Decades of thoughtful research into how we design health care systems has shown that primary care is essential. We know enough to confidently say that systems responsible for the overall health of patients (like health insurance plans or the Veterans Administration) that choose to skimp on primary care do so at their own peril. But in a time of limited resources (real or perceived) and limited organizational bandwidth to fix a broken system, many are searching for the magic bullet (that “one simple trick”) that might give a big boost to our primary care system.
Let me start with a story.
For the past few years, I’ve spent time getting to know community doctors delivering primary care in nearly every corner of Los Angeles as a part of a research study.
A few of the doctors my team met were checked out; more than a few were burned out. And one particularly memorable doctor turned out to deliver care that was almost criminal (literally). We watched him ignore patients during their actual visits in favor of catching daytime television (yes, each exam room had a TV). He later abruptly disappeared and we learned through public channels that he fled the country after a conviction for Medicare fraud. It was a multi-million dollar scooter kick-back scheme…not an unfamiliar story.
Yet despite working in a high poverty city with sizable medical under-service issues, the providers we met were committed. Pressed for time and often brusque? Yes. Serious about their care? Certainly. Interested in learning how to do a better job? I’d say, overwhelmingly yes. Most (nearly 80%) of the doctors we met joined our study with–and I’m being honest here–very little obvious reward. This even included a few of those who were burned out. And, quite surprisingly in hindsight, the criminal.
What stood out the most to me, however, was how frequently the doctors wanted to know what they could quickly do better. Some requested personalized reports, which we tried to oblige, and others shared their own assessments (like their own satisfaction surveys) with us. At the end of the study, our results produced a variety of messages that we wanted to communicate back to the doctors. But we found that they weren’t very interested in our full array of findings. They wanted to know the “one thing” they could do.
Like most people, they wanted the magic bullet.
Among those who study primary care, there is a sincere effort underway to figure out why this form of medical practice has such a powerful effect on individual people, whole populations, and health systems. This involves trying to figure out what elements of primary care have the biggest impact. And this stems from an interest in prioritizing in the face of limited resources.
Thanks to Barbara Starfield’s work in the 1990s, there is consensus on the clearly-defined elements of an effective primary care practice. These range from the clinical (offering a full scope of services tailored to the most common health issues in a community) to the relational (how the provider builds, or doesn’t, a partnership over time with patients). All of the elements of primary care are, of course, important.
One element that can be critical, but also very hard to do well, is coordinating care.
Coordinated care is a model in which primary care providers essentially act like CEOs, coaches, or (perhaps even more apropos) the leader of a group of skydivers. They take care of what they can directly, but then create critical linkages with other partners (like specialists) for patients with more complicated issues. Ideally, they remain responsible for the success of the whole team (and the whole health of the patient) and choreograph that care with any other services the patient needs.
This model likely helps to solve health problems more efficiently, reduces the possibility of taking inappropriate or conflicting medications, and reduces repeated medical tests. We all assume this coordination happens naturally, as a routine practice in medicine. But for the vast majority of us, it does not. At least not very well. And probably not without Herculean efforts.
Seriously, ask your doctor.
Yet we’re learning that care coordination is an important component of primary care. Arguably, there are enough hints now that if we were forced to choose one element of primary care in which to invest our limited money and energy, our best bet might be care coordination.
So, what’s the evidence?
First, a number of studies show that there is considerable room for improvement in coordination and that improvement is, indeed, possible. Take this recent study published in Medical Care, online ahead of print on April 25, 2016, that reported disparities in how patients received coordinated care. The study, by Stephen Martino, PhD, Marc Elliot, PhD, Katrin Hambarsoomian, MS, and colleagues, found that among Medicare beneficiaries, who have nearly universal coverage, there were sizable differences by race in getting timely follow-up on test results, discussing all of the patient’s medications, and saying their doctor had “up-to-date” information on care from their specialists. While the results are self-reported, they suggest that there is room for improvement in coordination of care.
Second, there are now some large-scale studies that show care coordination can have big effects. In addition to studies of small-scale interventions, which provide glimpses of what might work, there are also studies of big, systemic changes. Another study published ahead of print in Medical Care on April 25, by Dan M. Shane, PhD, Phuong Nguyen-Hoang, PhD, Suzanne Bentler, PhD and colleagues, reported the effects of an Iowa “health home” program to coordinate care for Medicaid patients with chronic conditions. Using health care claims data, the health home project was found to have reduced emergency department visits and thus lowered costs of care for each patient by about $130 per month. That’s no small savings.
Finally, some of the world’s best performing health care systems are banking on enhanced coordination. A recent analysis by Tessa van Loenen, Michael J. van den Berg, Stephanie Heinemann and colleagues looked at primary care trends from 2006 to 2012 in three European countries widely considered among the highest performing health care systems in the world (the U.K., Netherlands, and Germany). The authors found that in these three systems, the most prominent changes since 2006 included improvements in care coordination, mostly by the adoption of new, large-scale disease management programs to help patients with chronic conditions.
None of these studies suggests that the other elements of primary care are unimportant. In fact, Barbara Starfield assembled two decades of evidence supporting the idea that the full range of practice elements that define quality primary care are essential. But again, there does appear to be some suggestion that the “one thing” that could be improved might be care coordination, especially among patients with chronic disease.
What can individual providers and health systems do to improve care coordination?
There are lots of ideas and innovations. But there are also some proven strategies. In my next post, I’ll look at strategies that work, and those that don’t. You can get a preview from this thoughtful congressional testimony by Ann S. O’Malley, MD, MPH – one of the country’s thought-leaders on coordination in primary care.
Gregory Stevens