Barbara Starfield, MD, MPH, is right on target in “Family Medicine Should Shape Reform, Not Vice Versa” [Opinion, July/August 2009]. I support many of the principles of the patient-centered medical home (PCMH) and believe that, if implemented the way Dr. Starfield recommends, it has the potential to leverage important change. I agree that combining the PCMH with pay/punish-for-performance in a specialist-centered medical care system is a formula for disaster – much like the managed care debacle that framed primary care physicians as gatekeepers a decade ago.

Ever since its inception, the PCMH model has bothered me. I see it as a way to make family doctors become salaried employees in bureaucratic clinics controlled by administrators. Your article has clearly laid out the issues in another way: in terms of the four essential facets of primary care. Focusing on the person instead of the disease should be fundamental in any system embraced by family medicine. Yet, as you point out, measures for this principle and also measures for comprehensiveness of care are missing in the proposed PCMH designation criteria.

Indeed, family medicine should shape health reform and not the other way around. Your framework and the five ways you call on family medicine to mobilize certainly help me think more clearly about what I do every day.