The 3 Ps Reshaping Care
- carbesman
- Sep 17
- 4 min read
Updated: Oct 1
Primary Care, Pricing, and Place
Paul Schrimpf, Christine Arbesman
When people talk about rising health care costs, they often focus on prescription drugs, insurance premiums, or hospital stays. But a quieter force is shaping what patients pay every day: the consolidation of primary care. Ownership matters, and who employs your doctor influences the bill you receive, often in ways that aren’t obvious.
Primary Care: Who Owns the Doctor’s Office?
According to a 2025 Journal of the American Medical Association (JAMA) Health Forum study led by Dr. Yashaswini Singh of Brown University, ownership of primary care practices has shifted dramatically. In 2009, about 25% of primary care physicians worked for hospital systems. By 2022, that figure had nearly doubled to 48%. Private equity remains a smaller player, covering about 1.5% of primary care doctors, but is growing, particularly in states like Texas and Florida.
The same study showed how ownership patterns translate into costs. Hospital-affiliated visits were 10.7% more expensive than independent practices, roughly $15 more per visit, after adjusting for geography and insurer. Private equity–affiliated visits were 7.8% higher, or about $10 more. New patient appointments averaged $180 at hospital-owned practices compared to $147 at independent ones. Singh explained the significance: “It’s impossible, in the absence of price and ownership transparency, to really understand the trends in consolidation and corporatization in primary care, and then ultimately, what are the effects they are having on the prices you and I pay for health care.”
Pricing: Market Power Without Transparency
The per-visit differences may seem modest, but across millions of visits, they add up to billions. Singh’s team estimates that if hospital-affiliated doctors were reimbursed at independent-practice rates, commercial spending could fall by $1.5 to $1.8 billion annually.
Dr. Zirui Song, a health economist at Harvard Medical School, put it bluntly in a related JAMA Health Forum editorial: “Despite their size and power, insurers are either not able to or not willing to exert downward pressure on prices in highly consolidated markets.”
Why? One reason is leverage. Large systems can negotiate higher prices with insurers. Another is billing. Once a physician’s office is absorbed by a hospital, visits may be reclassified as outpatient hospital care, allowing providers to add on facility fees.
A 2024 Guardian investigation highlighted how patients sometimes receive facility fees of over $150 for routine care, even for simple services like a flu test. As one advocacy group told the paper, facility fees are “one of the most egregious examples of hospital financing at the expense of consumers.”
Place: When the Same Room Becomes a Different Bill
The “place” of care has become a hidden driver of cost inflation. To the patient, nothing changes — the same doctor, the same clinic, the same waiting room. But if the practice is owned by a hospital, the billing system changes dramatically.
As Dr. Ateev Mehrotra of Harvard observed in JAMA Health Forum, “Consolidation often turns a physician’s office into a hospital outpatient department on paper. For patients, that means paying more for the same service in the same chair.” This transformation of “place” reshapes the economics of everyday medicine — often invisibly to patients until the bill arrives.
The Quality Debate and Regulatory Blind Spots
Supporters of consolidation argue that larger systems can coordinate care, invest in technology, and achieve efficiencies. But evidence suggests the trade-offs are skewed. In a Harvard-led study published in JAMA Health Forum, Mehrotra and colleagues found that primary care doctors employed by large systems drove higher overall spending — more referrals, ER visits, and hospitalizations — without meaningful gains in preventive outcomes. Similarly, Dr. Hannah Neprash of the University of Minnesota found that in more consolidated markets, physician services cost 12–26% more and hospital services up to 31% more, with only modest quality differences.
Yet despite more than 1,000 hospital mergers in the last two decades, the Federal Trade Commission (FTC) contested only 13. A 2022 Wall Street Journal investigation revealed that hundreds of mergers likely raised antitrust concerns but went unchallenged. This regulatory gap has allowed consolidation to advance largely unchecked. And insurers, despite their leverage, have rarely stopped the price hikes that follow.
Primary care is supposed to be the most accessible and affordable part of the health system. But as consolidation reshapes Primary Care, Pricing, and Place, it is becoming a high-priced gateway instead.
Singh’s research shows that even seemingly small price differences add up to billions of dollars in extra spending. Song’s commentary underscores that insurers aren’t keeping costs in check. And Mehrotra’s work demonstrates that higher costs isn’t matched by better outcomes.
Consolidation isn’t inherently harmful. In some cases it stabilizes struggling practices and brings needed technology. But the weight of evidence shows today’s consolidation is fueling cost inflation without delivering commensurate gains in quality.
The 3 Ps — Primary Care, Pricing, and Place — may not sound as dramatic as drug breakthroughs or insurance shakeups. But they are quietly reshaping the economics of everyday care. As JAMA’s authors make clear: who owns your doctor’s office may matter just as much as what happens inside it.
Acknowledgements & Citations
This report draws insights and direct quotes from:
Singh Y. Hospital and Private Equity Affiliation of Primary Care Practices and Price of Office Visits. JAMA Health Forum. 2025.
Song Z. Insurer Leverage and Consolidated Markets. JAMA Health Forum. 2024.
Mehrotra A. Association of Health System Affiliation of Primary Care Physicians With Spending and Utilization. JAMA Health Forum. 2023.
Neprash H. Consolidation in Health Care and Prices for Physician and Hospital Services. JAMA. 2022.
The Guardian. “Patients Charged Hospital Facility Fees for Routine Care.” 2024.
FTC / Wall Street Journal. Hospital Mergers and Antitrust Enforcement. 2022.