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Health Affairs, 23, no. 6 (2004):
35
doi: 10.1377/hlthaff.23.6.35 © 2004 by Project HOPE |
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Physician Practice |
PROLOGUE
Physician Practice: Next Steps
PROLOGUE: Lingering visions of the ideal health maintenance organization (HMO) still color policymakers’ perceptions about the less organized provinces of the health system. It is still fashionable to argue that the object of policy should be to nurture competition for consumers’ allegiance between high-performance health plans. In fact, though, relatively few such plans exist. Evidently, a rare and fortuitous combination of circumstances is needed to incubate the kind of large multispecialty medical groups on which true HMOs are built. Meanwhile, most medical encounters still take place in rougher settings, and despite policymakers’ apparent lack of interest in the average neighborhood doctor’s office, it is in such offices that the current battle for improvements in quality and efficiency will probably be won or lost. After the experiences of the 1990s, a strategy of herding doctors into large corporate settings no longer seems to be a credible option.
The tools of quality improvement—performance measurement, incentive payments, information technology, and chronic care management—all work differently depending on the setting in which they are used. Moreover, the strategic and logistical challenge of deploying these tools throughout a highly decentralized system of small, largely independent units will be immeasurably more arduous and labor-intensive than the alternative scenario of galvanizing large organizations with competitive pressure. Small wonder that policymakers would prefer an industrial-strength market solution. But the market for physician services is not only local, it is personal, and impervious to big-bang approaches. Insurers, employers, and consumers who want more value for their health care dollars should prepare themselves for a long, hard climb.
Such a prospect, at any rate, is what the following papers by Robert Cunningham and by Diane Rittenhouse and colleagues appear to portend. Cunningham examines data from the American Medical Association (AMA) and other sources showing current trends in practice size, and he cites recent studies showing the stalled growth of multispecialty groups. Innovative payers have begun to recognize the importance of incentives for efficiency and quality improvement at the capillary level, and a role for medical professionalism is envisioned as well. Allan Korn, chief medical officer for the Blue Cross and Blue Shield Association, contributes a payer’s perspective.
Rittenhouse and colleagues take a different approach but reach similar conclusions. Their survey of California physicians finds that even when independent practice associations (IPAs) are involved in implementing supports and incentives for quality improvement, there is a wide gap between the performance of Kaiser’s integrated organization and the loosely organized medical groups in a typical IPA. They find that the current state of U.S. physician organization raises "disturbing questions" about closing the quality chasm.
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