Pham Hoangmai H, Schrag Deborah, O'Malley Ann S, Wu Beny, Bach Peter B
Center for Studying Health System Change, Washington, DC 20024, USA.
N Engl J Med. 2007 Mar 15;356(11):1130-9. doi: 10.1056/NEJMsa063979.
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.
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.
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.
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.
医疗保险中实施绩效薪酬有两个基本假设：一是利用索赔数据，可以将患者分配给对其护理负有主要责任的医生或医疗机构；二是医生提供的相当一部分护理是针对他们负有主要责任的患者。
我们分析了2000年至2002年医疗保险索赔数据，涉及2000年和2001年参与社区追踪研究医生调查的8604名受访者所治疗的179万名按服务收费的受益人。在单独的分析中，我们将每位患者分配给与之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医疗机构数量、从指定医生或医疗机构接受护理的百分比、随时间推移分配的稳定性，以及医生的医疗保险患者中其指定患者的百分比。
受益人中位数每年看两名初级保健医生和五名专科医生，这些医生在四个不同的医疗机构工作。受益人每年就诊次数中位数的35%是与指定医生进行的；33%的受益人指定医生每年发生变化。基于对任何医生的所有就诊情况，初级保健医生的指定患者占该医生医疗保险患者中位数的39%，占医疗保险就诊次数的62%。对于医学专科医生，相应的百分比分别为6%和10%。仅基于对初级保健医生的就诊情况，79%的受益人可以被分配给一名医生，受益人就诊次数中位数的31%是与该指定初级保健医生进行的。
在按服务收费的医疗保险中，患者护理在多名医生之间的分散，将限制依赖单一回顾性方法来分配患者护理责任的绩效薪酬举措的有效性。
