Lucy van Pelt used to charge five cents for advice. That's peanuts compared to what some patients will pay today for the services of "health care advocates," according to the Boston Globe. And although the intent is to help people navigate the system, their very existence illustates some of that system's biggest problems.

These firms specialize in coordinating a patient's care and helping them navigate our complex and often overwhelming health care system. What doctors to see, what treatments to seek, where to go with an emergency at 3:00 a.m.—they'll answer all your questions—for a price that can range from $150 an hour to $100,000 a year.

Advice on treatment options, disease management and the coordination of care can take many shapes and forms, but, arguably many of the services provided by these health care advocates, in an ideal world, should be provided by a patient's primary care doctor. Yet, one of the people interviewed for the Globe article said he called his advocate because he didn't want to bother his primary care doctor with routine questions. Having someone to answer your routine questions, to know when there's something bigger at stake, is part of why we need a primary care doctor in the first place! But our current system is set up so that all too often it obstructs rather than encourages such relationships, which are the foundation of health care. These firms, in contrast, are adding another layer of care—and only for people who can afford the fees.

We get what we pay for in health care, and right now we're paying primary care doctors to squeeze in 15 minutes (or less) with as many patients as possible. In its June report to Congress on Reforming the Delivery System, MedPAC made extensive recommendations addressing payment reform, comparative effectiveness, and, yes, primary care.

The report stresses the importance of primary care to the delivery of efficient, high-quality care. The two main recommendations are simple but needed:

1. Pay primary care physicians smarter. Medicare's reimbursement schedules are more byzantine than Constantine the Great. The basics of evaluation and management—the bread and butter of primary care—are undervalued relative to more intensive procedures like heart surgery because the fee-for-service payment is based on the manual difficulty of completing a medical service. When a heart surgeon becomes more efficient, he or she can perform more operations with fewer complications and is paid more because the volume of cases increases. But this fee-for-service system produces perverse results in primary care. The emphasis should be on education, coordination and management of complex disease—but doctors just aren't paid for putting in the time required to do those tasks right. Instead, they're paid (not much) by the visit. MedPAC proposes adjusting payments in a budget-neutral manner to more accurately reflect the value of primary care. Done correctly, it could allow primary care doctors to spend more time with patients doing the things some are now having contracted out.
2. Demonstrate the value and viability of a medical home model of care. A medical home coordinates a patient's care, including prevention and chronic disease management. Generally built around primary care doctors, a medical home can also incorporate specialists (like endocrinologists for diabetes). MedPAC also lays out some of the conditions it sees as the foundations of medical home model, including: pay for performance, health IT, and 24/7 access. Framing the proposal in terms of a pilot project—which unlike a Medicare demonstration project does not have to be revenue neutral and can be used to set payment policy—shows how serious the report's authors are about the potential value of a medical home.

We aren't criticizing individuals who go out and purchase something they think their family needs. But it really isn't an answer to the problems in our health care systems; problems which can be addressed by more and better primary care, more integrated delivery systems, and a payment system that rewards coordination instead of fragmentation. More sustainable reform, components of which MedPAC has laid out for us, would change the incentives of our current system so that primary care doctors are paid more for managing their patients' health. And that's something even good ol' Charlie Brown—and maybe even Lucy—could be happy about.