Author: Richard Saver


Will Physicians and Hospitals Ever Get Along? Prospects for Defragmentation in a Post Health Care Reform World

Elizabeth Weeks’ earlier post considers  how payment systems serve as a source of fragmentation, discussing the excellent example of how under Medicare reimbursement rules  physicians and other outpatient providers have little incentive to coordinate care with and consider the costs faced by hospitals.  Indeed, the misalignment between hospitals and physicians runs across many of the book chapters.   This is not surprising as the modern hospital is the epitome of fragmentation problems.  For example, Einer Elhauge (Introduction) notes how hospital-based services evidence team production problems. David Hyman (Chapter 2) observes that under the current reimbursement rules “providing integrated care doesn’t pay better than fragmented care – and in some instances, it pays worse.” Kristin Madison (chapter 5) discusses regulatory contributors to hospital-physician fragmentation, such as the corporate practice of medicine prohibition and health care fraud and abuse laws that may, counterproductively, impede even beneficial integration efforts. James Blumstein (Chapter 7) and Alain Enthoven (Chapter 4) call for greater regulatory flexibility to support integrated delivery systems. Also, Frank Pasquale (Chapter 11) thoughtfully discusses the hospital-physician battles over physician-led specialty hospitals.  A common theme is that at many medical centers physicians and hospital management work disconnected from each other or have relationships strained and full of discord.

The interesting question moving forward is whether health care reform will respond to these concerns and collapse the hospital-physician divide, a goal that has eluded reform attempts in the past? I’m hoping for the best but remain somewhat dubious.

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Where’s the Public Health?

Greetings. Thanks first to Frank Pasquale and Glenn Cohen for extending the invitation to comment on this terrific, provocative book and the important issue of fragmentation in the health care system. I enjoyed the book a great deal. The impressive list of contributors make a compelling case of how fragmentation runs across and unduly complicates many dimensions of the health care system. As a descriptive project alone, the book is immensely useful to scholars and policy-makers. It produces extensive evidence of fragmentation, demonstrating how lack of integration, misaligned incentives, too many decision-makers, unclear obligations and responsibilities of multiple actors in a complicated system, etc. generally result in underpowered, less effective medical care.

Because the book does such a great job of documenting and providing a typology of fragmentation problems and possible causes, I am hesitant to quibble about things that might have also been included but were not. Nonetheless, here is my quibble: where’s the public health?

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