The Un-managed System of Medicare Referrals
Since the passage of the Affordable Care Act two years ago, patient centered medical homes (PCMH) and accountable care organizations (ACO) have emerged as leading models to address our fragmented, high cost health care system.1 The Center for Medicare and Medicaid Innovation (CMMI) has been allocated $10 billion over a decade to test and spread these and other new models of care and payment, with the aim of providing better health for individuals and populations at lower cost.
Last December, CMMI chose 32 organizations across the country to participate in its “Pioneer ACO” program. These ACOs are defined as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve.”2 If the ACOs provide care for their patients at a lower cost than would otherwise be predicted, they share in the cost savings; if their costs are higher than predicted, they share the losses.
Notable elements of the ...
- Rittenhouse DR, Shortell SM, Fisher ES. Primary care and accountable care -- two essential elements of delivery-system reform. N Engl J Med. 2009;361:2301–2303.
- Centers for Medicare & Medicaid Services. Pioneer Accountable Care Organization (ACO) Model Program Frequently Asked Questions. Available at: http://innovations.cms.gov/documents/pdf/PioneerACO-external_FAQs_FINAL_12_20_11.pdf. Accessed January 9, 2012.
- Shea D, Stuart B, Vasey J, Nag S. Medicare physician referral patterns. Health Serv Res. 1999;34(1 Pt 2):331–348.
- Xakellis GC. Are patients who use a generalist physician healthier than those who seek specialty care directly? Fam Med. 2005;37(10):719–726.
- Pham HH, O'Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians' links to other physicians through Medicare patients: the scope of care coordination. Ann Intern Med. 2009;150(4):236–242.
- Barnett ML, Keating NL, Christakis NA, O'Malley AJ, Landon BE. Reasons for choice of referral physician among primary care and specialist physicians. J Gen Intern Med. 2011; doi:10.1007/s11606-011-1861-z.
- Forrest CB, Reid RJ. Passing the baton: HMOs' influence on referrals to specialty care. Health Aff (Millwood). 1997;16(6):157–162. CrossRef
- Laine C. Welcome to the patient-centered medical neighborhood. Ann Intern Med. 2011;154(1):60.
- Schoen C, Osborn R, Huynh PT, Doty M, Davis K, Zapert K, et al. Primary care and health system performance: adults' experiences in five countries. Health Aff (Millwood). 2004 Jul-Dec; Suppl Web Exclusives:W4-487-503.
- Ireson CL, Slavova S, Steltenkamp CL, Scutchfield FD. Bridging the care continuum: patient information needs for specialist referrals. BMC Health Serv Res. 2009;9:163. CrossRef
- Pham HH, Ginsburg PB, McKenzie K, Milstein A. Redesigning care delivery in response to a high-performance network: the Virginia Mason Medical Center. Health Aff (Millwood). 2007;26(4):w532–w544. CrossRef
- Einbinder JS, Klein DA, Safran CS. Making effective referrals: a knowledge-management approach. Proc AMIA Annu Fall Symp. 1997;330–4.
- The Un-managed System of Medicare Referrals
Journal of General Internal Medicine
Volume 27, Issue 5 , pp 487-489
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- Author Affiliations
- 1. Division of General Internal Medicine, Department of Medicine & Center for Innovation in Access and Quality, University of California, San Francisco at San Francisco General Hospital, Box 1364, San Francisco, CA, 94143-1364, USA
- 2. Department of Family and Community Medicine & Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA