Comments on: Does coordinating care save money, and if not, is it worth the effort?

By: Bill Peckham

Bill Peckham — Sat, 14 Feb 2009 23:35:00 +0000

Pay less for performance. Patients have more influence on outcomes then nurses

No healthcare worker can compel people to do what would be in their own best interests if they choose to ignore the healthcare worker. Frowney faces on lab reports aren't going to change an adult's behavior.

Cash. Cash changes an adult's behavior. Achieved your clinical goals? Staying out of the hospital? You get $240 off your quarterly Medicare premiums. Pay less for performance. If you preform, you pay less. This is easily testable. I predict that saving money on Medicare premiums is more motivating then a whole sheet of smiley faces.

By: Deron Schriver

Deron Schriver — Sat, 14 Feb 2009 23:24:00 +0000

A large reason for the failure of the Medicare projects and the declining health of the population is the behavior of individuals, not the systems themselves.

By: Carla Kakutani MD

Carla Kakutani MD — Sat, 14 Feb 2009 06:43:00 +0000

All this proves is that disconnected voices, with no personal connection with the patient or even their primary physician, making lots of phone calls does not improve outcomes. Most of the time when my patients are contacted by these sorts of programs (usually sponsored by a health plan) they react with annoyance or downright suspicion.
Currently my hospital system and medical group work together with a small consistent team of nurses to target the most vulnerable seniors. The patients are identified by their own docs as needing this outreach and the same nurse communicates consistently with patient, family and doc. Much of the support is connecting stressed out families with help like referrals to adult day health centers, life alert, etc as much as it is reinforcing the medical treatment. She actually works out of our office one day a week so we can troubleshoot complicated cases together in person. Ideally with payment reform under a medical home structure, it would be cost effective to set this up. Patients would get a service that actually helps and the doctor doesn’t have to feel all alone trying to keep these people on their feet and out of the hospital.
Real care coordination takes a lot of commitment. It is a piece of the medical home model, but not the whole thing. This study will be used, I’m sure, by the forces for the status quo to try to discredit the medical home and primary care. To me it just proves the point that the more layers of impersonal, disjointed information overload you inflict on patients, the less you accomplish.

By: Anonymous

Anonymous — Fri, 13 Feb 2009 23:53:00 +0000

"care coordination" is a vague term, frequently meaning VNS services, in the new york city area anyway. This is almost always a disappointing UNcoordinated approach with a series of nurses who don't really know the patient, generating paperwork but not really DOING anything. Frequently they don't even know who the patient's primary physician is!

It seems that the goal is to get the set fee from medicare for homecare services, then refer ASAP to physical therapy so they can get another medicare windfall, then discharge from services ASAP.

I think when you talk about the "medical home" model, you need to look specifically at care led by a DOCTOR, not a series of miscellaneous fancy-title do-nothing nurse managers.

By: Anonymous

Anonymous — Fri, 13 Feb 2009 23:23:00 +0000

Just because they created a program, put a coordination of care label on it, and hired case managers, doesn’t mean any coordination of care happened.

Our state has case managers for the chronically mentally ill medicaid population. No one involved in the care in of the patients enrolled has ever heard from any of the case managers. Could be a big scam with the progam budget going to offshore accounts for all I know.

By: Anonymous

Anonymous — Fri, 13 Feb 2009 19:33:00 +0000

Kevin, read the JAMA article more carefully. Then read the thoughtful accompanying editorial by John Ayanian.

The JAMA study was _not_ an evaluation of the medical home. It was an evaluation of care coordination by off-site "disease managers" who, by and large, never met the patients and never really interfaced with the primary care physicians of the patients in question.

Is it any wonder that these care coordination programs failed? Not to this primary care doc.

By: Anonymous

Anonymous — Fri, 13 Feb 2009 18:12:00 +0000

You do have to wonder about the participants if those in the experimental group couldn't identify what diet or activity plan they were supposed to be following.

Were they awake when all this assistance was happening? The places picked the participants themselves so you'd hope they'd have picked participants who had enough juice left to do something for themselves.

My MIL lived in a senior community with a Wellness aspect and as far as I could tell she and her friends did their best to avoid using it as they considered it to be for those circling the drain.

By: Anonymous

Anonymous — Fri, 13 Feb 2009 16:29:00 +0000

Primary care, preventive care, “medical home” whatever the hell that is……..has significant value TO THE PERSON RECEIVING THE SERVICE.

But no, it’s not saving the system money.

By: daccarte

daccarte — Fri, 13 Feb 2009 15:20:00 +0000

This is a dismal finding. Thanks for reporting on the research.

My mother's generation seems to take a passive approach to their health. It's a mindset that is so very hard to change. The only reason she is much healthier in her retirement community is that her Wellness Center is proactive in monitoring and 'nagging' her.

Do you think such research would show different results in 10 or 20 years from now as Boomers age? My friends/colleagues seems to very tuned in to good health and proactive about keeping that good health.

I know research/health system is dealing with critical current state of things....but is anybody out there thinking ahead of the curve?

BTW, yours is one of my favorite blogs!

Dale...