Finding a Parsimonious Path for Primary Care Practice Transformation

I would like to challenge some of the core tenets of this article on principle. First of all, the presumption that "there is no longer much debate that primary care...needs to be substantially renovated to meet an array of systemic challenges" with the implication that such transformation should take a course along the lines of value based payment schemes. Later in the article, it is boldly proclaimed as fact that "Fee for service payment...is fundamentally at odds with attainment of core primary care functions for patients" and further that this piece of opinion is "mathematical reality".

I respect the authors' obvious benign intentions, but such claims are not helpful to the legitimate debate surrounding health care reform. Time does not permit me to quote actual references, but there are ample sources calling into question the value of advanced payment reforms. The litany of such efforts dating back to the first capitation experiments of the 1990s HMOs, on through the Medicare Advantage and then the more recent ACOs, and now the current MIPS / MACRA adventures, have all failed to significantly move the needle of US health care towards the commonly-identified goal - care that is accessible, affordable, and high-quality. Just one of the many holes in these attempts at reform lies in the inability to properly secure the patient electronic data as it is pushed onto an unready information technology infrastructure (think Facebook and Cambridge Analytica, health care version).

As a thoughtful observer and participant (practicing primary care physician and health IT committee member many years now), I would like to declare my sincere and good natured dissent with the thrust of this post, and concomitant belief that a better way to care for patients lies in a return to a fee-for-service system; a move away from metrics-driven primary care (box-checking); and a move towards primary care physicians being accessible; of high quality / training; and independent / practice owners.

As I have written elsewhere, I believe the format in which this will take place is in 24 hour primary care clinics of 10-15 physicians owned and managed by those physicians. The relationships supported in such a model between the doctors themselves, their staff, and their patients, will engender a high-quality care standard, as well as be affordable on any budget - even without insurance. The authors here are no doubt entitled to their opinion, but I feel compelled to call attention to that fact - it is indeed an opinion; and one that is by no means without contemporary challenges - and no longer accepted dogma.

Competing interests: Pending formation of consulting LLC directed at private practice primary care interests