Physicians as Double Agents: Title and subTitle BreakMaintaining Trust in an Era of Multiple Accountabilities

HISTORICALLY, a physician's primary, and arguably exclusive, responsibility has been to his or her patients. The Oath of Hippocrates taken by physicians across the nation calls for a physician to practice medicine and prescribe treatment for "the benefit of his or her patients and abstain from whatever is deleterious and mischievous." More modern versions of this oath include references to purity of purpose and holiness of life, directing "every word and deed . . . solely to the welfare of these patients." Although some may argue that this oath is anachronistic and in need of revision, a physician's dedication to serving the needs of his or her patients has remained the "immutable bedrock of medical ethics."¹

Many view managed care organizations as a direct threat to a physician's ability to fulfill the Hippocratic oath. Critics argue that managed care organizations, through their arsenal of cost-control mechanisms (eg, gag clauses, guidelines, formularies, profiling, financial incentives), force physicians to consider not only the needs of the patient but also those of the organization and the physician's own financial interest. The latter motive was, of course, also prevalent in fee-for-service payment, often to the financial detriment of the patient or his or her insurer. Crawshaw et al² eloquently argue for a return to a trust-based relationship between physician and patient: "Medicine is, at its center, a moral enterprise grounded in a covenant of trust. This covenant obliges physicians to . . . use their competence in the patient's best interest." This call to medicine's moral grounding notwithstanding, the United States appears inexorably headed toward more managed care and not a return to the earlier days of "unincorporated medicine."³ It is, therefore, important to consider how this trust can be established in the framework of the existing (and developing) institutional structure.^{4 - 6}

This article is based on a study examining the challenges facing physicians and physician organizations today, focusing heavily on the pressures created by managed care. The first section of the article outlines the methods used in the study. We then examine the current institutional structure of the delivery of health care, highlighting the conflicts faced by physicians as "double agents" who must serve the interests of both patients and health care corporations. The next section introduces the concept of robust properties and identifies and defines a set of 5 such properties that hold promise for resolving the double agent conundrum. Concluding sections highlight the challenges to the profession and the role of the 5 robust properties in constructing a new moral fabric for physicians in the managed care era.

An extensive literature search dating back to 1987 was used to identify key issues facing physicians and physician organizations. Locator terms included physician manpower, physician organization, managed care, primary care, and quality of care. More than 100 articles were reviewed and specific content areas identified with regard to physician group practice formation; management and governance of physician organizations; physician compensation, incentives, and productivity; contracting activities; care management; and accountability. These content areas were used to develop a semistructured questionnaire for in-depth telephone and in-person interviews with 15 national leaders from a number of health care sectors. These individuals were intentionally selected for their national visibility and influence. They ranged from chief executive officers of large health care systems, physician group practices, and physician practice management companies to academicians with extensive expertise in the areas of health care delivery and physician behavior. Each person was mailed a 13-page, 22-item questionnaire for review prior to a telephone interview. The interviews lasted approximately 1.5 hours. The information was summarized and fed back to each informant for review and additional comment. Three study team members coded the final set of comments into the 5 content areas discussed herein. There was near unanimous agreement in the grouping of responses by content area, with the few differences resolved through joint discussion.

Patients traditionally have trusted their physicians to act in their best interests in all matters pertaining to health and well-being. This fiduciary, or trust, relationship arises from the relative disparity in medical knowledge between the parties and the psychological vulnerability of patients concerned about their illness or health status. Although this relative disparity has been changing in recent years, the continuing differences in information and knowledge and the psychological dependency of being in a state of illness or potential state of illness still forms the core of the long-standing physician-patient relationship.

For a member of a healing profession, one powerful motivation for entering into the relationship has always been the betterment of the patient. But there have also been other factors, principally the financial reward.⁷ Thus, when providing services, the physician would consider both the potential benefit of the service to the patient and the benefit to the physician. To the extent that the physician believed that more is better or that any possible benefit to the patient should be made available, the financial incentive and the betterment of the patient were well aligned. Moreover, to the degree that the patient was not paying for services directly but was covered through insurance, there was little conflict between the physician's different motivations.

Managed care both modifies the traditional relationship and introduces a second relationship into the equation, that of the physician and the managed care organization to which the physician is also accountable. Physicians still retain their financial motivation, but now with modified incentives. That is, financial incentives for the physician are no longer clearly aligned with providing services, but may turn on holding services to some minimum level. Moreover, the physician must now consider both the needs of the individual patient and the needs of the managed care organization, including all of its members, when making treatment decisions. As Fleck and Squier⁸ cogently state, "A physician in a managed care organization cannot be an unrestricted advocate of each patient's best interest. That is, a physician's advocacy can never ignore the needs of the rest of the managed care organization's members." Pellegrino¹ refers to this obligation as an "ethic of distributive justice," calling for a fuller development of this concept, especially as it relates to physicians operating in a managed care environment.

The concept of distributive justice is not a new one from a societal perspective; policymakers have long struggled with the fact that funding expensive and possibly experimental medical technologies may mean that there is not enough money to pay for basic, primary care for all members of society. Physicians, however, have been relatively isolated from the examination of this trade-off, being asked to be an individual patient advocate rather than a social planner. Under capitation and related forms of managed care, physicians are asked to consider the incremental benefit of a treatment to their specific, identified patient (the one with whom they have established a physician-patient relationship), not some abstract member of a population or group. They are expected to weigh that benefit against the incremental cost of that treatment to the patient and the managed care organization when making decisions. While fee-for-service (FFS) medicine encourages the physician to continue providing services until the incremental benefit is equal to the patient's cost (which is often as low as zero after meeting deductibles), capitated payment provides incentives for a physician to use fewer resources in patient treatment. Capitation forces the physician to pay attention to the denominator of all enrollees in the plan (or those on the physician's panel) and not just the numerator of the individual patient receiving treatment. Perhaps all too often made to feel like a real estate agent who represents both the buyer and seller of a house or a spy who is also a counterspy for another government, the physician becomes a double agent representing both the interests of the patient at hand and those of the organization and all enrollees. The incentive to use fewer resources is further reinforced by the physician's own economic incentive, which is that fewer services (not more services, as in FFS) result in more income. Thus, the physician's financial motivation now is more closely aligned with the new institutional relationship than with the individual physician-patient relationship. This change in focus introduces considerable complexity and potential conflict of interest into the physician's decision-making process. The new financial arrangement may not only result in less income for the physician, it may expose the physician to considerable financial risk at the group or organizational level as well.

Insurance companies have long understood the concept of pooling risk by putting together relatively large groups of insured clients with varying risks of adverse events. Physicians (or even many physician organizations) who assume the risk of caring for a substantially smaller number of enrollees do not necessarily have the means to manage the risk with which they are faced. That is, physicians are expected to understand the outcomes and trade-offs associated with different approaches to treating their patients, their own ability to deal with and absorb financial risk, and methods for minimizing or pooling risk. Information—good and timely data and a reasoned basis for using that information—is the key to managing the risk facing physicians. Yet, without detailed information concerning the patients in their care, the economic risks that they represent, and the impact of potential treatments, the ability of physicians to deal with risk is severely compromised. Beyond the complexity of the economic incentives, however, the high degree of uncertainty and ambiguity concerning the efficacy of many medical interventions further complicates the individual physician's ability to decide what is best for the patient and what is best for the organization. Similar limitations apply on the patient's side of the equation. Sharing information on the pros and cons of alternative treatments in terms that patients understand is the key to establishing and maintaining trust between the physician and the patient.^{9 - 11}

A third limitation on the traditional relationship is the growing instability of patient-physician relationships. In the perhaps mythical Marcus Welby days of medicine, patients established lifetime relationships with their physicians and placed absolute trust in that relationship. In turn, the physician was able to consider both the short- and long-term needs of the patient when making treatment decisions, knowing that a satisfied and well-cared-for patient was likely to remain for a lifetime. Whether this paradigm was ever the dominant reality, it clearly is no longer operative in the current and emerging marketplace. People are geographically mobile, changing jobs and health insurance and health care practitioners with relative frequency. Even people staying in one location and one job may see their health care coverage arrangements and practitioner options change with regularity. Mobility and change make it difficult for physicians and other health care practitioners to establish the long-term, personal relationships with their patients that characterized the prototypical simple trust underlying the earlier paradigm.

The dissolution of the prior trust-based relationship is becoming increasingly clear as concern grows regarding the potential for managed care arrangements to undermine the public's confidence that one's physician will work in his or her best interests.⁶ This has led to both regulatory and voluntary measures to guard against abuses and protect patient well-being. Regulatory initiatives include the Health Care Financing Administration's efforts to implement requirements with respect to physician incentive plans¹² and the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry with its proposed patient bill of rights and responsibilities.¹³ It has also led to voluntary quality assessment efforts, particularly the National Committee for Quality Assurance's Health Employer Data Information Set and report cards, efforts of the Foundation for Accountability to promote measures of quality, and new initiatives by the Joint Commission on Accreditation of Healthcare Organizations and those of business coalitions. Although sorting out what each of these efforts is seeking to accomplish is a task far beyond the scope of this article, it is clear that the public is seeking accountability from its health care practitioners. This movement for new accountability is complemented by a growing body of consumer-accessible health care information.

As managed care developed, the earliest efforts in holding physicians accountable focused on financial performance measures (eg, number and cost of referrals or inpatient admissions). This focus was probably the result of who was seeking the accountability (managed care organizations) and the data they had to work with (administrative data). Most of the efforts listed in the previous paragraph involve new measures of accountability and associated information technologies that are far more clinically and patient oriented (eg, satisfaction with care, quality of care, outcomes of care). Collecting, analyzing, and using these data require more sophistication and effort but have the potential to provide information that is far more meaningful to both patients and physicians.

Interviews with the 15 national leaders and the review of the literature identified 5 areas in which efforts would be required to develop a workable system of shared accountability based on mutual learning between physicians and the various groups to which they are accountable. These include (1) practicing population-based medicine based on assessing community health needs, (2) aligning financial incentives with system and population goals, (3) enhancing financial and clinical management and governance of physician groups, (4) developing and implementing new care management practices, and (5) implementing an outcomes management reporting system.

These requirements may be viewed as robust properties. Robust properties are approaches (ie, practices, policies, and strategies) of an organization that are likely to be useful in meeting the organization's goals regardless of the specific direction taken by future economic, legal, or political changes in the environment. Within health care, these are approaches that would serve the broad goals of professional organizations even as specific markets, financial arrangements, and health policies continue to change. Successful implementation of these approaches is likely to result in more judicious handling of the tensions inherent in balancing physician relationships with patients and managed care organizations and the physicians' own self-interest. They are also the mechanisms needed to provide the data to organizations demanding accountability based on evidence. Each of the robust properties we identified is discussed in turn.

One characteristic of the new accountability is the pressure for it to take into account not only the physician's role as double agent but also the needs of the community at large. As more medical problems have their etiological roots in the community (eg, domestic violence, unsafe sexual practices, substance abuse), managed care may create both pressures and incentives to deal with these issues, at least with respect to one's own enrolled population. Although individual physicians may not be held personally accountable for the health of the community, the managed care organization of which they are a part has a growing economic interest in such involvement. And although physicians and health care organizations may not have the expertise and experience to deal with many of these underlying causes, they may feel the responsibility to work with others on these issues.¹⁴

To be accountable for groups and populations of enrolled or managed care lives requires an expansion of the physician's role from the treatment of individual patients to concern about the health of the larger group or population.¹⁵ This will, of course, vary by the size of the group, the size of the enrollment base, and the degree of financial risk borne by the group and by the individual physician. Nonetheless, the fundamental fact remains that physicians—rightly or wrongly—will be balancing the immediate interests of their patients against the potential future needs of other enrollees and the attendant financial risk to the physician. One approach to minimizing this conflict that emerged from our interviews would be for physicians to take broader responsibility for the health of their population of enrollees. This will require identification of underlying community health problems such as substance abuse, violence, teenage pregnancy, and voluntary injuries, which, if not prevented, lead to increased use of the medical care system and increased financial burden for physicians. Thus, the incentive is to intervene as early as possible in the underlying causes of these problems. This will require working with schools, religious organizations, health departments, social welfare agencies, business and community organizations, and others with the required expertise, resources, and commitment to deal with these challenges.

Most physicians have neither the expertise nor the time to deal with these relationships. One strategy, therefore, is for selected physician leaders and health care executives and staff to develop such relationships on behalf of all physicians in the group. This will require an ability to forge community health care partnerships, set priorities, and mobilize resources to implement targeted interventions. Evidence from emerging relationships across the country^{16 - 17} suggests that this will engage physician groups in an ongoing dialogue with the community resulting in mutual learning and representing a new form of accountability. By working to eliminate health threats and destructive behavior early on, physicians reduce the number of times or situations in which they may have to choose between the health needs of an individual patient and those of the population at large. It is a win-win situation that helps to avoid part of the dilemma posed by the potentially conflicting agency relationships.

To succeed, community interventions must be carefully targeted to areas where positive outcomes can be achieved, such as teenage pregnancy reduction,¹⁸ immunizations,¹⁹ and bicycle injury prevention.²⁰ Although more research is needed on the cost and benefit of various interventions, the potential for reducing health care demand while enhancing population health makes this a robust property across different health care environments.

Much attention has been focused on the alignment of incentives.²¹ Specifically, unless the financial incentives of the individual physician and the group practice at large are roughly congruent with those of other providers (eg, hospitals), payers, and patients themselves, concerted action to provide more cost-effective care is unlikely to be taken. As Medicare, Medicaid, and private payers place providers at greater financial risk, global incentives are created to reduce the demand on the system for care. The issue for financial alignment is how to translate these global incentives into individual incentives for physicians to reduce unnecessary demand and provide more cost-effective care to those for whom care is necessary. Those interviewed believe this will require a combination of financial and nonfinancial incentives that reward physicians on the basis of multiple factors, including productivity, cost per visit, patient satisfaction, and selected clinical, quality, and outcome measures. While most efforts in this area are relatively embryonic, preliminary evidence suggests that successful incentive programs must be easily understood by physicians and clearly tied to behaviors and practices over which physicians exert control. In addition, physician participation in new incentive programs is strongly related to their level of effort in the development phases of these protocols and programs. Successful translation of organizational priorities into individual incentives will require a "buy in" that only comes with deliberate inclusion of physicians at all levels of the organization.

The issue of tying compensation incentives to outcomes of care becomes even more challenging when addressing community health problems such as domestic violence, teenage pregnancy, and substance abuse.²² Improving outcomes in these areas involves working cooperatively with other community groups. Thus, it is unfair to hold physicians alone accountable for these outcomes. But it is possible to provide incentives for participation in such initiatives. Examples mentioned in our interviews include the work of Fairview Physician Associates in the Minneapolis–St Paul, Minn, area to reduce the incidence of cardiovascular disease through community-wide healthy heart initiatives, efforts by the Henry Ford Medical Group and the Henry Ford Health System in southeastern Michigan to reduce teenage pregnancy and substance abuse, and the recent development of the Institute for Community Health Improvement jointly funded by the Care Group and Partners Health Systems in Boston, Mass, to work with the Cambridge and Somerville communities (S.M.S., T.M.W., K.W.B.C., unpublished data, 1997).

Nearly all of the those interviewed reported that one of the toughest challenges in responding to the changes in health care delivery is learning how to manage and govern physician groups (David Lawrence, MD, oral communication, November 7, 1996). This task is made particularly difficult because of the myriad forms of physician organizations in existence and the varied relationships these organizations have with other entities such as integrated and organized delivery systems, hospitals, management service organizations (MSOs) that provide management services to physicians, physician-hospital organizations (PHOs) that involve a joint venture between hospitals and physicians largely for purposes of managed care contracting, independent (or individual) practice associations (IPAs), and insurance companies. Few of these arrangements exist in pure form. For example, physicians may be practicing in small partnerships that are part of an IPA. The IPA, in turn, may be part of a PHO open to all physicians or available only to those identified as cost-effective providers for purposes of broader contracting. The PHO may be administered with support from a health care system's MSO. Most integrated health care systems or organized delivery systems will offer all models to physicians to accommodate different interests, practice styles, and market preferences.^{23 - 24} Each form of physician organization may have multiple arrangements with different managed care plans.²⁵

Our interviews revealed great variance, not only in the types of models, but also in their ability to manage financial and clinical risk, align financial incentives, and implement total quality management practices.^{26 - 27} A central issue involves power and control. The consensus of those interviewed is that the struggle for power and control reflects tension between clinicians and managers over loyalty to the 2 masters they must serve: patients and the organization. This tension manifests itself in issues of leadership, vision and mission, culture, decision-making skills, managing conflict, and the previously noted alignment of compensation and incentives.

Our interviews suggest that the key to managing and governing physician groups and their relationship with other parts of the health care continuum lies in a shared approach to governance that permits a balanced consideration of the needs of both patients and the organization. Many of the current financial and governance arrangements involving physicians and health care systems and among physician groups themselves are based on reactive responses to the market as opposed to planned behavior consistent with the group's vision, mission, and strategic direction. Where health care executives are willing to share power and control with physicians in a meaningful way and where there is a nucleus of physician leadership willing and able to reciprocate, opportunities exist for meaningful collaborative relationships. Physician involvement in strategic decision making is essential along with forums for continuous communication and coordination and a culture that promotes cooperative behavior. Where such approaches are missing, reflected in a lack of trust and an inflexible approach to problem solving, one can expect the continued growth of separate physician organizations and linkages with physician practice management companies.^{28 - 30} It is estimated that approximately 7% to 9% of all physicians are currently associated with physician practice management companies.³¹ It was clear to our respondents that the physician practice management industry will consolidate. The winners are likely to be those able to provide support for clinical care management and outcomes reporting and not merely support for administrative "back office" functions.

These observations are far from unique to health care. Many of the lessons derive from other sectors of the American economy^{32 - 34} and can be summarized as guidelines involving the 6 "I's" of effective strategic partnerships identified by Kanter.³⁵ These include importance, investment, interdependence, integration, information, and institutionalization. Importance relates to the observation that relationships will thrive as long as they remain strategically important to both parties. This means that the physicians, other health care practitioners, and executives need to focus on providing cost-effective care linked by shared economic incentives to maintain and improve the health of those entrusted to their care. In addition, the relationship must be viewed as a long-term investment with rewards balancing out over the long run. At a given point in time, one party may be viewed as giving more than the other, but each party must see their investment as equitable in the long run relative to other available opportunities. Interdependence is required because the marketplace and other external forces place demands on the parties that can only be met through a well-functioning complementarity. Most physicians do not have the capital or the managerial and organizational expertise to remain independent in the current and emerging market. Hospitals and other health care organizations, on the other hand, do not and cannot practice medicine. Thus, there is necessarily interdependence. These interdependent relationships will become increasingly integrated through the further development of group practices, more sophisticated information systems, and greater physician involvement in the management and governance of health care systems. As a result, the relationship will become more informed, as all parties are involved in joint strategic planning, implementation, monitoring, and evaluation. Finally, as the relationship becomes more interdependent, integrated, and informed, it also becomes more institutionalized in the sense of developing a shared culture of working together. Although cracks in the relationship will inevitably develop from time to time, the more mature partnerships will have a reservoir of past relationships, performance, success, informed databases, and a positive culture that enables the cracks to be repaired.

Many care management practices are currently being implemented under such headings as practice guidelines, protocols, critical pathways, and disease state management. Effective care management practices are those that change, reduce variations in, or better coordinate clinical practice in ways that actually increase the value of services delivered to patients through improved outcomes and reduced costs. All of the leaders interviewed expressed the belief that changes in clinical practice patterns were of central importance to making managed care work. As one respondent noted, "Consumer choice, based on both quality and price, triggers economic forces that provide impetus for quality improvement."³⁶ Some have described the appeal of guidelines, pathways, and protocols by comparing them to "a checklist that an airline pilot methodically goes through—that is why there are very few crashes. The checklist provides the standard but allows the pilot the latitude to use his experience and knowledge" (Kevin Fickenscher, MD, oral communication, August 22, 1996).

Development of effective care management practices is critical to the development of trust that is based on evidence because it puts emerging information and knowledge on effectiveness and cost into action, something patients must see happening to trust the practice of medicine. This is particularly true for the management of chronic illnesses such as asthma, diabetes, and hypertension, which depend on the patient's willingness and ability to follow treatment protocols. Once again, however, the tension between economic pressures and clinical considerations emerges with respect to care management practices. That is, although it is hoped that care management will improve quality and outcomes of care for patients, the parallel and frequently overriding reality was summarized by one respondent who noted that "the driving force behind care management practice is that communities have decided that they are paying too much for health care" (William Conway, MD, oral communication, September 6, 1996).

With few exceptions, the impact of changes in care management practices on costs and outcomes of care is unexamined.³⁷ Greater attention has been given to identifying the characteristics that appear to be most consistently associated with adoption and implementation of successful care management practices. Based on the key informant interviews and distillation of the literature, these characteristics are highlighted in Table 1. Aside from the incentives for change, perhaps the most important characteristic listed is the involvement of local physicians in designing new care management practices.^{38 - 40} There is emerging evidence that physicians will respond to these new approaches if they lead them rather than have them imposed from the outside.^{41 - 42}

Another major factor is the size and level of integration of the health care entity. Because of the economies of scale associated with care management efforts, the larger group practices tend to be more successful in implementing comprehensive changes in care management practices. For example, it is the larger physician groups and health care plans such as the Harvard Pilgrim Community Health Plan, Cambridge, Mass; Kaiser/Group Health Cooperative of Puget Sound, Seattle, Wash; US Healthcare, Blue Bell, Pa; and Humana, Louisville, Ky; that are more involved in overall disease management programs (Edward F. X. Hughes, MD, James L. O'Brien, MA, Teresa M. Waters, PhD, unpublished data, 1995). Nonetheless, great variability exists, ranging, for example, from the Henry Ford Health System in southeastern Michigan (which has 42 patient care pathways constituting more than 50% of hospital inpatients [William Conway, MD, oral communication, September 6, 1996]) to organizations that appear to face insurmountable problems in involving physicians in reexamination of clinical behavior. Those interviewed emphasized the importance of the context in which such work occurs. Some degree of integration among physicians, hospitals, and health plans promotes more effective implementation of care management practices. One respondent stated that "all pieces [eg, hospitals, physicians, health plans] must be viewed as strategic assets in this process and not merely a vendor of services" (Sandra Rorem, MBA, oral communication, November 15, 1996). It is difficult, however, to implement care management practices in an FFS environment or in situations where key groups are not at the table.

The reengineering of clinical practice also influences and is influenced by changes in the balance of power between primary care physicians and specialist physicians. Many groups are facing important questions such as what is the appropriate scope of care to be provided by primary care physicians? Are primary care physicians being forced to provide a broader scope of care? How will referral relationships be affected? What are the implications for cost, quality, continuity, and outcomes of care?

Although there is not extensive analysis of the impact of care management on outcomes of care, physicians can find guidelines and protocols to be useful sources of education offering potential for improving quality of care. Physician groups that have adopted such guidelines cite reductions in practice pattern variations due to them. Furthermore, 60% of groups believe that guidelines influence decision making in a positive fashion.³⁸ Matters are made more complicated, of course, by the lack of appropriate measurement capabilities.³⁶

The consensus of those interviewed is that care management practices will become more comprehensive, reaching across institutional boundaries. In some markets, such as Minneapolis–St Paul, care management practices will begin to focus on overall population management of communities in addition to individual case management. A continuing challenge will be the need to balance the interests of the multiple stakeholders—patients, employers, community groups, and governmental entities. As one respondent stated, "It is hard to argue against providing standardized information to help purchasers and consumers make better decisions and to educate providers. However, one person's standardized information is another's bureaucracy, intrusion, burden, and cost" (Arnold M. Epstein, MD, oral communication, 1996).

The fifth robust property identified by those interviewed as necessary to increase trust and address the demand for evidence-based accountability is an outcomes-management reporting system. This requires that physician groups commit more resources for investment in clinical information systems. For the investment to be wise, considerable advanced planning is needed to determine what kinds of information are needed, for what purposes, at what points in time, and for whom. In general terms, clinical information is needed for 3 purposes: internal continuous quality improvement in real time, external reporting and accountability to multiple groups, and tracking patients over time to assess trends and examine the long-run impact of improvement interventions. Each of these objectives makes different demands on the information system. Internal continuous quality improvement in real time requires data compatible with the clinical decision-making process of physicians, nurses, and other members of the health care team. The system will be focused on diagnostic and treatment test results involving laboratory, pharmaceutical, and radiological data along with observations on patient response recorded by nurses, physicians, and other health care professionals. Data will also be needed to track daily experiments in improving quality of care⁴³ and for capitalizing on new breakthroughs in clinical and biomedical research.

External reporting requirements will be driven by such organizations as the National Committee for Quality Assurance and the Joint Commission on Accreditation of Healthcare Organization. This will require aggregating data across patients and physicians to derive intermediate and outcome measures of both service and clinical quality such as immunization rates, mammography screening, and selected risk-adjusted morbidity and mortality rates. Finally, the ability to put together a database to track patients over time will require large data storage and processing capabilities and the ability to link information across multiple treatment settings, such as the home, physician office, hospital, nursing home, and other related settings.

Each of the above needs poses distinct challenges. Investment in clinical information systems is essential for meeting these needs. Due to the capital required for such investment, it is likely that only larger physician groups and health care systems will be able to make such investments. Clinical information will become the lubricant for outcomes reporting, and outcomes reporting in turn will be at the heart of accountability between physicians and multiple stakeholders.

A major issue is the extent to which the new technologies of and approaches to accountability will be developed by physicians, by external groups, or by combinations of the two. To the extent that physicians do not step forward to recognize the new demands for accountability, the managed care organizations and external bodies will fill the void. But even where physicians and the profession at large play appropriate leadership roles, external groups such as payers, accreditation bodies, patients, and community groups will be players, both in developing the criteria and, in particular, specifying the ways in which data are to be collected, reported, and communicated to the public. The implication for physicians is that they can no longer be the sole purveyors of what constitutes appropriate accountability. Rather, they must work collaboratively with other groups to develop a balanced set of accountability technologies that can appropriately meet the multiple interests and needs of different parties.⁴⁴ Forums among all parties, including patients, must be created to address issues of confidentiality, the proprietary status of selected information, and who should have what information and for what purpose. Although a growing number of physician groups, managed care organizations, professional associations, accreditation bodies, and state and federal governmental agencies are using some of the new technologies of accountability, little is known about their impact. Further work is needed to examine the linkage between external reporting accountability requirements and internal incentives for the provision of cost-effective quality care to patients. For example, even though 95% of health maintenance organizations and 55% of preferred provider organizations report using patient satisfaction surveys, only 18% of these organizations use the results to adjust payments to primary care physicians.⁴⁵

Whatever combinations of accountability approaches are developed, it is clear that they must address the double-agent challenge; they must motivate appropriate physician behavior in a way that acknowledges professional principles and peer respect, while at the same time meeting the needs of patients, purchasers, and other external groups; and they must provide information that inspires trust and instills confidence for all involved. For this to occur, it is critical that physicians, other health care professionals, and all relevant stakeholders have a clear vision of what they are trying to achieve, for whom, and over what period of time. At present, insufficient dialogue exists on these issues. Knowledge and wisdom is missing within a flurry of data collection activity. There is a need to focus discussion and action.

We suggest that the 5 robust properties provide a framework for focused discussion and action. They provide a platform for constructing a new moral fabric for the patient-physician relationship based on the mutual learning of all parties around shared information and expertise. Table 2 summarizes the characteristics of the old vs new moral fabric. As shown, the new moral fabric reflects both a broader set of responsibilities and accountabilities for physicians and a sharing of those responsibilities with others. An emphasis on population-based medicine is needed to deal with enrolled populations and the community at large and, in particular, to deal with the increased financial risk that physicians will be asked to assume for the care of such populations. Practicing population-based medicine with an increased emphasis on prevention will also be necessary to maintain credibility and trust with purchasers and accreditation bodies. A balanced set of aligned incentives involving productivity, cost per unit of service, quality, patient satisfaction, and selected outcomes measures is needed to build credibility and trust based on documented evidence of effective treatment and meet the physician's own organization and public accountability demands. Enhanced management and governance are needed to be responsive to the multiple demands for accountability that form the centerpiece of the new moral fabric. Development of new and effective care management practices is essential to meeting the demands for greater patient participation and empowerment, managing the health of populations of patients, providing evidence of more cost-effective treatment and outcomes, and developing trust. Finally, development of an outcomes reporting management system is central to meeting the multiple accountability responsibilities that are inherent in constructing the new moral fabric.

Taken as a whole, the 5 robust properties are stepping stones on a pathway from the old to the new moral fabric. Cast in this light, accountability and the physician's role within the process become part of a continuous journey to improve the health of individuals and communities. This is consistent with Frankford's idea of a "normative constitution of professional power" involving the participation of all involved.^{46 - 47} The full implications of these properties as a basis for developing a new moral fabric will require continuing examination and debate as managed care and related forces continue to evolve.