Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model

Hooray! Once again the Annals have proven to be a rigorous forum for family medicine. The sophisticated analysis by Dr Basu and colleagues demonstrates new heights in family medicine research and analysis regarding the complexities of paying for health services. Dr Magill puts their findings in historic context and voices the frustration many of us have regarding misplaced values in America's health care industry. Their work demonstrates the value of teams in family medicine. Most of us do not have the skill set to develop mathematical models nor the insights to put them in context. Much as we rely on our office staff to deliver the PCMH model, our discipline needs the researchers and the sages.

My career has spanned private practice, academics and most recently a stint with a large payer organizing a physician network to address the triple aim, or as Dr Magill expands it, the quadruple aim. It is my observation that all but the rare physician desires to do the right thing every hour they practice medicine. Insurers are stuck in a different model. Insurers live in a business world where doing the right thing is improving the bottom line for investors. Most payers want to do the right thing for "members", it just that the emphasis is different. So how does a business person trust a physician through the lens of business? Just as a rare few of our colleagues take advantage of weakness in the fee -for-service model, so too will a rare few of them take advantage of a global payment model. When your business model is paying for widgets, widget by widget, then fee-for-service makes sense and policing it is simplified to counting widgets delivered. Global payments, not so much. New strategies will be needed to be sure they get what they pay for and the bottom line is that their "members" must be happy through the next enrollment period. It still requires counting something. Candidates are annual visits, flu shots, glycosylated hemoglobin values, blood pressure or patient experience. Data systems are getting there.

I was not fully successful in convincing large payers to trust primary care physicians to deliver. In part this is because payers have experience with large specialty groups refusing participation if they are not paid what they think their services are worth.

Like Dr Magill, I believe that Medicare must lead the way. Only a government payer is independent enough to change the system and then to figure out how to supervise it. Likely pure fee-for-service must end for all physicians. However, no matter how it is paid for, primary care is the only proven base for health care that meets the triple aim.

Competing interests: None declared