Health Affairs, 23, no. 6 (2004): 36-47 doi: 10.1377/hlthaff.23.6.36 © 2004 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

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Physician Practice

Professionalism Reconsidered: Physician Payment In A Small-Practice Environment

Abstract

 
Traditional fee-for-service health insurance rested on the assumption that doctors have primary responsibility for decisions about care. Managed competition assumed a new model based on corporate medicine, which has not materialized; also, consumers’ ability to replace doctors as primary medical decisionmakers is unproven. Data on practice size show that doctors and patients continue to prefer the small-practice setting, where the doctor’s role as the patient’s agent is salient. The persistence of the small practice suggests that medical professionalism remains the cornerstone of the health system. If so, it may be more appropriate to pursue quality-oriented refinements of traditional payment approaches, rather than radical transformation.

Fifty years later, in the face of exploding costs and complexity and after a long period of erosion of public confidence in professional authority, payers rebelled against the perceived hegemony of the professionals: Insurers and employers laid claim to control, asserting that rationally organized health systems could tame costs and complexity through sophisticated corporate integration. It was an appealing notion, prefigured by the many successes of Kaiser Permanente and the nation’s other distinguished integrated delivery systems. The managed care/managed competition model was well suited to the market-oriented ideological climate of the Reagan-Gingrich era and tailor-made for the emergence of a new focus on quality improvement in the mid-1990s. The new system would run on capitated payment, and FFS reimbursement was frequently dismissed as a quaint and primitive anachronism.

Many still cling to this vision—witness the lavish subsidies for competing health maintenance organizations (HMOs) in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. But integration, selective networks, and capitation have been largely in eclipse since the late 1990s. An alternative vision of reform has been proposed that seeks to elevate patients and consumers to the role of key decisionmakers and market catalysts. But the viability of this construct has yet to be demonstrated. Some versions of "consumer-driven care" rest on the same assumptions about competing health plans that failed to materialize for the champions of managed competition. In its extreme forms, individualized insurance appears to offer the affluent an opportunity to buy concierge services from exclusive physicians while consigning the average working stiff and the chronically ill to second-tier access and quality. Concierge care puts an appropriate emphasis on the patient-physician relationship, but it represents a way to escape, not reform, the existing system.² And it is not apparent how a tiered scheme that allows consumers greater choice of insurers or providers according to their means makes any fundamental difference in a sick patient’s ultimate reliance on professional judgment for medical decision making.

That reliance was also reflected in consumers’ rejection of managed care and payers’ attempts to substitute their own judgment and authority for that of the professionals. Many observers have put the revolt of the payers in the context of a general erosion of public trust in professional authority during the past generation. But one leading scholar, Eliot Freidson, argues that the complexity of professional fields of work has stopped this erosion short of undermining the fundamental authority of the professions to control their own work.³ Both Freidson and Kenneth Arrow have written in recent years that they—like Paul Starr and many others—expected "the coming of the corporation" to medicine and believed that medical professionalism would be diminished as a result.⁴ Absent corporatization, though, Freidson and Arrow have both argued that complexity and uncertainty make it necessary for professional judgment, rather than market forces or bureaucratic regulation, to control medical decision making.

Herein lies the most crucial and least understood lesson from the failure of managed care to effect the transformation it promised. It was not necessarily that the payers attempted a willful usurpation of medical decision making to enrich themselves, as some suspected. Insurers and self-insuring employers for the most part probably never really wanted this job. Rather, they acted in the belief that corporatized medical practice could effect a cost-conscious synthesis of financing and delivery and tidy up a disorderly mélange of insurance and provider markets. Instead, the physician practice management industry collapsed, and the growth of large multispecialty medical groups ground to a halt. Absent corporatization, the small practice has reasserted itself as the dominant setting for primary care and the environment most conducive to the "relationship of trust and confidence" famously described by Arrow as the locus of professionalism.⁵

The purpose of this discussion is to assess the relationship between payment and practice size in the post-backlash environment. The emphasis is on a few key developments, including payers’ retreat from intrusive efforts to manage care; the persistence of the small practice, especially in primary care; renewed attempts at refining payment methods to encourage quality and efficiency; and the enduring centrality of professional judgment in medical decision making. The approach taken here is journalistic. It begins with a review of several recent analyses of physician practice trends in the health services research literature and data on practice size from American Medical Association (AMA) surveys and the Community Tracking Study (CTS). It then considers several experiments with physician incentives that address the particular challenges of the small-practice environment. These descriptions are based on interviews, published reports, and public and corporate documents. It concludes with a discussion of some of the implications of these data and experiments for the future direction of the system.

Changing Physicians’ Behavior

Top Changing Physicians’... Real-World Experiments Implications: Change The... Editor's Notes NOTES

 
In the aftermath of medicine’s revolt against managed care, the payers who initiated the abortive revolution of the 1990s have taken a gingerly approach to inducing changes in physicians’ behavior. Insurers have abjured micromanagement of care and retreated from forcing cost-consciousness on providers through capitated payment and the delegation of insurance risk. The nascent disease management industry is at pains to emphasize the focus of its interventions on patients. As an increasingly common adjunct to insurance or self-funded health benefits, disease management companies (some are insurer spinoffs) use claims data to identify potentially costly patients and then prompt them with notices and reminders about appointments, tests, medications, monitoring, and self-care. Imposing on providers is carefully avoided.

Even the most noncoercive methods for promoting quality improvement among physicians are fraught with difficulty. Implementing clinical practice guidelines, for example, has proved to be very slow work. In a 1999 literature review, Michael Cabana and colleagues catalogued hundreds of barriers to adherence and observed that guidelines have had limited effect on changing behavior despite widespread promotion.⁶ Physician profiling has been similarly problematic. Timothy Hofer and colleagues found that although profiling is used by many health systems, "few profilers have data with adequate risk adjustment measures, enough observations per provider, and enough providers to try to estimate the true reliability of their measures" and that profiling usually "exaggerates both the magnitude of physician practice differences and the savings that could be achieved by correcting the practice of the outlier physicians."⁷

In large medical groups, the use of quality-improving care management processes of the kind envisaged by the Institute of Medicine (IOM) is not widespread, and the employment of incentives and supportive information technology (IT) is limited and has only a slight impact on increasing the use of these processes. In a recent study of more than a thousand large medical groups and independent practice associations (IPAs), Lawrence Casalino and colleagues found that half of the groups used no more than four of sixteen selected care management processes. External incentives and the use of clinical IT were associated with score improvements of a point or two on a sixteen-point scale, but relatively few of the groups made much use of these tools. "This study provides strong confirmation for the IOM’s assertions that organized processes to improve quality of care are not common in POs [physician organizations] and that many physicians work in practices that have neither incentives nor IT capabilities to improve quality," the authors concluded.⁸

Failure to thrive. That’s the good news. The rest of the story is that these underachieving large groups represent only a fraction of the medical profession. According to two recent AMA surveys, nonfederal, postresidency, patient care physicians practicing in noninstitutional settings accounted for 62 percent of the 669,000 U.S. physicians in 2001 (Exhibit 1). Except in a few fields, only one in four or five physicians belongs to a group larger than eight physicians. In work based on a CTS survey of physicians, Casalino and colleagues found that fewer than 10 percent of private physicians practiced in groups of twenty or more in 2001, and that percentage did not increase between 1996 and 2001.⁹ According to the U.S. Centers for Disease Control and Prevention (CDC), 67.1 percent of all office visits in 2001 were to practices of four or fewer physicians.¹⁰

What is the fallback plan? If coercive tactics by payers are not an option, and the organizational framework generally considered essential for improving processes of care has not materialized on an adequate scale, what options are available for correcting the system’s defects in quality and efficiency? Can the mantra of pay-for-performance work in a small-practice environment? On this point, skepticism is certainly warranted. Echoing Hofer, a recent study by Bruce Landon and colleagues found that small sample sizes for individual physicians compounded generic problems in performance measurement related to case-mix adjustment, size of treatment effects, availability of adequate standards and metrics, and more.¹³ "Without the appropriate statistical models, every time you start ranking doctors or putting a number of stars next to their name people are going to be misclassified," Landon told the Wall Street Journal.¹⁴

Donald Berwick, founder and president of the Institute for Quality Improvement, said in an interview that pay-for-performance strategies for individual physicians are not yet mature. Measurement problems are only part of the reason, he said. At a time when the cost and complexity of dealing with patients with multiple chronic conditions is emerging as the greatest challenge facing the health system, it may be impossible to assign the locus of responsibility for the quality of patient care to any single actor. For chronic care, the critical factor is coordination, Berwick said.¹⁵ Casalino expressed a similar concern. Reflecting on his own experience as the leader of a small group practice, he said that even with electronic systems that would facilitate the sharing of information among providers, entering detailed patient data into electronic record systems is inevitably a time-consuming, labor-intensive task. "A small practice just cannot afford the staff to do that, and it’s a little hard to see how a health plan could do it for them, or an IPA," Casalino said, since introducing a third party into the process would complicate communication and coordination tasks.¹⁶

Real-World Experiments

Top Changing Physicians’... Real-World Experiments Implications: Change The... Editor's Notes NOTES

 
The disconnect between real and ideal notions about physician organization has become acute enough that some stakeholders have begun to experiment without waiting for the delivery system to reshape itself according to the dominant policy model. In 2002 Blue Cross of California (BCC) began implementing a performance bonus program aimed at individual physicians in Northern California. About 12,000 doctors see 80 percent of BCC members, according to vice president and corporate medical director Jeff Kamil, and most of them are in solo and two-and three-physician practices. In the initial pilot phase of the PPO Physician Quality and Incentive Program (PQIP), about 7,000 physicians in eleven specialties were given an opportunity to participate, and about 1,500 signed up to participate in the first five months. PQIP uses fifteen clinical quality metrics, including cancer screening, immunizations, and various measures of care for diabetes, depression, asthma, and cardiovascular disease. Additional points can be awarded for board certification, accessible practice hours, stability of patient relationships, generic prescribing, and electronic claims submission.¹⁷ If a diabetic sees both a general internist and an endocrinologist in given year, and the patient gets both glycosylated hemoglobin testing and a retinopathy exam—no matter who provides them—both doctors get points for both indicators in the PQIP system. "People will complain about the methodology, and I can understand their complaints. But this is the best we can do based on what we’ve got," Kamil said. Bonuses in the first phase of the program are capped at $5,000 a year per provider.¹⁸

Reaching critical mass. Incentives won’t work unless they apply to enough patients to make a noticeable difference in office income. BCC has about a 25 percent market share in Northern California, which helps it get individual physicians’ attention. BCC is also participating in a consortium with five other California insurers under the auspices of the Integrated Healthcare Association (IHA) to use common metrics for performance incentives, although antitrust law prohibits their collaboration on payment. PQIP is modeled on a five-year-old physician bonus program of the Hawaii Medical Service Association (Blue Cross and Blue Shield of Hawaii), which has a 70 percent market share. The Bridges to Excellence (BTE) program, spearheaded by General Electric (GE), is seeking to form collaborative arrangements with other large employers and insurers in several test markets. BTE assumes that it takes 50,000 lives or 8–10 percent of the local population to create a patient base that is large enough to matter, especially in a small-practice environment. The program is designed to pay top performers an extra $10,000 a year.¹⁹

"We operate in the real world, and it’s not made up of Kaisers and Health-Partners," said François de Brantes, head of the Corporate Healthcare Initiatives unit at GE. "We have [employees] everywhere, and in most places we don’t have organized systems of care." BTE has launched its physician incentive program in a mixture of trial markets that includes a variety of physician environments, including Boston, Cincinnati, Louisville, and the Albany-Schenectady area of upstate New York. Boston is dominated by large, sophisticated group practices and health systems that have been able to gear up quickly to hit BTE performance targets and reap the incentive payments. Cincinnati has a mix of organized groups and small practices. "What’s happened there is the early adopters have been the more organized groups, and now we’re getting to that second layer of the more atomized physicians," de Brantes said. "Louisville is almost all individualized moms-and-pops. The goal is...to make this work in Louisville, because if we can make it work in Louisville, we can make it work anywhere in the country."²⁰

The acquisition and deployment of IT plays a major role in the innovators’ vision of change in the small-practice environment, as it does in other reform scenarios. The purchase of technology and investment of time in changing care processes to capitalize on it is a large part of what BTE expects bonus payments to be used for. BCC’s parent company, WellPoint Health Networks Inc., announced early in 2004 that it plans to donate $40 million worth of computers to 19,000 physicians in its networks in several states including California, to facilitate both care management and electronic claims filing—a program hatched separately from PQIP but congruent with it, Kamil said.²¹ But even its most ardent champions recognize that IT in itself is not a magic bullet. "Physician practices, especially solo/small-group practices, require support to carry out the time-consuming workflow and other complementary changes needed to generate financial and quality benefits from ‘out-of-the-box’ EMRs [electronic medical records]," Robert Miller and Ida Sim wrote recently in this journal. "There is no simple solution to accelerating EMR adoption and use for quality improvement."²²

A "vicious treadmill." The difficulties are rooted in the everyday predicament of the average primary care physician, according to David Kibbe, director of the Center for Health Information Technology of the American Academy of Family Physicians (AAFP). Seventy percent of the AAFP’s 60,000 active members are in practices of five or fewer, Kibbe said. "They want EHRs [electronic health records] to make information flow more quickly from their offices to pharmacies, for example, or from laboratories to their offices, or for...intra- or inter-office messaging. There are a whole host of workflow and information-flow issues that come...to the surface very quickly when you talk to small- and medium-sized medical practices.

"As their costs go up and their reimbursements either stay the same or drop, and as the patients that they take care of are getting sicker and sicker, they take more medicines, they have more chronic problems; they’re on a kind of vicious treadmill where in order to earn the same amount of money they have to see more and more patients, because that’s the only thing they’re reimbursed for," Kibbe explained. "That leaves less time for management of those patients," he said. "The academy would like to see a system evolve where the primary care physicians are paid a management fee that would reimburse them for the things that they’re already doing and turn this vicious cycle around—or at least stop it from getting worse. What they’d like to do is see fewer patients per day, work the same number of hours, manage their patients better, and get paid the same."²³

Medicare. A demonstration targeting individual physicians is one of several MMA provisions that will augment quality initiatives already under way at the Centers for Medicare and Medicaid Services (CMS). Section 649 of MMA calls for a three-year, four-site demonstration that pays performance incentives to individual physicians for care of chronic patients based on coordination of care, compliance with evidence-based guidelines, and the use of information systems. Bridges to Excellence is the model, said Stuart Guterman, director of the CMS Office of Research, Development, and Information. The CMS has contracted with the Academy of Family Physicians to work with its Quality Improvement Organizations (QIOs) in implementing the project.

"The physician office setting is probably the most difficult setting to deal with" when it comes to measuring and rewarding performance, Guterman said. "We don’t want to just pay doctors to go out and buy computers. We want to be able to encourage them to use that technology to improve the care that they provide to their patients," he continued. "One of the advantages of Medicare as opposed to even a group of very large employers is that in any given area, Medicare is likely to have a larger pool of patients to use as leverage...so that we can reach practices of smaller size because we’ll have enough patients to be able to exert the kind of influence over performance that we want...We’re not going in there and saying, ‘This is a raid. We’re going to inspect your office and we’re going to throw you out of Medicare if you don’t have the right kinds of IT.’ We’re saying, ‘We’re going to reward you if you do the things that we’d like you to do and that we think are going to pay off in the long run."²⁴

Implications: Change The Priorities

Top Changing Physicians’... Real-World Experiments Implications: Change The... Editor's Notes NOTES

 
Policy languishes under the spell of outmoded and dysfunctional models. A distinguished group of CTS researchers recently concluded that "the way the world is apparently structured at the moment, health plans cannot be the key change agent...They are not the catalytic savior we thought they were ten years ago."²⁵ "We can’t be gatekeepers," said Leonard Schaeffer, chairman and chief executive officer of BCC’s parent company, WellPoint, in a 2004 Washington speech. "We learned the hard way that you cannot force health care professionals to do it one way or the other," said Schaeffer, who uses the term "infomediaries" to describe the role of health insurers in the future.²⁶ In his recent study of Aetna’s retreat from managed care, James Robinson concluded that the HMO backlash "is driving the industry back toward traditional insurance principles," by which insurers manage financial risk and leave providers to manage care. Meanwhile, payers’ forays into disease management emphasize changing patients’ behavior, "with only cautious and information-oriented outreach to physicians."²⁷

That said, traditional insurance was never as uncomplicated as some contemporary reformers tend to assume. Only a minority of the early Blue Shield plans paid doctors just with simple indemnities. Under pressure from consumers for comprehensive benefits, many of these pioneering medical plans attempted to mimic the "service benefit" offered by the Blue Cross hospital plans, which required doctors to accept the plans’ reimbursement rates as payment in full either for all of their subscribers or for those below a stipulated low-income threshold. Doctors were sometimes at risk for service volume, since the early plans rarely held large reserves and paid only a fraction on the dollar when claims exceeded premium income. The impact of deductibles on service use was always hotly debated in Blue Shield circles. The advent of cheap, high-deductible, "major medical" coverage in the 1950s prompted a wave of product experimentation throughout the insurance industry, although without fundamentally displacing more comprehensive coverage. The study of practice patterns began in the 1950s, and a few Blue Shield plans began testing "prevailing fee" systems in the following decade, before Medicare opted to pay "usual, customary, and reasonable" rates. Finally, a circumstance almost always overlooked in contemporary critiques: Price competition among health insurers was always brisk, resulting in tension between insurers and providers over reimbursement rates and utilization long before the relatively recent revolt of payers and the rise of managed care.²⁸

Centrality of physicians’ role. The point of this history lesson is to show that the sovereignty of the medical profession over health insurers has never been absolute and that payment strategies have always represented a taut balance between the profession’s demand for clinical control and the market’s demand for affordability. Disequilibrium set in after the long, post–World War II economic expansion ended in the 1970s and cost growth began to pinch—at a time when societal changes had also begun to erode the prestige of the medical profession. But the payers failed to justify their bid for control to the public’s satisfaction, and consumers have yet to be shown capable of assuming it. In the meantime, the persistence of the small practice suggests that the eclipse of medical professionalism as a governing factor in the allocation of health resources has perhaps been overstated by the apostles of change. Patients and doctors have voted with their feet to uphold a framework in which their intimate relationship can be sustained. Under these circumstances, it is reasonable to hypothesize that some aspects of professional authority have declined more than others. Society may have lost faith in medicine’s ability to regulate itself, or to maintain its mastery of new scientific knowledge, or to protect its interests in the political arena without undue selfishness. But in the critical function of representing the patient as a trusted agent in medical decision making, the professional’s role remains primary. Stronger and smarter standards of performance and mechanisms of accountability are needed. But the enduring centrality of the physician’s role suggests that it is probably more appropriate to think about further refining traditional payment modalities than dismantling them.

Quality and physician payment. The quality movement has conveniently supplied a fresh and appealing set of goals for improving physician payment along with many other aspects of the health system, and emerging concern about the burden of chronic illness has provided further justification for refining traditional approaches to payment—without tearing down the serviceable foundation they provide. The more care coordination is valued, the more sense it makes to include a payment component that compensates for this function, such as the retainers paid in concierge care, Medicaid’s primary care case management (PCCM) fees, or incentive programs that reward for indicators of continuity and coordination of care. The challenge in a small-practice environment is to apply this principle to individual physicians who lack the capability to share risk for the incidence of illness but ought to be responsible for controlling the risk of overuse with a given patient. The English National Health Service (NHS) pays a combination of FFS and capitation to its general practitioners (GPs) on this principle, not unlike Medicaid PCCM.

Like BCC and the BTE program, the NHS has also begun to add a third component to its physician payment system based on quality indicators. The new system will distribute about 18 percent of all GPs’ income on the basis of a point system that reflects both clinical quality indicators and measures of "practice organization" and care management. Pilot testing of the system found marked improvements in chronic disease management. "The financial incentive was necessary to encourage participation and focus attention on desired change. However, the professionals were also motivated by a sense of professional autonomy and ownership," Peter Smith and Nick York wrote in this journal.²⁹

The goal of quality improvement, including the resource-sensitive dimension of appropriateness, provides a plausible framework for payers and providers to resume pursuit of payment systems that strike the right balance between resource sensitivity and clinical judgment. Consortium arrangements, insurance consolidation, and experimentation by Medicare and Medicaid may help speed diffusion of promising new mixes of payment methodology. But a preoccupation with limited or abstract models such as managed competition and consumer-directed health care has deflected policymakers’ attention from the challenge of getting payment right in the real world of primary care, where patients rely on doctors in small-practice settings to make decisions about what is best for them.

This fixation on managed competition has repeatedly blinded Congress to opportunities for introducing innovative payment approaches in FFS Medicare. The National Bipartisan Commission on the Future of Medicare began its deliberations in 1998 by reviewing a fresh and authoritative study of these opportunities by the National Academy of Social Insurance (NASI) but never followed through on NASI’s recommendations.³⁰ Despite the abject failures of Medicare+Choice in the intervening years, Congress again lavished attention and subsidies on private plans in MMA but left FFS reform to the vagaries of the demonstration process, with only one limited project focused on the small-practice physicians who dominate the FFS environment.

Politics and ideology drive some of this misdirection, of course. And some of the prevailing confusion about the role of professionalism is justified. The political and self-regulatory behavior of organized medicine, for example, often reinforces the public’s perception of doctors as self-interested economic animals. Just as insurers’ strategies for managing care in the 1990s were distrusted as profit seeking in disguise, doctors’ efforts to assert clinical control may be construed as attempts to wield economic leverage; in many instances, doctors have responded to economic pressures by becoming more entrepreneurial. Such tensions and ambiguities are inherent and perennial in third-party payment and are unlikely to be transcended with simplistic, deus-exmachina solutions such as medical corporatization or consumer-driven care. A renewed emphasis on quality at a time when chronic illness is emerging as the system’s primary challenge means a renewed emphasis on continuity and coordination of care, as well as adherence to best practices. Quality begins with the patient-physician relationship. The rapid advance of the biomedical sciences increases patients’ reliance on professionals who can manage the increasing complexity and uncertainty of the care process for them, just as Arrow and Freidson explained in their definitive works. The payment system should promote and support this capability as reliably and transparently as possible.

Editor's Notes

Top Changing Physicians’... Real-World Experiments Implications: Change The... Editor's Notes NOTES

 
Rob Cunningham (rcunningham{at}projecthope.org) is a deputy editor of Health Affairs.

The author thanks Bob Berenson, Don Metz, and three anonymous reviewers for their helpful suggestions.

NOTES

Top Changing Physicians’... Real-World Experiments Implications: Change The... Editor's Notes NOTES

 

1. R. Cunningham and R.M. Cunningham, The Blues: A History of the Blue Cross and Blue Shield System (DeKalb: Northern Illinois University Press, 1997), chapters 2–4.
2. See "Consumer-Directed Doctoring: The Doctor Is In, Even If Insurance Is Out," hearings of the congressional Joint Economic Committee, 28 April 2004, jec.senate.gov/index.cfm?FuseAction=Hearings.Hearing&Hearing_ID=76 (17 August 2004).
3. E. Freidson, Professionalism: The Third Logic (Chicago: University of Chicago Press, 2001), 197–222.
4. E. Freidson, "Professionalism and Institutional Ethics, 1999," in The American Medical Ethics Revolution, ed. R. Baker et al. (Baltimore: Johns Hopkins University Press, 1999); and K.J. Arrow, "Reflections on the Reflections," Journal of Health Politics, Policy and Law 26, no. 5 (2001): 1197–1203.[CrossRef][ISI][Medline]
5. Freidson, "Professionalism"; and K.J. Arrow, "Uncertainty and the Welfare Economics of Medical Care," American Economic Review 53, no. 5 (1963): 941–973 (republished in Journal of Health Politics, Policy and Law 26, no. 5 [2001]: 851–883).[ISI]
6. M.D. Cabana et al., "Why Don’t Physicians Follow Clinical Practice Guidelines?" Journal of the American Medical Association 282, no. 15 (1999): 1458–1465.[Abstract/Free Full Text]
7. T.P. Hofer et al., "The Unreliability of Individual Physician ‘Report Cards’ for Assessing the Costs and Quality of Care of a Chronic Disease," Journal of the American Medical Association 281, no. 22 (1999): 2098–2105.[Abstract/Free Full Text]
8. L. Casalino et al., "External Incentives, Information Technology, and Organized Processes to Improve Health Care Quality for Patients with Chronic Diseases," Journal of the American Medical Association 289, no. 4 (2003): 434–441.[Abstract/Free Full Text]
9. L.P. Casalino et al., "Benefits of and Barriers to Large Medical Group Practice in the United States," Archives of Internal Medicine 163, no. 16 (2003): 1958–1964.[Abstract/Free Full Text]
10. D.K. Cherry, C.W. Burt, and D.A. Woodwell, "National Ambulatory Medical Care Survey: 2001 Survey," Advance Data from Vital and Health Statistics no. 336, 11 August 2003, www.cdc.gov/nchs/data/ad/ad337.pdf (1 March 2004).
11. Casalino, "Benefits of and Barriers to Large Medical Group Practice."
12. Lawrence Casalino, interview, 17 January 2004.
13. B.E. Landon et al., "Physician Clinical Performance Assessment: Prospects and Barriers," Journal of the American Medical Association 290, no. 9 (2003): 1183–1189.[Abstract/Free Full Text]
14. L. Landro, "Doctor ‘Scorecards’ Are Proposed in a Health-Care Quality Drive," Wall Street Journal, 25 March 2004.
15. Donald Berwick, interview, 18 December 2003.
16. Casalino interview.
17. Jeff Kamil, interview, 18 February 2004; and "Blue Cross of California’s PPO Physician Quality and Incentive Program (PQIP)" (corporate document).
18. Kamil interview.
19. François de Brantes, interview, 16 March 2004. See also, "For Prospective Purchasers," on the BTE Web site, www.bridgestoexcellence.org/bte/newpurchaser/index.htm (17 August 2004).
20. De Brantes interview; and "Overview," www.bridgestoexcellence.org/bte/pdf/overview.pdf (17 August 2004).
21. Kamil interview.
22. R.H. Miller and I. Sim, "Physicians’ Use of Electronic Medical Records: Barriers and Solutions," Health Affairs 23, no. 2 (2004): 116–126.[Abstract/Free Full Text]
23. David Kibbe, interview, 11 March 2004.
24. Stuart Guterman, interview, 5 March 2004.
25. L.M. Nichols, "Are Market Forces Strong Enough? Confidence Is Waning" (conference transcript), 12 March 2004, www.hschange.org/CONTENT/668/?id_conf=16 (17 August 2004); and L.M. Nichols et al., "Are Market Forces Strong Enough to Deliver Efficient Health Care Systems? Confidence Is Waning," Health Affairs 23, no. 2 (2004): 8–21.[Abstract/Free Full Text]
26. L.D. Schaeffer, "How Health Plans Can Help Reshape Health Care," speech at American Enterprise Institute, Washington, D.C., 6 April 2004 (author’s notes).
27. J.C. Robinson, "From Managed Care to Consumer Health Insurance: The Fall and Rise of Aetna," Health Affairs 23, no. 2 (2004): 43–55; and [Abstract/Free Full Text]J.C. Robinson and J.M. Yegian, "Medical Management after Managed Care," Health Affairs, 19 May 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.269 (17 August 2004).
28. Cunningham and Cunningham, The Blues, chapters 1–5; and L.S. Reed, Blue Cross and Medical Service Plans (Washington: Federal Security Agency, 1947), 169–181.
29. P.C. Smith and N. York, "Quality Incentives: The Case of U.K. General Practitioners," Health Affairs 23, no. 3 (2004): 112–118.[Abstract/Free Full Text]
30. R. Cunningham, "Medicare Panel Ponders Tight Congressional Control of HCFA," Medicine and Health Perspectives, 15 June 1998, 3–4.

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