Health care reform while focusing to a great extent on reforming healthcare insurance is myopic about delivery-system reforms that "will be required to improve the quality and coordination of health care and slow the growth of spending."

Two widely discussed models for delivery-system reform are 1) the 'patient-centered medical home' (PCMH), which gives weight to the primary care foundation of the health care system and 2) the 'accountable care organization' (ACO) that stresses provider accountability and incentive alignment across the continuum of care.  It is noteworthy, however that the "ACO model does not explicitly require support for primary care" and that is problematic because it will perpetuate the existing disparity of earnings— i.e., hospitals and specialists instead of primary care physicians (PCPs) garner a disproportionate share of earnings and savings.  Surely this economic driver will further contribute to a surfeit of specialists and a dearth of primary care doctors.

The authors tell it like it is in a nice and polite way….

"The challenges to implementation of the PCMH model include two issues that lie beyond the direct control of the primary care practice. First, although the model calls for primary care practices to take responsibility for providing, coordinating, and integrating care across the health care continuum, it provides no direct incentives to other providers to work collaboratively with primary care providers in achieving these goals and optimizing health outcomes. Second, although evidence suggests that increased investment in primary care can result in savings from several types of reductions — for example, inappropriate use of tests and procedures, emergency department utilization, and hospitalizations for conditions that could be treated in an outpatient setting — most primary care practices do not have financial arrangements that allow them to share in these savings. The effect on total costs of implementing the PCMH model alone could be limited, because primary care physicians have little direct leverage over other providers in the care continuum, and under the largely fee-for-service payment system it is unlikely that other providers will respond to reductions in the number of referrals or admissions by allowing their incomes to fall."

What needs to be done should be clear.

Rittenhouse DR, Shortell SM, Fisher ES. "Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform." Posted by NEJM • October 28th, 2009