Using information technology to align physicians and hospitals.

IN THE FEATURE ARTICLES, Cohn, Friedman, and Allyn and Petasnick adeptly point out the changing landscape of healthcare delivery and the corresponding flux of reimbursement dynamics. These forces have, in turn, often put physicians and hospital at odds. Today's climate is of course a result of healthcare strategy starts and stops over the past 30 years or so. One of the more salient points that Cohn and colleagues make in this regard is when they reference payers moving decision making away from providers to third-party intermediaries in the 1990s. STRAINED RELATIONSHIPS This shift of control, which actually started in the mid-igSos with the movement to managed care, began the disenfranchisement and dissatisfaction of so many physicians. Under managed care, healthcare became a commodity. Free (or $5 copay) visits caused patients to devalue healthcare. The change in control not only saw the increased role of insurers, but also a fundamental shift in doctor-patient relationships. In physician lounges, talk was of studies showing patients were willing to sacrifice long-term relationships with their primary care providers to save $5 in copays. This notion was incredible to many physicians; many could not believe that relationships could be severed for so little. I believe that patients' willingness to abandon these relationships resulted from a creeping mistrust that started with managed care. The term "gatekeeper" suggested to patients that physicians were withholding treatment for their own financial gain. The term implied that the healthcare system was out of control because of physician greed. Unfortunately, recent surveys still suggest that one of the main reasons people believe the healthcare system is broken is because of physician greed (Healthcare Financial Management 2007; USA Today/Kaiser 2005). The managed care reimbursement paradigm served to create a chasm between patients and physicians, and this divide is still fractionating providers and physicians today. Physicians are not blameless in all of this. Managed care, after all, was a reaction to the abusive days of fee for service. These two reimbursement systems collide today in the hospital. Hospitals are paid based on diagnosis-related groups (DRGs) while physicians are now usually paid per hospital visit. This reimbursement misalignment creates a divide and mistrust between physicians and hospitals. Physicians accuse hospitals of withholding care or endangering lives because of their payment paradigms, whereas hospitals are frustrated by physicians' seemingly carefree attitudes regarding timetables around discharge. Petasnick's article asserts that tensions between hospitals and physicians have been long standing. I believe these tensions are a more recent phenomenon based on the above. Certainly, the intensity of this tension is more of a latter-day occurrence. Physicians have seen their reimbursements remain flat and their incomes decline while well-managed hospitals have thrived. As Petasnick points out, the growing and recent complexity of economic, legal, and care-delivery machinations have made the old model of governance by the organized medical staff structure obsolete. This complexity also necessitates the justified generous reimbursement of successful hospital administrators. Physicians, however, become bitter when asked to "volunteer" time to help an administrator who is making multiples of their salaries. This rift has occurred between parties who should be partners in care delivery because of payment paradigms and misalignments. PAY FOR PERFORMANCE Pay for performance along with transparency is the most important opportunity borne out of the changes suggested by Cohn, Friedman, and Allyn and Petasnick. Patient-Centered Care Many of the changes that Cohn and colleagues point out in the marketplace are driven by a desire to move the patient to center of the care delivery system. …