1. Wasson, John H. MD

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IF you do not know who is in charge, whom do you hold accountable? That is the question raised in a recent article and the accompanying editorial about the adverse effects of fragmented care (Davis, 2007; Pham et al., 2007). But neither the article nor the editorial explicitly considers the patient perspective.


At the same time these articles about fragmented care appeared, a national business newspaper in a front-page story suggested that its Web subscribers complete a health assessment (Naik, 2007). Of the 600 affluent respondents aged 18-69, a quarter with no chronic disease and more than 50% with 2 or more common chronic diseases reported that they were receiving care from 2 or more physicians. When 2 or more physicians were involved in their care about a quarter of these well-heeled subscribers were not sure which doctor was in charge. The associated impacts of not knowing versus knowing who was in charge are shown in Table 1.

Table 1 - Click to enlarge in new windowTABLE 1. When well-heeled patients are asked, "Is one doctor in charge of your care?"

All differences are significant at P < .01 after adjustment for age, gender, and number of diseases. None of these respondents have insufficient money to buy the things they need versus 20% of respondents to the same health survey nationwide (Wasson et al., 2006).


Asking patients a question about fragmented care is more "patient-centered" and arguable as accurate and efficient as trying to attribute accountability for care using retrospective administrative data.


Among industrialized nations, the United States is unique in promoting and paying for fragmented care (Starfield et al., 2005). When they have more than 1 doctor, even our well-to-do citizens often do not know who is in charge. Don't we as a nation need to ask whether a patient does not know who is in charge, why should there be any payment at all?




Davis, K. (2007). Paying for care episodes and care coordination. The New England Journal of Medicine, 356, 1166-1167. [Context Link]


Naik, G. (2007, February 23). Micro management: Faltering family MDs get technology lifeline. Wall Street Journal, p. 1. [Context Link]


Pham, H., Schrag, D., OMalley, A. S., Wu, B., & Bach, P. B. (2007). Care patterns in Medicare and their implications for pay for performance. The New England Journal of Medicine, 356, 1130-1139. [Context Link]


Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. Milbank Quarterly, 83, 457-502. [Context Link]


Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & Mackenzie, T. A. (2006). Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, 29(3), 199-206. [Context Link]