Ideal Medical Practices

Hospitals, Practice Administrators and Clinicians: You Gotta Learn to Love Patient Ratings – Health Affairs Blog

You are increasingly being held accountable for the outcomes of the health care you deliver. Pay for performance; shared savings in ACOs; public report cards…the list of strategies to monitor and measure the effects of your efforts is lengthening. Many of you seem dismayed by the increased weight accorded to the patient experience of care ratings embedded in most of these programs.  Here’s why you should embrace them: The care you deliver cannot improve our health outcomes or even maintain passable ones without the knowledgeable, active participation of us patients and our families.

via healthaffairs.org

There is good evidence linking patients' experience of care to important outcomes.  Here are a couple of examples: 

• Hospitalized Medicare beneficiaries who can't tell who is running the show and perceive conflicting messages from clinicians are much more likely to be readmitted within 30 days than those reporting good experiences. (Boulding 2011)
• People receiving care in practices with good access, less wasted time, and better communication are more likely to report that treatments have helped reduce problems with pain & emotions, have improved markers of chronic conditions, and reduced use of the hospital & emergency room. (Wasson 2006)

We think that if we adhere to evidence-based guidelines our patients will achieve excellent outcomes, but if we also know that if patients experience delays getting a timely appointment they are less likely to follow up for needed care (Lacy 2004), and people who experience in-office waits and delays are less likely to follow through on appropriate care recommendations (Ling 2006).

Clinician adherence to evidence-based guidelines only goes so far and all the best health information technology for disease tracking is of limited use if the health care team fails to communicate effectively with people who struggle to manage their conditions.  Before we write people off as "non-compliant" we can and should ask ourselves if we have inadvertantly created a series of hurdles and barriers that negatively impacts our patients.

These fundamental attributes of primary care are a good starting point:

1. Access:  how easy is it for people to get a timely appointment?  The ultimate answer comes from those you serve - don't just rely on administrative data.
2. Person-focused care over time:  what percent of your patients say that they can identify a 'go-to' medical person?
3. Comprehensiveness: Recognizing that people must manage their own conditions the overwhelming majority of time, what percent of those with chronic conditions report that they understand what to do and have the confidence to manage?

We showed that it is possible to implement tools to measure and address these issues even in solo independent primary care practices. (Moore 2007)

I agree with Jessie Gruman that we should embrace patient experience data as a powerful addition to our understanding of system performance as well as insight into why some people struggle with effective self-managment.

L Gordon Moore

 

Boulding W, Glickman S, Manary M, Schulman K, Staelin R.  Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days  Am J Manag Care 2011 17(1): 41-48

Lacy, N., Pullman, A. Reuter, M., Lovejoy, B. Why we don’t come: Patient perceptions on No-shows. Annals of Family Medicine 2004;2:541-545.

Ling BS, Klein WM, Dang Q.  Relationship of communication and information measures to colorectal cancer screening utilization: results from HINTS.  Journal of Health Communication. 11 Suppl 1:181-90, 2006.

Moore LG, Wasson JH.  The Ideal Medical Practice Model: Maximizing Efficiency, Quality, and the Doctor-Patient Relationship.  Family Practice Management September 2007 pp. 20-24.

Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, July-September 2006 29(3), 199–206

Breakthroughs in patient outcomes – helping people address lifestyle change and healthy behaviors

John emailed to say how happy he was for one of his patients with diabetes.

 

The anecdote:

 

“He rarely ever follows up with me and rarely ever gets his blood work done (I always have to beg his wife to get him in), and his last 4 HGBA1Cs were 14.9, 12.7, 10.6, and 12.0 (in Dec 2011). Yesterday, his HGBA1C was 7.5! He is walking 30 minutes a day and is writing down everything he eats. He is down 8 pounds from the beginning of the year and feels great.” - John

 

John’s setting:

 

John has a solo independent family medicine practice and uses an electronic health record.  John’s intervention was to hire a part-time nurse wellness coordinator and house her in his office.  This RN enjoys the interaction with patients and the ability to use a greater range of nursing skills and training than is typical in most practices.  The intervention starts with four one-hour long sessions, either one-on-one or with family, and then graduates to follow up phone calls.

 

John’s revenue comes exclusively from insurance payments (no membership or extra fees charged to his patients).  He pays the RN for 16 hours per week of work, yet his practice receives no extra payments, bonus, or incentive dollars for the wellness coordination work or the improved outcomes. John worries that charging patients for this additional support will discourage participation by those who most need the help, so he is reluctant to charge a fee for these services.

 

The evidence base for the intervention:

 

• Changing health behavior has the greatest potential…for reducing morbidity and mortality and for improving quality of life across diverse populations…50% of mortality is from 10 leading causes of death linked to lifestyle changes such as tobacco use, poor diet, inactivity, alcohol and drug use, and sexual behavior[i]
• Randomized trials of simple coaching demonstrate lasting impact on patient outcomes.[ii]
• This coaching can be replicated and used by primary care practices to help patients improve outcomes.[iii]

 

Comments:

 

This collaborative physician/nurse coaching model is likely to help other patients in the practice.  Efforts like this tend to improve overall clinical outcomes, the experience of care, and the total cost of care.

 

High performing health systems are founded on good primary care.  Good primary care leads to better outcomes and lower total costs of care.  Good primary care includes much work that is not part of the current funding stream.  This lack of adequate primary care funding hamstrings effective primary care and is one of the root causes of the cost/quality we face today.

 

One solution may be the aggregation of small practices into larger health systems.  This solution is receiving almost all the attention of those interested in improving health care, but some evidence points out that this aggregation adds to the overall costs of health care without necessarily improving outcomes.[iv]

 

Would it not be interesting to support networks of primary care practices like John’s to:

• Reduce the threshold of adoption of techniques that improve outcomes
• Achieve economies of scale in population health management across solo and small practices
• Provide a sufficient attributed patient population for accurate tracking of outcomes (real outcomes like hospitalization rates, ER visit rates, not a bevvy of bioclinical intermediate measures that often have little to do with what really matters[v])

 

Health plans should by all rights be very interested in this approach but seem to spend all their time negotiating with hospital-centric ACO types that must by their nature struggle with goring their cash cow to achieve “shared savings.”  A primary care virtual ACO has no such conflict of interest.

 

I’m not suggesting anyone drop the hospital-centric ACO work, but where is the action on the primary care virtual network model?

---

[i] Evelyn P Whitlock et al., “Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach,” American Journal of Preventive Medicine 22, no. 4 (May 2002): 267–284.

[ii] Tim A Ahles et al., “A Controlled Trial of Methods for Managing Pain in Primary Care Patients with or Without Co-occurring Psychosocial Problems,” Annals of Family Medicine 4, no. 4 (August 2006): 341–350.

[iii] John H Wasson et al., “Clinical Microsystems, Part 2. Learning from Micro Practices About Providing Patients the Care They Want and Need,” Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources 34, no. 8 (August 2008): 445–452.

[iv] Gardiner Harris, “More Doctors Taking Salaried Jobs - NYTimes.com”, n.d., http://www.nytimes.com/2010/03/26/health/policy/26docs.html?pagewanted=all.

[v] David B. Reuben and Mary E. Tinetti, “Goal-Oriented Patient Care — An Alternative Health Outcomes Paradigm,” New England Journal of Medicine 366, no. 9 (March 2012): 777–779.

More doctors charging extra for services that once were free - Business Monday - MiamiHerald.com

Want to see your doctor without an appointment? You may have to pay a little extra.

via www.miamiherald.com

No surprises here: financial pressures have an impact on behavior. I don't fault the docs for trying to stay in the game rather than quitting, but if we want better overall outcomes we must continue to push for changes in the underlying paradigm of payment and measurement.

People with significant out of pocket costs may delay care for what they perceive as less important issues – screening, prevention, minor symptoms, routine follow up for chronic conditions.

Health plans trying to keep premiums down may put in place prior authorization policies to reduce unnecessary use of medical resources.

Medical practices with increasing costs due to increased prior authorizations may add new service fees.

Each choice makes some sense when considered in a silo but this adds up to a vicious cycle. Increased out of pocket costs drive people to avoid care until their health is really bad, driving higher costs. Higher costs drive plans to increase pressure on physicians. Increased costs to practices cause physicians to pass costs on to patients, increasing the “only go to the doc when it is really bad” behavior.  'Round and 'round we go.

We must break this cycle.

We want to keep and enhance good primary care.  Absent fundamental changes in payment, docs may see administrative fees as their only option, but administrative fees don’t change the underlying broken paradigm.  The docs and patients can't change the system alone - plans and purchasers must align payment and measurement policies with the outcomes we all want.

The game changers:

• Reward outcomes not volume: health care payments AND physician compensation must align with outcomes

• Fund the essential work of high performing primary care: primary care payments are inadequate to the essential work of:
    o 24/7 access – not just to ‘visits’ but all channels of communication
    o Person-focused relationship over time – continuity to a doctor/nurse who knows the patient
    o Comprehensive services – expanded scope of primary care services pegged to the needs of the population they serve
    o Care coordination – eliminate the silos. The primary care practice is responsible for their patients no matter where they are in the larger health system

• Measure what is important, not what is convenient: don't mistake the means with the ends - shift measurment to outcomes and away from process and technology indicators
    o Outcomes are important – risk-adjusted hospitalization rates, ER visit rates, patient experience of care, functional status, total cost of care
    o Use the absolute bare minimum of "means-to-the-ends" indicators when outcomes are impossible to measure due to small denominators.  Enough with the "33 of these and ten of those with 15 out of the 65 of the following.  See the incredibly detailed tables after you pay your substantial fee."  The continual piling on of various measurement indicators is not helpful.

Strong and weak indicators of quality and outcomes: not what you'd expect

The prevailing quality paradigm starts with the simple observation that we can observe gaps in care when we create an evidence based guideline and assess observed care against expected.  One study says that we meet these expectations about 56% of the time.[1]

This observation leads to the seemingly logical conclusion that we can aggregate gaps in care as strong indicator of quality.  This is important as we assume that more of this quality will lead to improved outcomes.  We know from other studies that quality and cost are out of whack in the U.S. and health care costs are sucking the life blood out of employers, further exacerbating dismal job growth.Because we desperately want improved quality, we must have more of this gap closing work.

The prevailing quality paradigm has a number of flaws.  It is expensive, overly focused on process measures, and may not predict the outcomes we want and need.

Expensive

Delivering evidence based care is a good thing, but the burden of managing the vast array of discrete data elements is beyond the capabilities of the vast majority of EMR vendors in spite of their claims to the contrary.  Data entry is laborious and back end analytics infuriatingly complex, weak, or non-existent. Vendors have jumped into the breach to extract information from electronic records and even dictations but these solutions add significant cost that might not be recuperated in outcomes.

Overly focused on process

With years and years of disease management experience we know that process improvement does not always result in outcomes improvement.  In a time of limited resource we should avoid the added cost and work burden of meaningless measurement.

Weakly predictive of outcomes

Making the case is a recent article from Duke.  Boulding and colleagues used Hospital Compare data to analyze thousands of hospitals, looking at predictors of re-admission.  They found evidence-based gap analysis a weak predictor of outcomes (re-admission in this case).  The strongest predictor was the patients report of good communication.[2]

This study adds to the growing literature that is trying to tell us something:  Patients perception and report of their care is tapping very important attributes of quality.  These attributes appear to have strong correlation with important outcomes.

Good patient experience data can inform hospitals about structural weakness in communication that increases readmission risk.  Patient report on primary care key performance indicators (access, person focused care over time, comprehensiveness, care coordination) can identify structural weakness far upstream.  When we address these structural elements we improve population health in meaningful ways.

This is a measurement burden we can bear. This information is a powerful addition to our understanding of quality and outcomes. The health care industry tends to disparage or only provide lip service to patient-reported outcome measures.  We continue to do so at our and our patients' peril.

 

[1] McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., et al. The quality of health care delivered to adults in the United States.  N Eng J  Med, 2003; 348, 2635–2645.

[2] Boulding W, Glickman S, Manary M, Schulman K, Staelin R.  Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days  Am J Manag Care 2011 17(1): 41-48

An Open Letter To Primary Care Physicians | Care And Cost

via careandcost.com

There are two recent posts that deserve a read:

Paul M Fischer and Brian Klepper's Open Letter to PCPs alerts us to the deleterious effects of the RUC - the Resource Utilization Committee of the AMA.  This committee of 29 has a representative from each of the primary care specialties: Family Medicine, Pediatrics, Internal Medicine.  That's about 10% of the voting power.

No shock at all to discover that the RUC recommends payment shifts that reward complex procedures at the expense of the fundamental work of primary care.  What may be a surprise to many is that the Centers for Medicaid and Medicare Services accept about 94% of the RUC recommendations.  Procedures over primary care is one of the main drivers of our incredibly expensive and dysfunctional health system: we have the best rescue system in the world fed by the missed opportunities and failures in early intervention based on a hamstrung and demoralized primary care workforce.

The net effect is that the RUC is the hand on the tiller steering the US health care boat over the precipice.

Read their letter and send it on.  It is time to uncouple payment policy from the destructive recommendations of the RUC.

The second post: How to Fix Primary Care - Step 1 urges primary care to take off the kid gloves and start fighting for what is right.  Dr George A Lundberg calls for putting the RUC recommendations aside (and this from the guy who was the AMA's Editor in Chief for Scientific Information - overseeing JAMA among other things!).

Dr. Lundberg: "No more Dr. Nice Guy PCPs until you do a better job of fixing our broken system."

The bottom line: primary care is the foundation of high performing health systems.  We must push back against the systematic underfunding of our work, the payment and policies that hamstring what our patients need.  We are not an afterthought or a 'loss-leader,' with our work on prevention, early diagnosis and intervention we are the key to achieving high quality lower cost care.

Paging Dr Luddite: health information technology, the hype and the reality

My wife handed me the Atlantic article Paging Dr. Luddite.  I felt like I'd die if I had to read yet another article gushing over the wonders of electronic health records and all they are going to do to save health care. I grit my teeth and read it.

While the title imples that the main obstacle to better health care are those luddite doctors, the article is somewhat better rounded.  Sure, there are Luddite doctors resisting EMR adoption, but the real story is more complex.  Much of the current crop of health information technology falls woefully short of the functionality we need.

Everywhere we turn we're given glimpses of the promised land through the lens of those infatuated with technology:

• No matter where you show up, the health care system will have your totally secure records at hand.
• No more unnecessary or duplicate tests - every part of the system will be working off the same data set.
• Patients will be able to communicate their needs via email, secure messaging, video.
• We'll finally be able to roll out standards so that everyone gets the exactly the care they need.

Puh-leeeze!  Some people been drinking the PR koolaid. Time for a dose of reality:

• Most health information technology solutions do not communicate with other vendor solutions, so the silos are still in effect.
• In spite of their own hype, most elecronic health records are trumped up billing engines (as the Atlantic author correctly pointed out) and do not enable the kinds of chronic disease tracking the health delivery system desperately need to better help their patients (sure, they all say they do, but talk to the dissapointed and frustrated practices desperately trying to get reports out of most of them and you'll hear a very different story).
• The impediment to emailing and other virtual communication with doctors is not the electronics - it is a payment system that will not support this mode of communication.
• Guideline driven standards of care are mostly based on studies of people with single conditions and exclude the majority of people with chronic conditions, leaving open the question of best practice standards for the bulk of people who have more than just one diagnosis or condition.

I spent last week with a rural community health center network.  They are one year into implementing a whiz-bang EMR with a great national reputation. 

I listened with horror but not surprize to the woes of the senior clinical management team as they told me that their new and very expensive EMR forced them to run separate reports (from scratch) for each of their nine clinics, separate reports from scratch for each variation in the drug warfarin (there are many), and how the vendor "help desk" has crashed their system multiple times when they come in to "help."  A recent crash lost an entire week of laboratory data which must now be entered anew.

They are unable to get a clean and accurate list of women who are due for a Pap test.  This is due in part to the arcane and difficult workflow processes embedded in the EMR that makes it difficult to use in real time with patients, and in part due to the fact that (like almost every EMR creator) the makers are clueless about serving the real-world needs of practices that want to better manage population health.

And this is one of the "good" EMRs getting all sorts of accolades from folks in D.C. who think that EMRs are going to revolutionize care.

Electronic records hold immense promise.  We need good technology to help us manage oceans of data and help our patients get the care they want and need.  I want to have one that does the things described in this and all the other articles touting the benefits of technology in health care.  Too bad most of the current crop doesn't deliver on the hype.

Why is it so hard to get primary care practices to change?

There is a good deal of talk about support for primary care.  That support is demonstrated in AHRQ grants targeting interventions that support independent small and medium size practices, in a blizzard of Medical Home initiatives, and more.  There is also a good deal of concern that these initiatives may prove disappointing unless we can overcome the glacial pace of change in primary and fractional improvements observed.

What can we do to accelerate primary care transformation?  Hypotheses abound.  Some point to disappointingly incremental results of the Learning Collaborative model, others to the lack of aligned payment, still others to overly broad 'change package' that fail to promote fundamental changes. 

Many things have to go right if primary care is to make the transition. 

• We need an approach that invites the participation of all kinds of practices.  Participation costs (time away from patients, travel expense, etc) must be set very low if we are going to include the full spectrum of primary care practices including solo and rural.  The Ideal Medical Practices project demonstrated one path with group learning and practice coaching by conference calls plus online resources, all tied together with a simple measurement strategy addressing the fundamental changes required.  Group learning can break out of major urban centers and meet practices closer to home.  Regional learning can be complemented with conference call and online support.
• Assistance must address the heterogeneous nature of practices.  Coaching support, peer mentoring, and improvement pathways can be nuanced to address developmental stage, baseline capacity and infrastructure, variation in population needs.  Using a measurement system based on the fundamental features of high performing primary care can identify practices in need of further assistance.
• Launch projects in supportive environments:  Teaching transformative change without aligned payment is a waste of everybody's time.  At best we can prepare participants for a future when payment will support the work, but the full work of effective primary care is ruinous in our current payment environment.  Payment aligned with the work is necessary but not sufficient: the financial incentives must flow all the way to the front lines of work. If the aligned payment dissapears into health system general funds and has no impact on staffing and support of the work in the primary care office it is a wasted effort.
• Improve the signal to noise ratio of the measurement paradigm: Flying in the face of numerous studies we have adopted a measurement system holding primary care practices accountable for outcomes for which they are sometimes only fractionally responsible.  The primary care team is not responsible for the agriculture bill supporting terrible food choices, nor is it responsible for the epidemic of obesity and our society's willingness to restrict access to health care services based on socioeconomic status.  We play a role but often not the dominant role in a diabetic person's A1c level.  Why should we beat up practices with bad quality scores when the reason the A1c is because patients can no longer afford to take their meds because they've lost their jobs?  We can and should measure practice behaviors that predict good outcome: access, relationship over time, comprehensive services, care coordination (all easily and inexpensively measured through patient experience of care).

Primary care practices want to change.  Our professional ethics are aligned with the work of effective primary care.  Change happens when the forces are aligned with the desired results.

Primary-Care and Specialists Get Their Wires Crossed - and what to do about it

What we’ve got here is a failure to communicate.

via blogs.wsj.com

"Don't you guys talk?"  Well, to be perfectly honest..... not so much, and it costs us all:

• Primary care practices spend a significant part of staff time on tracking down information from emergency departments, hospitals, and specialists, filling out forms that - if approved - would make it possible for the practice to then call to try and arrange a scan, a consultation, etc.
• Specialists are sent the wrong patient for the wrong reasons with the wrong work-up or have no information at all and a patient who has no idea why they are there.
• Patients of course suffer the most. 

A colleague of mine surveyed a high-functioning group of individuals (readers of a reputable online news service). Some of these people reported that they were receiving care from their PCP and a specialist. 

Asked "Do you know who is in charge?", 25% said "No."  Those 25% were twice as likely to report having been hospitalized within the past year.

This striking correlation has a number of possible explanations.  One possible explanation is that we in the health care system are operating in silos and are put the people we serve at risk when we fail to communicate well across those silos.  This explanation has some face validity since poor communication and lack of coordination is a near-universal experience.

What can we do about this?

1. Require seamless communication across health information technology platforms.  The rules we have in place are either inadequate or inadequately enforced.  Right now we have lip service commitment to cross-platform communication but systems almost never communicate well and the cost of bridging the gaps is completely out of reach of the average practice.
2. Require insurers to pay for care coordination by primary care.  The evidence supporting good care coordination abounds yet practices receive only lip service - requests to do more without the means to do the work.  Primary care is the weakest part of our health care system because we have systematically starved it beyond its ability to perform the basic functions of primary care.  "Help" that stipulates "do this extra work and we'll consider maybe paying you in the future if you get those pigs to fly" is a non-starter.
3. Make 'patient experience of care coordination' a core quality metric.  We over-emphasize relative trivia while mostly ignoring the core functions of primary care.  This distracts the national conversation, the work of practice transformation, and new payment models with lower impact work while fundamental benefits to the public are ignored. We don't have to give up measuring 'the percent of diabetics who have had monofilament foot exams', but we should focus first on a core set of primary care measures addressing the core features of primary care:  access, relationship over time, comprehensive services, and care coordination.

Transforming our health care system so that we may achieve better outcomes at lower per capita costs will take monumental effort.  That effort should focus first on the most important aspects of our current failures - the ones that have the greatest possible benefit for the widest number of people.

Supporting primary care transformation does just that - but only if the transformation addresses the fundamental attributes of primary care.

Physician Groups Use of Data from Patient Experience Surveys

Patient reported experience of care can be accurately measured and can identify important aspects of practice performance.(1)  Patients who report good experience with key attributes are more likely to have good outcomes and cost the health system less.(2)  Key attributes include: good access to care, good communication, support for self-management, good continuity, care coordination.

I love that we're seeing patient experience in more publications but I'm a bit perplexed by this article:

M. W. Friedberg, G. K. SteelFisher, M. Karp et al., "Physician Groups' Use of Data from Patient Experience Surveys," Journal of General Internal Medicine, published online Dec. 17, 2010.

It is an interesting observational study looking at how physician groups in Massachusetts used patient experience data to inform quality improvement.

The study tells us that financial incentives for patient experience measures predicts work on patient experience.  No surprise, but it is good to confirm widely held belief in studies.

The summarizing conclusion seems to be a circular arguement.  Here's the statement:

Groups with more integrated organizational models were especially likely to engage in group-wide improvement efforts, and all groups facing financial incentives based on patient experience reported improvement efforts of some kind.

Here's the authors' definition of integrated organizational models:

For this study, integrated medical groups were defined as those in which most decisions about policies, staffing, and resources were made by a group manager or management team.

So the authors have concluded that group wide activity is predicted by having an organization with a group leader.

Should we push independent or loosely affiliated groups into 'integrated' groups with central control?  I don't think we can make the call based on this study.  Community Care of North Carolina succeeds in improved population outcomes without resorting to centralized practice administration.

We mustn't mistake the means with the end.  The goal is improved outcomes and bending the cost curve, it is not 'centralized administration of practices' unless and until we have definitive studies linking centralized administration with improved outcomes.

(1) Safran DG. Defining the future of primary care: what can we learn from patients? Ann Intern Med. 2003;138:248–55.

(2) Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, July-September 2006 29(3), 199–206.

Building a high performing medical neighborhood - better care, better outcomes

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