I recently wrote about how P4P is very unlikely to work based on the way that patients run their lives and see various doctors. Exercising their freedom to choose whatever physician they want, patients may see numerous physicians within a year making it, in many instances, impossible to administratively "assign" a given doctor to a given patient.
The American College of Physicians (ACP) has proposed what they call The Medical Home and suggested that physicians be paid on the basis of a defined bundle of services and provide "patient centered care" through a "qualified medical home" in which a physician accepts overall responsibility for the care of the patient and leads a team that will provide integrated,comprehensive care.
If Mr Jones sees Dr. White, a primary care physician who recommends a treatment plan according to the very latest ADA guidelines, and then decides to see instead Dr.Black who recommends something else, who is "responsible" for his care ? What is Dr. White to do when Jones does not return for his 4 week followup,what does he do if Mr.Jones decided not to get his colonoscopy according to the latest American Cancer Society, or his eye exam according to ADA guidelines, or did not return for his flu shot which was recommended, etc etc. If later Mr. Jones injured his knee while bowling and went to see an orthopedist that his brother had recommended without letting Dr. White integrate his care and an "unnecessary" ( by some Ottawa decision rule or whatever) MRI and then arthroscopy were done, will Dr. White be responsible for misuse of "scarce medical resources"?
Here's the thing. As long as people are free to see whatever doctor or doctors they want and are free to conform with or ignore medical advice and take medicine or not the, ACP's suggested medical home ( and as mentioned before, P4P) will not work. If it could work without coercion, I would like to hear how. Does it make any sense outside of a single-payer-single tier system? Maybe that is what ACP wants.
Maybe Mr. Jones would have to sign a contract to adhere to the doc's plan or maybe there will come a time when a entity (government or a government sanctioned insurance agency) will assign Mr.Jones to a primary care doctor and permission wil have to be obtained to change doctors.