Rich Keller from Treo Solutions has an interesting post. He's talking to health plans about why it might be in their best interest to support high performing local medical neighborhoods.
I've worked as a solo physician and in a big group. No matter the setting, I always worked as part of a larger team - coordinating the care of those whose needs exceeded the comprehensive services our practice had to offer. Our teamlet (RN and I) preferred to work with wider team members who: communicated clearly and in a timely manner, provided a clear and convincing rationale for doing procedures that might put our patients at risk, provided timely access.
The relationship we had with the wider team was fostered in part by our willingness to provide good information, do the right work-up in advance, and generally to refer the right type of cases. We did not have this type of relationship with all the specialists and other providers in our community; some we preferred to avoid, others were just less well known. This group of better-known specialists is the 'medical neighborhood.' We built these relationships over time and solidified them through trust built on repeated good experience.
I can site for my patients published examples of the benefits to patients of good collaborative care between PCP and specialist, examples of benefits when there is good communication and choice of specialists who don't consider my patient referral as license to use every device and procedure likely to generate revenue.*
If I want to build an Accountable Care Organization to better care for a population of people, I would only consider doing so with my team, my neighborhood, the group with whom I have built trust over the years. When patients ask to be referred outside my trusted group I am willing to do so, but I explain the risks and benefits of working with specialists I do not know: the care might be terrific or they might be exposed to unnecessary testing and procedures that put them at risk of unnecessary complications and harm.
*Zastrow RJ, Quadracci L. Engaging Quad/Graphics Employees in the Improvement of Their Health and Healthcare Journal of Ambulatory Care Management, 2006 29(3), 227-231
Fuhrmans, V. Radical Surgery -- One Cure for High Health Costs: In-House Clinics at Companies Wisconsin Firm Saves Money By Hiring Its Own Doctors
Patients Get More Time, The Wall Street Journal, Feb 11, 2005