Care patterns in Medicare and their implications for pay for performance
Care patterns in Medicare and their implications for pay for performance
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DOI：
10.1056/nejmsa063979
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发表时间：
2007-03-15
影响因子：
158.5
通讯作者：
Bach, Peter B.
中科院分区：
文献类型：
--
作者：
Pham, Hoangmai H.;Schrag, Deborah;Bach, Peter B.
背景：两个假设支撑了医疗保险中绩效薪酬的实施：通过使用索赔数据，患者可以被分配给对他们的护理负有主要责任的医生或诊所，并且医生提供的护理中有很大一部分是为他们负有主要责任的患者提供的。方法：我们分析了2000年至2002年间179万服务收费受益人的医疗保险索赔，这些受益人接受了2000年和2001年社区跟踪研究医师调查的8604名受访者的治疗。在单独的分析中，我们将每位患者分配给患者就诊次数最多的医生或初级保健医生。我们确定了每年就诊的医生和诊所的数量，从指定的医生或诊所接受治疗的百分比，分配随时间的稳定性，以及医生的医疗保险患者成为他们指定患者的百分比。结果：受益人中位数为2名初级保健医生和5名专家在4个不同的实践中工作。每年有35%的受益人就诊是由他们指定的医生进行的；33%的受益人每年更换指定的医生。在所有医生就诊的基础上，初级保健医生指定的患者中位数占该医生医疗保险患者的39%，占医疗保险就诊的62%。医学专家的比例分别为6%和10%。仅根据对初级保健医生的访问，79%的受益人可以被分配给一名医生，并且中位数为31%的受益人访问了指定的初级保健医生。结论：在按服务收费的医疗保险中，患者护理分散在多名医生之间，这将限制基于单一回顾性方法分配患者护理责任的按绩效付费举措的有效性。
BACKGROUND:Two assumptions underpin the implementation of pay for performance in Medicare: that with the use of claims data, patients can be assigned to a physician or to a practice that will have primary responsibility for their care, and that a meaningful fraction of the care physicians deliver is for patients for whom they have primary responsibility.METHODS:We analyzed Medicare claims from 2000 through 2002 for 1.79 million fee-for-service beneficiaries treated by 8604 respondents to the Community Tracking Study Physician Survey in 2000 and 2001. In separate analyses, we assigned each patient to the physician or primary care physician with whom the patient had had the most visits. We determined the number of physicians and practices seen annually, the percentage of care received from the assigned physician or practice, the stability of assignments over time, and the percentage of physicians' Medicare patients who were their assigned patients.RESULTS:Beneficiaries saw a median of two primary care physicians and five specialists working in four different practices. A median of 35% of beneficiaries' visits each year were with their assigned physicians; for 33% of beneficiaries, the assigned physician changed from one year to another. On the basis of all visits to any physician, a primary care physician's assigned patients accounted for a median of 39% of the physician's Medicare patients and 62% of Medicare visits. For medical specialists, the respective percentages were 6% and 10%. On the basis of visits to primary care physicians only, 79% of beneficiaries could be assigned to a physician, and a median of 31% of beneficiaries' visits were with that assigned primary care physician.CONCLUSIONS:In fee-for-service Medicare, the dispersion of patients' care among multiple physicians will limit the effectiveness of pay-for-performance initiatives that rely on a single retrospective method of assigning responsibility for patient care.