Study: Dispersion of Care Erodes Physician Motivation

Medicare patients typically see a variety of physicians during the course of a year, and that dispersion of care could make it difficult for Medicare pay-for-performance programs to award meaningful physician performance bonuses, thus limiting the effectiveness of such P4P initiatives, according to a study published in the March 15 New England Journal of Medicine.

The study, "Care Patterns in Medicare and Their Implications for Pay for Performance," analyzed Medicare claims from 2000 to 2002 for 1.79 million fee-for-service Medicare beneficiaries treated by 8,604 physicians.

Study researchers were from the Center for Studying Health System Change, a policy research group funded by the Robert Wood Johnson Foundation, and Memorial Sloan-Kettering Cancer Center in New York. They excluded pediatricians and other specialists with only limited responsibility for ongoing patient care, such as radiologists, anesthesiologists and pathologists, from the study.

Among other things, the researchers found that

"The involvement of many providers in the care of each Medicare beneficiary … impedes the ability of any one assigned provider to influence the overall quality of care for a given patient. Such a limitation may limit the potential of incentives to improve the quality of care," say the study authors.

In addition, the "instability of (patient) assignments may decrease the motivation of physicians to invest in long-term improvements in care for patients with chronic conditions (e.g., hiring patient educators), or the ability to target interventions to specific patients, if they perceive that the benefits to patients will take years to accrue and that many of their patients are unlikely to remain assigned to them," say the authors.

The researchers call for the incorporation of strategies that address care dispersion, including the use of models of shared accountability to prospectively designate responsible providers for each patient.

Bruce Bagley, M.D., AAFP's medical director for quality improvement, seized upon that suggestion as the most important recommendation to come from the study and an accompanying editorial in NEJM.

"Fragmented care is not a necessity; it's a symptom of our broken system of care" said Bagley. "We shouldn't necessarily accept the idea that every person needs six to eight doctors," he added.

Bagley pointed to the benefits of the personal medical home -- especially for patients with multiple chronic conditions -- where someone can coordinate care among the specialists. "If no one assumes those care coordination responsibilities, the patient is not getting the highest quality care possible," said Bagley.

He suggested the need for incentives to compel Medicare beneficiaries to select a medical home, but called the concept "a lightening rod issue" and "a hard sell."

"The minute someone suggests patients must have a primary care provider, too many people recall managed care and gatekeepers of the mid-1990s," said Bagley.

"That's not what we're talking about at all. Rather than limiting care -- which was the public's perception of managed care -- we're talking about assigning one physician responsibility for the care of the patient, and then asking that physician to coordinate that care in a complex health care system," said Bagley.