Both of us have, in our consulting and training work, been called in to help a clinic replace a failed “integrated” service with one that utilizes the PCBH model. What we have observed is that, almost without exception, when a service fails, it is because of one fatal flaw: a failure to understand and appreciate primary care. The reality is that primary care is an incredibly important, and powerful, part of a good healthcare system. Barbara Starfield famously taught us all that countries with the most robust primary care have the healthiest populations. And while it might not be as flashy as the operating room, and might not raise adrenaline like the emergency room, we owe much of our health to good primary care. Even with all of its problems, primary care is a place where miracles happen everyday.

Unfortunately, many integrators seem to believe that what primary care needs is a good dose of specialty care. Instead of the accessibility so central to primary care, they build an integrated service that requires burdensome paperwork for a PCP to refer a patient or one that allows schedules to fill up with meetings and follow-up visits; instead of working as a generalist, they focus only on helping with certain populations or problems; instead of seeing the high patient volume so crucial to primary care, they insist on long visits that reduce productivity to a trickle; or instead of working on a team-based approach, they discourage interruptions, hunker down in their offices, and focus solely on patient care. The theme behind all of this is the same: it is a failure to understand and appreciate what primary care is all about.