In the midst of the U.S. health insurance debate, a research team led by Elliott S. Fisher at Dartmouth Medical School has asserted that reform of the health care delivery system should include two important components: the patient-centered medical home (PCMH) and the accountable care organization (ACO). The team published their findings in the New England Journal of Medicine in late October.

The PCMH model focuses on expanding the role of primary care. Substantial evidence has shown that the expansion would reduce costs by limiting medical spending in unnecessary specialty operations and treatments, while improving general quality of care.

The ACO is a broader model aimed at integrating health care through holding primary care physicians, specialists, and hospitals responsible as an organization for patients’ overall medical outcomes. This would distribute costs and benefits among health care providers, and better ensure patient accountability through the efficiency of networked health providers.

However, both models have shortcomings limiting their present impact.

The issues with the PCMH model are financial. While the PCMH unifies the responsibility of patient care under primary care providers, it provides no financial incentives for other members of the health care community. This includes specialists, who would receive fewer patients under the new model. Also, the money saved by PCMH from the prevention of additional tests, health emergencies, or hospitalization would not necessarily return to those primary providers responsible.

In contrast, the ACO is lacking in effective primary care. Research shows a current shortage of primary care, which is also poorly organized. Fisher’s team states that improvements could be made with greater investment. However, ACO’s are often specialist-dominated, which would likely result in little investment made in primary care.

Fisher’s team thus concluded that the PCMH and ACO are complementary to each other. ACO requires strong primary care organization which PCMH provides, and PCMH needs a broader medical infrastructure which ACO provides. An effective delivery system reform thus relies on the successful integration of the two models. In conjunction with insurance reform, delivery system reform will help realize the sought-after changes in U.S. health care.