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Pay-for-performance systems depend on linking an individual patient to a single, responsible healthcare professional or practice. Investigators used the Medicare database to assign patients to individual providers on the basis of use of services. For the purposes of this analysis, each beneficiary was assigned to the provider (or practice) who billed Medicare for the greatest number of evaluation and management visits by that beneficiary in a given year.
In 2000, Medicare beneficiaries visited a median of two primary care physicians and five specialists, working from four different practices. The number of visits tended to be highest among patients with coronary artery disease, diabetes, or lung cancer. Beneficiaries saw their assigned providers for a median of 35% of all their physician visits and 53% of their evaluation and management visits. From 2000 to 2001, and again from 2001 to 2002, the assigned provider changed for about one third of beneficiaries. Over a 3-year period, assignments changed at least once for 46% of beneficiaries.
Pham HH et al. Care patterns in Medicare and their implications for pay for performance. N Engl J Med 2007 Mar 15; 356:1130-9.
Comment
As this study shows, individual Medicare patients are often cared for by an array of practitioners. This reality limits the ability of pay-for-performance systems to properly attribute responsibility for a single patient's care or outcomes.