Building the Best Team

The executives of a major medical center meet with the physician leadership to discuss the formation of their new physician hospital organization (PHO). The Vice President for Managed Care explains that a PHO is a necessary vehicle for entering into at-risk capitated contracts with local managed care organizations and employers, but then he adds that the current mix of primary care providers and specialists on the staff is ill-suited to capitated contracts. “Look,” he says, “it's as if we have a sports team made up only of guys with big salaries and narrow talents and there's a new league limit on team salaries. Our medical ‘team’ is keeping our costs too high for us to be competitive. We need to build a team of versatile players-we'll need fewer of them, we can pay them less, and we'll be able to respond more flexibly to changing situations.” The uncomfortable silence is broken when the Dean asks, “But can a team like that win?”

The economic forces brought to bear in the health care marketplace by the recent growth in managed care have led to intense pressure on provider organizations to shift away from the current, prevalent pattern of specialist-based care [1] to one in which generalists provide longitudinal primary care and act as “gatekeepers” for access to specialty services [2]. Such a strategy, based almost entirely on the poorly documented notion that generalist-directed care is less costly than specialist-based care, has profound implications for government policies aimed at affecting physician …