Health Insurance Hospitals Physician Compensation Supply of Medical Services

Fragmented Medical Care II: The Models

Yesterday I wrote about the problems with fragmented medical care in America.  Is a single payer system the only solution?  A Commonwealth Fund report shows that the single payer system is not the only path towards improved, more integrated care.

What we want

The report outlines six general improvements that need to be made to improve the quality of care in the U.S.:

  1. Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems.
  2. Patient care is coordinated among multiple providers, and transitions across care settings are actively managed.
  3. Providers both within and across settings have accountability to each other, review each other’s work, and collaborate to reliably deliver high-quality, high-value care.
  4. Patients have easy access to appropriate care and information, including after hours.
  5. There is clear accountability for the total care of patients.
  6. The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery.

These are high ideals that need to be translated into specific action-items for providers.  However, a variety of different organizational structures have been able to accomplish each of these six goals.


There are four general types of structures and all can be successful in delivering high quality care.

  • Integrated delivery systems such as Kaiser Permanente and Geisinger Health System.
  • Large multi-speciality groups such as the Mayo Clinic and Partners Healthcare.  Both groups are nonprofits.  While the Mayo Clinic directly employs doctors on a salaried basis, Partners contracts with over 1000 PCPs and 3500 specialists to provide high quality care to patients.
  • Private networks of independent providers, such as Hill Physicians Medical Group and Northland Health Alliance, generally receive a capiation payment from insurers for each practice but doctors are compensated on a FFS basis.  This is similar to RVU compenation.
  • Government-facilitated networks of independent providers.  Here, the government does not directly provide care, but instead coordinates care between providers.  This has worked will for Medicaid patients in North Carolina. Denmark’s universal health care system coordinates physicians, who are paid via fee-for-service plus a fee for serving as the patients medical home.  Ninety-eight percent of physicians have paperless offices, prescriptions and lab tests.

Shih et al. (2008) “Organizing the U.S. Health Care Delivery System for High Performance“, Commonwealth Fund Report  no. 1155.