This issue of the journal, broadly speaking, focuses on 2 trends in ambulatory services-payment and access to information. The journal has published extensively on the 2 types of healthcare encounters that occur in the outpatient setting: visits and episodes of illness. This issue of the journal presents 3 articles on a new classification system for ambulatory visits and its implication for many aspects of payment reform. In particular, after introducing the topic of payment for ambulatory visits and then discussing implementation in a prospective manner in Maryland, the third article focuses on the crisis in access/payment for primary care physicians (PCPs). This article uses both an outpatient visit-based methodology and one that examines episodes to propose a new means of paying PCPs that will result in significantly higher payment for PCPs while measurably increasing quality. In particular, this new approach to payment encourages the "medical home" concept that many physician organizations are encouraging as a means to improve coordination of care for the entire PCP panel of patients. I am in the process of soliciting comments and alternative approaches to paying PCPs, a key policy dilemma confronting us today. Medpac is the arm of Congress that provides significant input into health policy in general and Centers for Medicare & Medicaid Services (CMS) policy in specific. The next article provides an excellent summary of the current CMS payment system for hospital outpatient services.
In a brief commentary, John H. Wasson, an associate editor of the journal, pointedly asks whether we should be paying for fragmented care. He provides supporting data that indicate patient perceptions on this critical question. The next article continues this exploration of healthcare encounters with an article by Davidson and colleagues on a new approach to measuring episodes of illness.
Access to information and the cost of obtaining information is the theme of the next set of articles in this issue. Apolone invokes the hoary ghost of Marx and uses his insights to begin to understand the reasons for availability (or lack thereof) of information pertaining to healthcare, in this case, focusing on the pharmaceutical industry. In the first of 3 responses, Reinhardt clearly expresses his background in political economy and provides an important perspective, emphasizing the economic barriers to information. From my perspective (maybe reflecting the fact that I did graduate work in history, not economics, before finishing my medical degree), there are many sociologic barriers to complete information in healthcare. Not the least of these barriers is the interesting melding of economic interests emanating from pharmaceutical companies (who want to bring to market medications that may not want to finish a complete trial) and consumers (many of whom are desperate to try medications whose benefits are limited to a few weeks of additional potentially low quality life expectancy). Cesario and Aaronson continue with other commentaries on Apolone's argument. Apolone will continue the discussion with a response in the next issue. Transparency is an often-used term. This set of articles demonstrates some of the inherent challenges in truly implementing the term in healthcare settings.
The next 2 articles focus on organizational and measurement aspects of quality improvement. In an ideal world, the two should be correlated.
Lastly, we continue with our regular Trot Line and Physicians for Human Rights columns.
Norbert Goldfield, MD
Editor