Yesterday, we had a meeting about leakage.

No, it was not about urinary or fecal incontinence, but it was about care that could have been provided within our institution that ended up, for a multitude of reasons, happening with providers beyond the walls of our institution.

Representatives from our accountable care organization had requested a meeting to go over some issues they’ve been having with our practice, including low levels of usage of HCC coding and limited use of Open Notes (a column for another day), and eventually we got to talking about leakage and its effect on the accountable care organization and its bottom line.

In an accountable care organization, the organization has taken responsibility for managing the care of their patients, and hopes to keep costs contained by managing patients within the organization. Internal care is, in theory, always better, more efficient, and the institution has more control over costs.

The minute you open the door, the minute the floodgates open, and patients can go elsewhere, well, there’s no telling what might happen, and what it might cost.

It’s in the institution’s interest to keep as much as possible of the care of our patients within the ACO, therefore making us more “accountable.”

In this meeting we talked about the reasons for leakage, when and where and why it happens, and thought about ways to address it, if in fact addressing it is the right thing to do for patients.

Let me give you an example of a leaky system:

Just a few days ago, one of my partners came into my office, asking my opinion about getting help for one of his patients.

She was an elderly woman, new to his practice, who had fallen several times in the past few weeks, prompting multiple emergency room visits all over the city for multiple lacerations, many of which had required suturing.

On his exam, some of the sutured lesions needed immediate attention, to the point where he thought that the sutures needed to be taken out and redone, done right. He thought that due to the nature and location of the lesions, this would be best handled by a plastic surgeon.

Our front desk staff had tried calling multiple surgeons, plastic and otherwise, within our institution, but no one could give her an appointment, and in fact we were told that nothing was available for several weeks with any of these providers.

What was he to do?

The answer was leakage.

I told him about a plastic surgeon I’ve worked with for many years, who used to be at our institution, but left and went into private practice in the surrounding community, and had a thriving business open not that far away from where our practice is. In the past, he has always seen my patients incredibly quickly, and was happy to see patients on a same-day basis if need be. My colleague called his office, and his assistant said to send the patient over to see him immediately, and that he would take care of everything.

So her care was leaked, it spilled out of our institution (and billed out of our institution), and we were unable to control the costs. And while this plastic surgeon does not use our electronic health record so we couldn’t see any of his notes, in the end the patient got the care she needed. Isn’t that what really matters the most?

During our meeting with the manager from the ACO, she told us that in recent meetings with specialists and subspecialists, she has been told that their main problem is that they are unable to get patients who they see who lack a primary care provider in to see an internist, a pediatrician, or any primary care doctor, and so they feel forced to send those patients outside the institution as well.

Every week, despite our best efforts to improve efficiency, lower our no-show rate, and increase access, we turn away at least 150 patients who are seeking a new primary care provider in our practice, simply because we can’t get them in.

I can understand the frustration of our specialist and subspecialist colleagues who would love to keep the patients that they’ve been seeing for their complex medical conditions in the institution, with a primary care doctor who is easier for them to communicate with and work with.

So what are we left with? Primary care doctors can’t get patients in to see the specialists, and specialist can’t get patients in to the primary care doctors.

Leakage from both ends.

How do we fix this? How do we make this more patient-centered?

The answer is clearly going to need a multipronged approach, involving creatively increasing access, driving down the no-show rate, and using the right provider for the right type of visit at the right time.

The specialists need to get some of the patients that they’ve been following with chronic stable medical problems out of their practice and back into the hands of the primary care doctor. Free them up so that they can see the difficult complex patients that we have questions about, that we no longer feel comfortable managing, but once they’ve figured out a solution, let those of us in primary care manage those problems with their advice and back up as needed.

And resources, always resources.

Give the primary care doctors the resources they need to become more efficient, to take care of minor problems in an easier way, to make the system work for us instead of against us, so that we don’t end up with a 30% no-show rate, unable to fill it with patients because we didn’t know that time was going be free until after it was past.

And more than anything else, don’t just ask us to do more work, but get more doctors and other providers in here to do the work of primary care. Our patients need it, and our healthcare system needs it. Somehow we have to build a better system that makes people want to do this kind of care again, because the need is obviously there, this huge shortfall of primary care physicians that we see as only getting worse needs to be stopped, needs to be fixed.

Or else the system is just going to continue to leak, to bleed, to waste away, and that is not going to help anyone, no matter how accountable we try to make it.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

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