We're talking about highly motivated highly entrepreneurial physicians are working in small organizations so that peace the presentation hypothesis seems to make sent on the second piece the presentation about this is there any evidence that fragmentation care delivery actually leads to I'll higher costs low quality and I think the answer to that is yes though the studies had been a in my opinion quite limited here's a study up I 'me so that you studied commercials were studied at done with the chief's job in Britain France and Karen joint I unpublished in time to go to its details only very Schedule E I don't like it we don't have time to slide once good for you up but basically out the journal that we looking at the publisher when they're a anyways we constructed in yet we had eight and a million chronically ill patients from a big commercial insurance company we construct an index of how fragmented we divided their care for similarly patients into fragmentation quadrilles states this axis and here and the vertical axis different dimensions up costing quality so this is the desire aggression adjusted cost and quality outcomes and this is per patient costs if you look at the second to the third quarterly you seek big jumps in per patient cost this is controlling for all kinds of things we can measure about the disease did patients it's in perfect but I it suggested at least you see the something here with the probability that someone is going to be hospitalized for a blue care sensitive diseases .
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