I read with interest Dr. David Kibbe's article “PCMH and ACO: Opposed or Mutually Supportive?” [November/December 2010] on the potential for patient-centered medical home (PCMH) embodiments within accountable care organizations (ACOs).

Dr. Kibbe concludes that the discussion of ACOs represents “the best thinking about ‘systemness’ in health care.” As a systems engineer with a long-term interest in health care systems, I can say with confidence that health care has yet to learn how to think in terms of systems. For example, neither the ACO nor the PCMH models discuss how to generate sustainability in family physicians. The workload and lifestyle issues that discourage medical students from entering family medicine will not be addressed even if the compensation model is resolved more in their favor. The PCMH and ACO concepts start with payment model fixes and try to build a system around them and in so doing begin with system constraints rather than system requirements. It is like specifying that a car should cost $5,000 or less and using that as the starting point for defining what a car should do.

Medicine needs to come to terms with the inherent intimacy of its domain and stop looking first to economies of scale for cost fixes. Economies of scale in medicine have a history of breeding special interests and power grabs. The result is a system with local optimization and quality here and there, rather than global optimization, where quality is inherent in the system's function. The health care industry continues to see patient-centeredness as a view of the patient from the provider's perspective. Until leaders are able to crawl around to the other side of the image, see medicine as patients see it, and view the true trajectory of illness, health and wellness as patients experience it, then patient-centeredness will not be achieved. And until family doctors are able to accept that they deserve to have their physical and mental health and family life safeguarded, no system will exist. If these perspectives can be achieved, then structured techniques can be applied to define a health care system that meets requirements and satisfies constraints.