THE PRIMARY CARE crisis has become an innovation problem for states.

The problem, at its root, is that not enough physicians are choosing to go into or remain in primary care to meet demand. Fixing long-standing issues with lower reimbursement rates for primary care – a big cause of the crisis – is a complicated puzzle that involves federal policy. It’s not a challenge that states can easily overcome on their own.

But “what states can do is think about primary care in new ways,” said Zirui Song, associate professor of health care policy and medicine at Harvard Medical School and a physician at Massachusetts General Hospital.

Song talked with John McDonough of the Harvard TH Chan School of Public Health and Paul Hattis of the Lown Institute on the monthly Health or Consequences episode of The Codcast.

Primary care practice “has continued to not be attractive enough for the majority of our trainees to stay in the field,” Song said. “And at the same time, there is a growing off-ramp of exits from traditional primary care practice into more free market models of practice, including concierge primary care, direct primary care — models of practice that are a little more detached from the traditional delivery system, the integrated delivery system, or the large group practice, and in some cases, or detached from health insurance completely.”

Long-time primary care physicians are finding “more autonomy and more restored joys of practice” and more time face-to-face with patients outside of those traditional models, he said.

“So the exits are growing, the entries are slowing,” he said, “just at a time when we need more supply for a growing demand for primary care. And that is the national crisis that we face.”

States can exert more direct control than “just toggling the fees up and down” for certain primary care options, Song said. States like Massachusetts, which has a dedicated primary care task force making recommendations to up state spending on primary care, can reform payment models to be more tailored to the people receiving care at any given primary care clinic.

Some states have experimented with a multi-payer system, Song noted, while others like California, Colorado, and Delaware have moved toward setting state targets for primary care spending.

“The most, innovative, or the farthest departure from primary care being simply part of the fee schedule is probably thinking about primary care as a public utility,” Song said.

That would mean reframing primary care as “something akin to when you turn on the faucet in the kitchen, water runs. You expect water to run. When you flip on your light switch, you expect electricity to be running… Fundamentally, thinking about primary care as a public utility allows a state or a self-insured employer, or any entity responsible for paying for care, to lift It out of the fee schedule and concept and then that opens up possibilities for financing, for dispersing the financing, for potentially even organizing the care.”

On the episode, Hattis, McDonough, and Song discuss the primary care crisis nationally (3:30) and in Massachusetts (8:30), and dive into the promise and issues with private equity in health care (19:30).

Updated Dec. 29 – an earlier version of this article misspelled Zirui Song.