Friday, February 11, 2011

The Reform Mindset and The Many Faces of Health Care "Fragmentation"

To hear health care critics speak, you would think America’s health care’s dysfunction stems mainly from “fragmentation” of the system.

“Fragmentation,” in critics’ minds, means:

• Too many specialists are doing too many things without knowing what other doctors are doing, causing duplication, waste, and errors in the process.

• Too many patients are seeing too many specialists without going through a single primary care practitioner coordinating care in a medical home.

• Too many people, patients and doctors alike, are making too many uninformed choices.

This fragmentation, say critics, is too inexpensive, and the end, too unsustainable. The answer, says Jim McDermott, MD (Democrat, Washington State), a member of the House of Representatives, is straightforward.

“Sustainability requires that all patients in system receive the right care, in the right place, at in the right time, in the most effective manner possible. It therefore demands a robust primary care workforce that encourages coordination throughout the health care spectrum and provides accountability.”

But what is the right care, the right time, the right place, and the most effective care? And what does accountability mean?

How does one achieve these noble ends?

By ending fragmentation, of course. And how does one end fragmentation?

• Offering incentives to medical students to become primary care practitioners (though this will take a decade to significantly impact the physician shortage).

• Coordinating the system through a centralized government system(though Americans resist, fearing this smacks of government “overreach”).

• Organizing doctors and hospitals into accountable care organizations with fixed budgets (though doctors oppose this approach by 2:1).

• Channeling patients through primary care-directed medical homes (though these homes will take years to develop).

• Connecting patients, consumers, doctors, hospitals, and other health care facilities with a common computer system that shares real-time information ( though this has been painfully slow to gain enough critical mass to be effective and threatens privacy).

• Re-directing care by paying-for-performance based on outcomes, rewarding doctors on salary who comply with “best practice” guidelines, protocols, checklists, and federal standards and regulations (though many in “center-right” American say this smacks of bureaucracy, rationing, and “socialized medicine”).

These massive restructuring moves will take time, and in the meantime (from now to 2014), too many costs will rise too rapidly, too many people will lose their current plans because the plans don’t meet government standards, too many employers will drop employees’ and retirees’ health plans with expectations of shifting them to Medicaid or other plans with government subsidies,and too many of Obama's favorite supporters will be waivered out of the system to spare them the expense and rigors of the health reform law.

No one ever claimed redesigning 1/6 of the nation’s economy will be easy. Anyway, thinking ‘big” politically puts you on the right side of history. One giant leap for humankind, cascading down from the top, beats a series of smaller steps, bubbling up from the bottom - health care tax credits for all, shopping across state lines, a federal health employee-type health plan for everyone, tort reform, deregulation to unleash innovation and market forces, health savings accounts, states developing their own health plans.

Unfortunately, one man’s mindset is another man’s hindset.

Richard L. Reece, MD, blogs a Medinnovation and has a website under constuction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with but does not speak for The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at


HaynesBE said...

Fragmentation can also mean "decentralized" or "customized to the individual."
Proponents of the new law don't like either of those.

Richard L. Reece, MD said...

Beth: You are right, of course, and the "experts" seem to forget this fundamentally important element, which may constitute the lasting importance of the Internet.