I attended a conference in Charlotte, NC that was focused on Best Practice Models to Improve Health Care Outcomes. The conference, which was held by the not for profit COSEHC had speakers from all over the southeast discussing PCMH, ACOs, Bundled Payment, Integrated Care Systems, and Direct Pay. Attendees were present from all over the country and even a few physicians from several other countries. After an entire day of discussion the audience was asked which model of care was the most likely to actually improve patient outcomes, reduce costs, and improve primary care compensation and workforce. The surprising answer was that by far, with over 50% of the electronic vote, Direct Pay was the favorite. The second closest was PCMH at --%. ACOs came in third. The consistent point that was raised was that in PCMH models or ACO models that increased reimbursement is ultimately still at the discretion of either the payer or integrated hospital system. This means that increased pay for NCQA certified PCMHs and ACO shared savings may be provided for a year or two-but once all practices are PCMH then the bonus payments will go away as this type care is considered standard. Continued shared savings will require more savings over projections each year and as the limbo bar continues to be lowered- at some point there is no more shared savings because the new projection becomes based on what was saved in previous years. So, even though PCMH as a delivery system is ideal, continuing incentive payments for it is unlikely after a couple of years. Shared saving under ACOs will likely not trickle down to primary care physicians in hospital centric ACOs and even where it does, those bonuses will be short lived. Cutting out the middleman of insurance filing by having individuals and employers contract directly with the providers of care is the best way to keep costs down and quality optimal. This makes health care a competitive customer service driven model which incentivizes patient satisfaction.