The U.S. health care reimbursement system was built for a different era — one that prioritized high-stakes “cure” interventions over the nuanced “care” interventions better suited to the ongoing needs of today’s patients, physicians, and other providers. To improve outcomes, satisfaction, and value, we must upend this outdated approach and build a model that rewards thoughtful, relationship-driven care rather than volume and costly procedures. It’s time to fundamentally rethink how we pay for health care in America.

What we need is a reboot: change the underlying valuation to reward cognitive care services rather than high-tech cure services. This would yield something that is currently hard to imagine: providers incentivized to listen, think, communicate, and coordinate care with one another, and with patients and their families.

That’s what patients want — and so do doctors and other health care professionals. Over the past few decades, there has been a degradation in the personal side of medicine, the side that is the most gratifying for patients and doctors alike. Patients are frustrated by lack of access, fragmented care, and inability to see doctors of their choice or to see any doctor for any reasonable amount of time. Doctors, especially primary care doctors (including pediatricians), are burned out and retiring early. They don’t want to continue to be a slave to the electronic medical record and to wait for insurance companies to approve their recommended treatments. They suffer from moral injury, which is the frustration of not being able to do the right thing.

I am a geriatric psychiatrist, and my bias is toward cognitive services. There are relatively few geriatric-trained physicians of any sort (psychiatry, internal medicine, neurology) in our delivery system these days, and that’s been the case for decades, as young physicians strapped with huge debt tend to select technical procedural fields like dermatology rather than the unsexy, poorly paid, and demanding fields within geriatrics. But this proposal could change all that.

This new system would require Medicare to pay doctors and other health care professionals significantly more for spending time and fostering relationships than does our current system.

Of course, the design and implementation of such a change will be challenging and will have far-reaching consequences. For example, we already have a shortage of primary care physicians, and this new model would require additional providers by orders of magnitude, since cognitive services require more time in general. We would need to enhance efforts to recruit, train, and properly compensate primary care physicians as well as other health care professionals like nurse practitioners and physician assistants.

This might be an opportune time to reevaluate the role of doctors and others to consider how to deploy human health care workers most efficiently. “Credentialing” could take on new meaning. Maybe physicians can navigate toward being the executive managers of the health care team and non-physician specialists would perform common technical procedures such as colonoscopies, cataract surgeries, routine dermatologic excisions, and many others. After all, doctors were accepted to medical school based on their cognitive skills and performance, not their hand-eye coordination.

The new model could even be a good job creation program. Well-qualified pre-meds and all kinds of other health care providers (or anyone with good hand-eye coordination!) could be recruited. By expanding the pool of qualified professionals, health care systems can become more accessible, diverse, and affordable.

Attitudes would have to change. A gastroenterologist colleague shared with me that he’d like to take the time to get to know his patients with heartburn and reflux as individuals, to learn about their dietary habits and discuss lifestyle approaches to ameliorate their symptoms. But he can’t make a living doing that, and patients often want a fix (cure) anyway, so it’s much easier to do a technical procedure like an endoscopy, even if the medical reasons are not very compelling, and there’s little opportunity for a real relationship. In a new system in which he is adequately compensated for his cognitive services, patient and doctor satisfaction would improve and there’d be better outcomes, with fewer technical procedures and lowered costs.

But the cure model, like racism and ageism, is baked into our society. Indeed, the action orientation is as American as it gets. We are also a youth-oriented culture, and it is primarily the old who have chronic conditions. So it’s easy to understand why the soft care model of caring for old people goes against our grain. Indeed, our love for technical procedures and the revenue generated by doing a lot of them wins out, so we spend most of our health care dollars on expensive, low-yield procedures toward the end of life. And emergency departments have become the default primary care treatment center for many patients with chronic conditions (while there is an alarming paucity of primary care providers, emergency room doctors are produced in excess).

Proposals to change the reimbursement system have included capitated payments (instead of fee-for-service, capitated means providers get paid a lump sum for providing care to a population), leading to managed care, gatekeepers, and the like. Left-leaning approaches have been to increase collaboration, a la “it takes a village.” That’s the idea behind accountable care organizations, medical “homes,” integrated care systems, value-based care, and a 2021 proposal by the National Academies of Science, Engineering, and Medicine. There was also a proposal to introduce a new reimbursement code for bedside nursing, by Rebecca Love, in these pages almost two years ago. The hope is that through active management, coordination of care, attention to results, and improved reimbursement, efficiency and outcomes will be improved, and costs will be saved.

From the right, the main idea is to shift financial responsibility to the individual beneficiary, as a consumer of health care services. That’s the idea behind insurance vouchers, premium support plans, and a bold proposal in STAT a few months ago by Charles Silver to use Social Security as a model. The hope is that individuals will then be incentivized to shop for the best value, with market forces shaping the services. The market has already delivered the “concierge” model in which physicians charge an annual fee to deliver good old-school health care, with an emphasis on a therapeutic relationship, but few can afford it. Meanwhile, market-driven medicine has resulted in the corporatization of healthcare. Most Medicare-enrolled hospitals are structured as corporations or limited liability companies, and most physicians are employed by those entities.

Despite the gloom of our current healthcare quagmire, I hope and believe that the situation will improve, and that game-changing treatments will emerge in the next decade or two. While clinical medicine has lagged, there have been major advances in basic sciences (the gene-editing technology CRISPR is a good example), in understanding the underlying biology of disease, and in building the infrastructure needed to support the anticipated clinical advances of the near future. Progress in genetics, in particular, will pave the way for precision medicine where treatments will be individually tailored and matched to disease mechanisms. Telemedicine and remote monitoring will expand access and improve disease management. Artificial intelligence and biotechnology will be used to discover and develop novel drugs and to design efficient models of delivery.

Thus, we are poised to develop treatments that will be well matched to prevalent conditions. Maybe in the future we can even return to a model of high-tech procedures and forget about the quaint old notion of actually talking with each other. Or we can pivot to a different system, one that is best suited to the challenges of the day. But for now, we need a reset that will incentivize us to better manage chronic conditions as well as the resources allocated to health care.

I recognize that this solution might be too disruptive and bold for current tastes, and would ruffle many feathers, including hospital systems, big pharma, device manufacturers, private insurers, and countless other lobbies. My hope is to raise awareness and stimulate dialogue about how we can save the best elements of health care and still achieve good outcomes in a fiscally responsible manner.

Perhaps by putting American ingenuity to work, we can figure out how to better promote the kind of care that is best suited to our current medical needs, and to accommodate what our patients and our regulatory agencies and our markets are telling us we need. In one fell swoop we can accomplish the trifecta: enhanced processes of care, improved outcomes, and lowered costs.

Daniel A. Plotkin, M.D., M.P.H., Ph.D., is a geriatric psychiatrist in private practice and a clinical (voluntary) professor of psychiatry and biobehavioral sciences at UCLA.