Western Massachusetts, a patchwork of rural communities and low-income cities, is a difficult place to find a primary care physician if you don’t already have one. Frustrated patients often turn to online forums, asking for leads or advice on how to find a practice that is accepting new patients.
One name repeatedly crops up in these discussions: Valley Medical Group.
With four locations in the Connecticut River Valley, the practice has been a mainstay of family medicine since the 1990s. Valley Medical’s flagship office in Florence sits on Main Street, next door to a pizza restaurant and near a Friendly’s.
Valley has 90 medical providers — including physicians, nurse practitioners, and physician assistants — as well as on-site labs, X-rays, and vision care. With tens of thousands of patients, it has become one of the largest independent practices in western Massachusetts.
It forms a key part of the region’s health care infrastructure, yet Valley Medical has rarely been under more strain than it is now. In January, the practice laid off 40 employees — 10% of its 400-person staff — mostly in support positions.
Despite patient demand — there are waiting lists to be seen — primary care providers take on more clinical responsibilities, and for less pay, than most medical specialists, said the group’s CEO, primary care physician Paul Carlan, MD. Rates are outlined in the group’s contracts with insurance providers.
“It has to do with the fact that our contracts don’t pay as well as we think they should,” Carlan said. “The cost of everything is going up.”
Valley Medical Group is far from alone in this predicament. Thousands of primary care practices, a key gateway to the medical system, are fighting to remain financially viable — and independent.
In response, many are banding together to form Independent Physician Associations (IPAs). The goal is to increase their market power, change the way they are paid, and retain control over how they treat patients.
Threats to Physician Autonomy
Primary care practices in the US are in serious trouble, according to workforce surveys. The American Association of Medical Colleges estimates a deficit of up to 86,000 primary care physicians by 2036, as more primary care physicians retire and fewer enter the field.
The number of people who can’t find a primary care physician has grown by 20% in the past decade, according to a recent JAMA Internal Medicine report.
Lower relative salaries and higher professional stress are disincentives when medical students consider a career in primary care. Newly minted physicians can earn more in specialties such as cardiology or surgery.
Financial stresses in US health care, exacerbated by the covid pandemic, have led to the closure of many primary care practices, according to the AAMC.
The Massachusetts Health Policy Commission released a report in 2025 partly blaming the crisis on the relatively low insurance reimbursement rates for primary care. The revenue problem for primary care is projected to worsen when Republican-backed cuts to Medicaid start to take effect later this year.
As they seek financial security, many primary care practices have merged with large health systems, with physicians becoming employees of those systems.
But the physicians at Valley Medical Group were determined to avoid that fate. Joining a health system takes away the autonomy physicians need to make the best clinical decisions for their patients, Carlan said. It also siphons income into the larger hospital system.
“Our priorities get muddled up,” he said. “And I think when you’re part of a health system, you’re constantly being asked to bend for the needs of the organization. Hospitals get paid when their beds are full.”
By contrast, primary care providers need time and resources to manage or prevent illness, Carlan said, and their insurance reimbursement rates should reflect that work.
In December, Valley Medical Group announced it would be joining an Independent Physician Association. Like a union, an IPA combines individual primary care offices, giving them power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies.
“It’s a moment of transition,” said Lisa Bielamowicz, chief clinical officer of TrustWorks Collective, an independent health care consultancy that works with health systems and physician groups.
IPAs are gaining momentum as older physicians retire, especially following the challenging years of the covid pandemic, Bielamowicz said.
“As the baby boomers move out and younger physicians take leadership roles, these kinds of models become more attractive.”
The American Academy of Family Physicians, a trade group, is hearing from practice owners who joined health systems but now want to break away and return to smaller practices.
“So if independent IPAs can create the infrastructure support to make independent practice viable, then that’s a good thing,” said Karen Johnson, a vice president at AAFP.
IPAs can bring more clout to the table when negotiating rates with insurance companies. Some insurers say they like working with these partnerships because they help stabilize primary care practices, maintaining access and options for insured patients.
Otherwise, some physicians shift their business model to “direct primary care,” which bypasses insurance altogether.
“We’re looking at independent practices that aren’t buoyed by … these large health systems and can support members in the community in the ways that they want to be supported,” said Lisa Glenn, a vice president with Blue Cross Blue Shield of Massachusetts.
A Different Payment Model
When those independent practices band together, Glenn said, Blue Cross can offer “value-based” contracts. Instead of getting a payment for each visit or procedure, the medical practice receives a budgeted amount for each patient’s care, which provides an incentive to keep patients healthy so they need fewer treatments.
Medical providers “make different kinds of choices than they would if they’re paid for every procedure, every visit, every widget,” Bielamowicz said.
If there is money left at the end of the year, it’s split between the practice and the insurer.
The catch, Glenn said, is that a value-based contract works only if there is a large enough pool of patients to spread out the risk in case a few become seriously ill.
Otherwise, she said, “the risk of ending up above or below the budget becomes somewhat subject to random variation rather than performance.”
Value-based contracts were supposed to be the next big thing when the Affordable Care Act passed in 2010 — an innovative way to bring costs down for the health system as a whole.
But they were slow to catch on; the traditional fee-for-service payment model was too entrenched. Experts say that could still change if enough primary care providers work together to build market power through IPAs.
“If we keep people out of the ER, keep them out of unnecessary hospitalizations, we save money for the system,” said Chris Kryder, CEO of Arches Medical IPA in Cambridge, Massachusetts, the IPA specializing in value-based contracts that Valley Medical joined.
“And we create more income for the PCPs [primary care providers], which is dreadfully needed.”
These contracts also allow more flexibility in staffing, Kryder said, because nurses, physical therapists, and medical assistants can take on some less complex medical tasks, saving the practice money.
IPAs Can Help, Depending on Who’s in Charge
But IPAs are not a panacea for primary care’s problems, according to some health care leaders.
There are hundreds of IPAs, but not all offer the independence and autonomy many physicians want. Some IPAs are actually owned by health systems or private equity companies and are less focused on preventive care.
The American Academy of Family Physicians advises its members to seek IPAs with “integrity” — ones that give physicians a strong role in decision-making.
“Who’s calling the shots, who’s making the decisions, and is it really focused on the best interests and long-term benefit of physicians in practice and their patients?” asked AAFP’s Johnson.
Arches Medical is owned entirely by physicians and focused specifically on primary care, Kryder said. But to be more effective, Arches needs to recruit more practices interested in value-based contracts.
That can be a hard sell, said Glenn of Blue Cross. Under that payment model, physicians might see a lag of more than a year between providing care and realizing savings.
“It doesn’t happen overnight, and it does take an investment,” she said.
That lag is one reason Valley Medical Group had to lay off staff after joining the Arches IPA, Carlan said. But he believes that, over time, the practice will become more financially stable, be able to offer higher salaries, and — most important — keep the physicians in charge.
This article is from a partnership with New England Public Media and NPR.
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