that reduce duplicate work, streamlining technology solutions to reduce documentation time, and facilitating an approval process across insurers are ways to address the primary health care shortage [44] .

Some medical schools have attempted to address these issues through dedicated primary care tracks, rural training programs, and community-based education initiatives, but these efforts remain insufficient compared to the scale of need. Early exposure to mandatory primary care clerkships is needed in medical school rotations. Every medical school needs a primary care track focusing on underserved areas, population health management, and team-based care [45] . There also needs to be training of medical school faculty on primary care bias and how to not play into the falsity that trainees who go into primary care are only doing because they could not get into other, more competitive specialties. Primary care bias and the falsity that trainees going into primary care do so because they cannot get into more competitive specialties will change with medical school faculty training [46] .

Funding medical school loan forgiveness programs for physicians committing to primary care, supporting residency programs focused on primary care (especially in rural and underserved areas), and investing in retention programs to keep physicians in primary care practice is critical [47] . These same commitments should apply to other members of the primary health care team, such as Physician Assistants, Nurse Practitioners, Nurses, Medical Assistants, Pharmacists, and Care Managers. Pipeline programs are important, as those who grew up in rural and underserved areas are more likely to serve in underserved areas later, but are less likely to afford and have the same opportunities for medical school or health careers as students from more affluent backgrounds. These modalities can bridge the urban-rural divide and improve the quality of care in underserved areas.

As a result of the primary care crisis, more patients are utilizing Emergency Departments for low-acuity medical conditions. When patients lack access to high-quality primary care, minor health problems can become chronic diseases, care management becomes more difficult and less coordinated, visits to emergency departments rise, preventive care lags, and health care costs rise to unsustainable levels [48] . Emergency room providers are trained in acute medicine with limited training in chronic disease management and preventive care.