NEJM: Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform (Diane R. Rittenhouse, M.D., M.P.H. et. al)

This article makes a good point that most of the current health reforms being debated in congress focus on health insurance and not on the delivery-system reforms ultimately needed to control costs and improve the quality of health care. The article talks about the two main models of delivery-system reform: 1) Patient-Centered Medical Home (PCMH) and 2) Accountable Care Organization (ACO).

In the PCMH model, primary care is emphasized and provides care that is “continuous, comprehensive, and coordinated across the care continuum”. This approach would be patient-centric, and the physician compensation would be based on quality measures as opposed to the current fee-for-service payment method. The problem is that there is currently no system that rewards primary doctors for providing better care at a lower cost based on this PCMH model. For instance, if a primary doctor does succeed in reducing the number of unnecessary lab tests performed, visits to the ER, and hospitalizations, he/she will currently not receive any incentives for achieving any of these targets.

An ACO is a provider-led organization whose mission is to control costs while providing high quality care. ACOs would consist of several specialties. The article argues that ACOs need to focus on providing a strong, high performing primary care unit in order for the ACO to be a success. A concern is that the current shortage of primary care physicians may lead to deficient primary care in ACOs. An interesting concept of ACOs is that incentives and risks are shared between providers in the network, thereby holding physicians accountable to their peers. “ACOs could receive fee-for-service payment and share in any cost savings achieved relative to a risk-adjusted projected spending target for their patient population; alternatively, payment could be partially or fully capitated, with risks and gains both being shared by all providers.” Evidence indicates that ACOs that are more tightly organized have the greatest potential for success.

An integration of these two models would theoretically produce the highest quality of care. That is, in an optimal delivery-system there would both be an emphasis on primary care (PCMH) and a provider-led organization structure with various specialists to offer patients a continuum of care (ACO). Models like these need to be piloted and then supported by federal agencies (i.e. Medicare and Medicaid).

Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform