Background Two assumptions underpin the implementation of payfor performance in Medicare: that with the use of claims data,patients can be assigned to a physician or to a practice thatwill have primary responsibility for their care, and that ameaningful fraction of the care physicians deliver is for patientsfor whom they have primary responsibility.
Methods We analyzed Medicare claims from 2000 through 2002 for1.79 million fee-for-service beneficiaries treated by 8604 respondentsto the Community Tracking Study Physician Survey in 2000 and2001. In separate analyses, we assigned each patient to thephysician or primary care physician with whom the patient hadhad the most visits. We determined the number of physiciansand practices seen annually, the percentage of care receivedfrom the assigned physician or practice, the stability of assignmentsover time, and the percentage of physicians' Medicare patientswho were their assigned patients.
Results Beneficiaries saw a median of two primary care physiciansand five specialists working in four different practices. Amedian of 35% of beneficiaries' visits each year were with theirassigned physicians; for 33% of beneficiaries, the assignedphysician changed from one year to another. On the basis ofall visits to any physician, a primary care physician's assignedpatients accounted for a median of 39% of the physician's Medicarepatients and 62% of Medicare visits. For medical specialists,the respective percentages were 6% and 10%. On the basis ofvisits to primary care physicians only, 79% of beneficiariescould 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 effectivenessof pay-for-performance initiatives that rely on a single retrospectivemethod of assigning responsibility for patient care.
Source Information
From the Center for Studying Health System Change, Washington, DC (H.H.P., A.S.O.); the Health Outcomes Research Group, Memorial Sloan-Kettering Cancer Center, New York (D.S., P.B.B.); and Social and Scientific Systems, Silver Spring, MD (B.W.).
Address reprint requests to Dr. Pham at the Center for Studying Health System Change, 600 Maryland Ave. SW, Suite 550, Washington, DC 20024, or at mpham{at}hschange.org.
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