Physicians may be the key for affordable healthcare

Subscription-based primary care could ensure access and an affordable healthcare system for all stakeholders, according to a proposal by longtime healthcare journalist and author Ken Terry. Terry spent 14 years as an editor at Medical Economics before becoming a freelance healthcare journalist. His first two books outlined a healthcare delivery model on the foundation of Medicare for all.

In his current book, Beyond Medicare for All, Terry envisions a system where primary care groups would manage basic care and some specialty services, which would be paid for by subscription fees. Employers, consumers and the government would cover the costs of these subscriptions the same way they now pay for insurance premiums.

Private insurers would be cut out of basic care, Terry said, but could continue selling major medical coverage for hospital care, post-acute care and outpatient services such as surgery, cancer treatment, imaging and specialty drugs. People would choose among major medical plans, similar to the way they do on the healthcare exchanges created through the Affordable Care Act. These costs would be shared by employers, workers and the government on a sliding scale; Medicare and Medicaid would buy into the same major medical system.

“In my first two books, I built a new care delivery model on the foundation of Medicare for All, which seemed possible in the run-up to the 2020 election,” he said in an interview with Managed Healthcare Executive. “Since then, I've realized that Medicare for all is unlikely to be adopted because of fierce industry opposition. I came up with another method to guarantee healthcare to all without Medicare for All. I would emphasize that this is a free-market alternative to Medicare that won’t put managed care companies out of business.”

Why healthcare reform is needed

In his book and during an interview, Terry explained that the healthcare system, and particularly primary care, is not sustainable as it is now. Vertical integration among many players in the industry, including hospitals and physician practices, as well as with insurers and the pharmacy supply chain, has given more leverage to these players to control price and access.

He pointed to fee-for-service payment as one cause of the misaligned incentives seen in the healthcare system. “It basically incentivizes hospitals and physicians to provide more services rather than better health,” he said. “Healthcare is so profitable.”

That consolidation, he said, has stripped physicians of clinical autonomy and left many primary care doctors frustrated with what he called “assembly line conditions.”

Terry said a new healthcare system is needed. Earlier reform efforts have not gone far enough, he said, because they focused on financing rather than on healthcare delivery. He credited the Affordable Care Act with reducing the uninsured rate but said it failed to control the rise in health spending.

“You need to deal with both financing and care delivery, and both of them have to be fundamentally restructured,” he said. “Incremental efforts are not going to save us, and I believe that healthcare should be run by physicians. Basic care should be managed by primary care doctors, and that basic care is the care that most of us need most of the time.”

A system built on value-based care

Terry’s idea for a new healthcare system focuses on physicians. He takes value-based and population-based care and structures his proposal around physicians instead of hospitals or insurance companies. “The central part of my model is competing primary care groups that manage basic care, and they charge subscription fees,” he said. “The idea basically is to improve population health and to prevent people from having to be referred to specialists or admitted to the hospital unless they really need to be.”

Terry believes the primary care system could collapse without a significant effort to make it more viable for young doctors. A subscription-based primary care system would give physicians autonomy with realistic payment.

“Doctors know where the waste is in healthcare, and they know what can be safely eliminated and what can't be,” Terry said. “Fee-for-service is basically the root of our problem. It incentivizes hospitals and physicians to provide more services rather than better health. Of course, doctors want their patients to get better, and they want to prevent chronic diseases from getting worse, but it's easy to order another test, refer a patient to a specialist, admit them to the hospital, or perform a procedure when that leads to higher revenues.”

Primary care groups, he said, would compete on their subscription fees, as well as on quality and patient experience ratings. In his proposed plan, everyone would have a basic care subscription, and it would be covered by employers, consumers and the government on a sliding scale. Insurance companies would step in to cover specialty care. “Once a cost passed a certain level, it would seamlessly pass over to major medical insurance,” he said.

As used in today's Medicare and Medicaid pilot programs, the value-based care is designed around provider performance and the patient experience. Studies have shown that value-based care can increase the quality patients receive. For example, one study published in September 2025 in JAMA Health Forum found that value-based programs in Medicare delivered better quality compared with fee-for-service, especially with increased risk-sharing for physicians.

Insurers such as UnitedHealth Group and Humana have had positive results from value-based programs in their Medicare Advantage plans. Humana’s Medicare Advantage members in value-based care arrangements, for example, had 24.3% fewer inpatient hospital admissions and 13.4% fewer emergency department visits than those in original Medicare in 2024. The MA programs have saved $12.8 million. Optum Health, a division of UnitedHealth Group, found that value-based programs for its dual-eligible patients had better outcomes in 17 of 20 measures compared with traditional Medicare.

Physicians, however, historically have had a lack of trust and engagement in the value-based programs, according to a systematic literature review published in February 2023. The American Medical Association in a survey last year found that fee-for-service remains dominant, but more practices are taking part in alternative payment models.

In his book, Terry says not enough consumers are part of value-based programs for physicians to consider changing their practice. “There has to be fundamental change, and they [physicians] have to be placed in a position where they can actually influence how care is delivered and financed.”

Maryland’s all-payer model as an example

In Terry’s plan, state and regional authorities would provide oversight, and states would continue licensing insurers and negotiating hospital budgets. New regional health authorities would be set up that are modeled loosely on England’s system, but they would be governed by employer, consumer and patient representatives.

These health authorities would regulate competition among basic care groups, and they would contract with third-party administrators that would process claims, manage IT and handle quality measurement for the primary care groups.

Terry suggested that payments to hospitals could be modeled on Maryland’s example. From 2014 to 2018, Maryland implemented the All-Payer Medicare Model, which aimed to slow unnecessary readmissions and growth in hospital costs.

Beginning in 2019, Maryland implemented the federal government’s Total Cost of Care Model, which gave the state flexibility to tailor initiatives in population health improvement, care redesign and provided new tools and resources for primary care providers​ to better manage complex and chronic conditions. The Total Cost of Care Model generated $689 million in Medicare savings and a 16.8% reduction in preventable hospital admissions, according to HealthAffairs paper published in April 2026.

Terry said a system similar to Maryland’s would strip hospitals of the market leverage they use to negotiate rates from private insurers. Additionally, primary care doctors would gain clinical autonomy and could earn more than they do as employees if their groups deliver care under their subscription budgets. He distinguished his approach from the group-model HMOs of the 1990s, which he said worked well when built around salaried physicians but failed when extended to fee-for-service practices.

“I get rid of that problem by having my basic care groups set their own subscription fees,” Terry said. “Insurers do not have anything to say about how they practice or how much money they spend.”

This year, Maryland implemented the Achieving Healthcare Efficiency through Accountable Design (AHEAD) program, a voluntary program that aims to expand the total cost of care model through primary care and strengthening population health. AHEAD sets a savings target of approximately $879 million by 2032 and expands cost control across Medicare Advantage and Medicaid.

What about prescription drugs?

In Terry’s model, prescription drug prices would be negotiated by the federal government in the same way as many European countries. The United States, as part of the Inflation Reduction Act of 2022, has begun negotiating prices for the highest-cost drugs in Medicare. This law also caps insulin prices at $35 a month for Medicare beneficiaries.

Additionally, the Most Favored Nation (MFN) pricing, established by an Executive Order by President Donald Trump, ties U.S. drug prices to those in other developed countries through international reference pricing. MFN benchmarks U.S. prices against a basket of nations, often selecting the lowest or second-lowest price among peers such as the United Kingdom, France, and Denmark. The goal is to align U.S. prices more closely with the global market, where drug costs are typically lower.

A big part of Terry’s plan for drug negotiation includes an evaluation of their cost-effectiveness, similar to the work that is done by the Institute for Clinical and Economic Review (ICER). But ICER’s determinations are not binding, and Terry said this review needs to be done as part of the government’s efforts in healthcare to see an impact on costs.

This idea for using cost-effectiveness to negotiate drug prices, Terry said, comes from the work done by David Eddy, M.D., Ph.D., who in the 1990s coined the term “evidence-based medicine.” Eddy developed the Archimedes model, a mathematical simulation of clinical and cost effectiveness, that could be used in these negotiations to predict and analyze care decisions.

Terry also envisions a citizens’ advisory council to provide the patient perspective about the use of new drugs and technologies. Primary care and specialists would manage utilization, and insurance companies would pick up costs beyond a certain threshold.