Care coordination is key to fixing health care

Author of the new book “The Future of Health Care Delivery” and the former CEO of the University of Maryland Medical Center, Stephen C. Schimpff, MD, FACP, says effective care coordination, especially for patients with chronic illness, requires technology, more involvement of primary-care physicians and a health-care system – not a medical-care system.

A physician, educator and cancer researcher for more than 40 years, Dr. Schimpff shares his insights with Curaspan Connections:

Curaspan: Why is effective care coordination a challenge?

Stephen C. Schimpff: We desperately need to improve the quality of care and care coordination plays a significant role. The problem now is that doctors in acute care don’t understand what happens in long-term care or rehab. This is true on the other end in the post-acute setting where there’s a knowledge gap of what is going on in acute care. There often aren’t very good processes in place, so patient transitions can be very ad hoc.

Could technology help improve care coordination?

There’s an opportunity for technology to help fill in the gap, because there is a lack of processes and knowledge by providers at both ends. EMRs are the start of this connectivity, but you need innovative software to truly connect. There are solutions out there that bring together both sides.

Where does care coordination break down?

There’s not a good handoff between primary care and the hospitalist and back again. This is why 20 to 25 percent of patients on Medicare end up back in the hospital within a month after discharge. This is an incredible number and indicates a major problem in our system of care. Insisting that a patient be seen by his primary-care provider within three days of discharge will help give the patient a thorough checkup from someone who truly knows him physically, mentally and emotionally. If a patient is sent to long-term care from the hospital, the primary-care physician should see the patient within 48 hours to be sure the correct care protocols are in place. It makes a big difference, and readmission rates would be dramatically reduced.

Why are avoidable readmissions a problem?

There’s a lot of pressure to get a patient out of acute care because of reimbursement requirements. That’s not necessarily bad, but maybe the patient really should be in the hospital longer. It comes down to the importance of a good handoff between levels of care.

What role do payers play in care coordination?

Payers need to appreciate that good care coordination increases quality and decreases costs. EMR systems are not able to communicate with each other. Right now, there’s such a disconnect. Siloed systems can’t talk to each other so that when a patient goes from hospital A to hospital B, you can’t access the medical record, because the hospitals are using different systems.

What are the care-coordination challenges for chronic illness?

We are seeing a shift from acute illness to chronic diseases, such as heart failure, diabetes with complications, chronic lung or kidney disease, cancer and others, which are generally lifelong once developed, difficult to manage and expensive to treat – yet mostly preventable. Payers recognize that 75 to 80 percent of health-care claims paid go to the treatment of these chronic illnesses. So we need to follow the money and put our efforts there.

So care coordination needs to be more collaborative?

We don’t have a health-care system; we have a medical-care system, one that was developed to care for patients with acute problems such as pneumonia or gall stones. For the former an internist gave an antibiotic, and for the latter the surgeon cut out the gall bladder. In both cases, the patient was cured. Not so with chronic illnesses which really require a multidisciplinary-team approach to care that includes various specialists.

How does this work?

For example, the diabetic patient might need to be seen – over time – by an endocrinologist, a podiatrist, an ophthalmologist, an exercise physiologist and a nutritionist, among others. But that team needs to be well-coordinated and the primary-care physician is in the best position to do this. And if the patient is hospitalized, say with pneumonia, the primary-care physician needs to be involved with the hospitalist because the PCP is the one who knows the patient best.

So primary-care involvement is essential?

The patient’s primary-care physician has treated this person for years and should be more involved. A hospitalist who’s very good at treating pneumonia but may not be good at taking care of chronic diseases could miss the underlying reason why the patient is sick. Primary-care physicians are well-trained and they want to do a good job. But there’s only so much you can do in a 15-minute visit. You can’t really give a patient the time he needs.

Why is there a lack of primary-care physicians?

There’s a lack of primary-care physicians because of the reimbursement methodology. If you look at what a primary-care doctor takes home, it hasn’t changed in 10 years. To offset this, the primary-care physician has to see more patients, up to 20 to 25 a day, which is why there are so many 15-minute visits. It is the old story of “make it up in volume.” In order to see that many patients in a day, the PCPs may decide to stop seeing patients in the hospital and in the ER. This gives them more time in the office to see patients.

How do you see physicians adapting to these changes?

I think a lot of doctors are going to move to pay-at-the-door or retainer-based models. Doctors are saying, “I’m not going to take insurance anymore. I will charge you a reasonable amount for each visit.” That’s one way. I also see physicians establishing retainer-based practices. Instead of caring for 1,500 patients, they’ll reduce this to 500 patients and spend quality time with each. They’ll spend time on preventive care, give patients their personal cell number to use 24×7 and take care of them when they’re in the hospital, ER or in a nursing home. The patients will pay a retainer of $1,500 to $2,000 for a year. The result is that patients are getting better care. I think this is the future – pay at the door or by annual retainer.

Care coordination is key to fixing health careStephen C. Schimpff, MD is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and consults for the US Army, medical startups and Fortune 500 companies. He is the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery, published by Potomac Books. 

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  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    There will be little or no care coordination unless each physician sees and understands how the other half lives and what they do and why.  With the elimination of the old rotating internship, young physicians get no exposure to the thought process and care of patients in disciplines they choose not to enter but will need to work with. During their third year of medical school they get some exposure but not nearly enough. With medical school graduates able to ” match” into specialty programs right out of medical school they get little or no post graduate exposure to the other specialties.
    During the publics opportunity to comment on the new Health Care proposals I proposed extending post graduate training and re establishing the rotating internship plus a physician, nurse, ARNP, and PA one year mandatory service in a new National Health Corp. These physicians would be distributed to SNF’s ( skilled nursing facilities)  Rehab centers, adult and child day care centers, community public health clinics, public schools for conducting clinics and coordinating and teaching basic health life skills. In return for service these physicians would get a break on student loan repayment.  By placing young aggressive well trained health care personnel in these facilities you could prevent the costly carousel of trips to the ER for ailments that could be treated far less expensively on site and just as well in most cases. At the same time I believe the Federal Government must use its financial support for training clout to  force training programs to limit specialty residency programs severely while increasing primary care slots and those specialty areas that are identified as needing a larger workforce.

    Internists and family practice doctors need to be financially incentivized to follow their patients into the hospital and continue to care for them. The plan to take family practice residents and internal medicine residents and separate them into those training for outpatient care and those training for inpatient care is a dumbing down of the profession. The ACP influenced by wealthy subspecialists and financially desperate PCP’s has moved in this direction which will lead to a less well rounded more isolated practitioner exactly what you do not want !  

    Retainer practice models I agree allow physicians more time to coordinate care but it is near impossible to do even with increased time because of patient choice and freedom. Take the case of my 86 year old cognitively impaired woman who with her older husband decided to go ahead with three dental implants even though her life expectancy is probably less than two years. Her dentist and periodontist did not consult a medical doctor and premedicated her with a gram of amoxicillin one hour prior to the procedure because six years ago she had a knee replacement ( a questionable decision if you look at the Infectious Disease literature). They then sent her home on tylenol and codeine for pain ( not reviewing her usual medications and why a narcotic might not be a good idea) and post op amoxicillin. When she started to vomit intractably the covering dentist  answered her husbands call and suggested he call 911 and he sent her to the ER. I got the call at 1AM, my first knowledge of this dental fiasco and went in and admitted her for observation , giving her fluids and antiemetics for a medication reaction. This type of incident happens daily despite patients having cell phone, email and text message access to ask questions

  • Anonymous

    The only way to really address this problem is to get all care “under-one-roof”. Do professionals have to be literally in the same building? It’s not necessary to be in the same building but it is necessary to be under one roof regarding a single management team that’s all working toward the same goal which is to improve wellness for patients while maintaining economic viability. I think we all agree that a healthy patient is a less expensive patient. Today, usually it’s a solo primary care physician (PCP) that does everything to maintain wellness while none of the other specialists for a specific patient have any skin in the game. The key for lowering costs going forward is simple. To get all providers “invested” in the wellness of their patients. How is that done? How is anything done? Money! Financial rewards! Take a diabetic for example. Normally, at minimum, a diabetic needs care from a foot specialist, and eye specialist as well as a PCP. We are told that the PCP coordinates everything. Usually, that is false. The PCP might get reports from the specialists, but they never sit down together, like they do in a hospital setting, and coordinate a program for their patient. Outside of a hospital setting where all of the professionals on staff are paid by a single source, patient care coordination is a joke. Coordination will only become important when it’s tied to money. That can only be done “under-one-roof”. Our best chance of that happening in the future is the Accountable Care Organization model (ACO) which makes all professionals on staff dedicated salaried employees all working toward the same goal…together…like a team. There is no other plan on the table at this time. 

  • http://www.thehappymd.com/ Dike Drummond MD

    I agree with all the points in this article. It reflects my experience as a primary care doc coordinating the care of my patients as they would enter the realm of specialists. Everyone had their turf … and if I had dropped out of the picture, no one would have taken care of the “whole patient”. If one person is taking care of just her kidneys and another only her brain … and no one knows she lives alone with 16 cats … this discharge is not going to go well.

    Coordination and proper respect and reimbursement for Primary Care are keys here. How do we make that happen when all the money flows to specialties and procedures. Tough task and a good battle to fight.

    My two cents,

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • http://www.healthasahumanright.wordpress.com/ Erin Gilmer

    Care coordination is sorely lacking still from our health care “system” (I would also argue the lack of coordination means we don’t really have a system per se).  With increase of EHR’s and the move to Patient Centered Medical Homes and ACO’s this might increase – but I am not convinced coordination will really improve.  Part of this in my view is the advent of hospitalists who, while they have some good attributes, ultimately lead to the gaps in care coordination (http://healthasahumanright.wordpress.com/2011/05/14/mixed-feelings-about-hospitalists/).  I wouldn’t put as much emphasis on PCP engagement but follow up by care
    teams in a hospital – who are also responsible for after care.

    Another interesting view on how we can learn care coordination from the military was written last April – http://articles.latimes.com/2011/apr/18/health/la-he-medical-handoffs-20110418.  This is a huge aspect of care – not just coordination from hospital to doctor but also from doctor to doctor and one that needs to be addressed if we really want to make stride in improving care and decreasing costs.  We need to think of coordination on a larger scale though – across all specialities and including non-medical providers such as therapists, nutritionists, and others.  Of course doctors already have a lot on their plates, which makes such coordination difficult with no remuneration and thus means we need to focus on a solution to encourage coordination and communication between providers to truly provide the best care for their patients.

  • Anonymous

    Do you think that a health coach facilitates the coordination of care of the company’s employees?  According to your expertise, what is your definition of a health care coach?  Do you see any economic conflict of interest between PCPs and specialists that would be aggrivated by the application of EMRs?

  • http://twitter.com/chasedave Dave Chase

    You make many good points but I have two points to add. First, the $1500-2000 per patient model doesn’t scale to a broad enough population. The primary care organizations that I have seen produce the best outcomes AND are affordable are Direct Primary Care Medical Homes (DPC for short). Go to http://www.delicious.com/chasedave/DPCArticles to read some of what I’ve written here on KevinMD. The pricepoint for these is more typically in the $50-80/mth. Because they run with such low overhead, they are able to do it profitably at 400-500 patients, very profitably at 800 patients but they tend to cap their panel size at 1000-1500 (still much less than 3000+ than is typical).

    The second point is there needs to be a great emphasis on the patient and/or family member when you are referring to chronic disease management. After all, it’s the decisions by the patient/family that drive outcomes (do they fill Rx, take it to completion, diet, exercise, etc.). In my review/implementation of over 100 healthIT systems, the “patient” isn’t much more than a vessel to for billing codes. Successful care coordination (in post acute care) will have to recognize the most important member of the care team — the individual (aka “patient”). As you might imagine, a system that has as its core goal to get as big a bill out as fast as possible is unlikely to address this need so they must be built or added to the current systems.