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.
Stephen 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.