30 – 32 Included would be monies for essential infrastructures and systems, most importantly, an interoperable electronic health record with decision support. 29 The payment would be directed to cover all practice expenses and salaries related to operating a robust, modern primary care practice (Table 1), one that would qualify as an “advanced medical home” for adults, a practice structure that enables efficient provision of comprehensive, coordinated, patient-centered care. It would replace all encounter-based payments made to the primary care physician under the resource-based relative-value scale (RBRVS) system. 3 – 5, 12, 16 – 18, 23 – 28 We propose a new payment model for primary care that realigns incentives and makes possible the establishment and operation of accountable, modern primary care practices capable of providing the personalized, coordinated, comprehensive care essential to a well-functioning health care system.Ī risk/needs-adjusted comprehensive payment would be made to the primary care practice for the comprehensive care of each patient. 6 – 11 The reasons for this decline are multifactorial, 3 – 5, 7, 9, 11 – 23 but a central factor has been a succession of dysfunctional payment systems that discourage proper delivery of primary care. medical school graduates and residents planning to enter primary care practice is plummeting to levels that will lead to serious physician shortages. 3 Practicing primary care physicians are demoralized, retiring early, and advising others not to go into the field. Ironically, at the very time definitive data are confirming primary care’s essential contributions to health care (i.e., health status is improved and costs are reduced), 1, 2 adult primary care in the United States finds itself on the brink of crisis. Field tests of this and other new models of payment for primary care are urgently needed. Attainment of these goals should help offset and justify the costs of the investment. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Income to primary physicians is increased commensurate with the high level of responsibility expected. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system.