Coordinating Care Coordination

Care coordination is one of the four pillars of Meaningful Use, one of the six NCQA Patient Centered Medical Home (PCMH) standards and one of the main goals of Accountable Care Organizations (ACO). Care coordination, particularly for patients with multiple chronic conditions, is expected to reduce unnecessary repetition of laboratory testing or imaging and the number of avoidable admissions. Other than reducing overall costs, care coordination is also supposed to improve quality of care. According to experts like Joe Flower, “Lack of care coordination is at the core of the mess healthcare is in”, and nobody in their right mind would argue that it is best that medical care remains disorganized and uncoordinated, if it is indeed so. It seems that our fee-for-service, fragmented and fractured (lots of f-words here) health care system is not conducive to care coordination. When patients float around in a sea of hospitals, physicians, nursing homes and other facilities, each care provider gets paid, and is responsible for the piecework performed at their independent entity and nobody is minding the handoff of patients to the next provider of care, and nobody is assembling a comprehensive picture of the entire care process, let alone orchestrating, or coordinating, the progression of patients between stages of care and the overall needs of patients in transit. What would it take then, to see that the bits and pieces of health care we now have, become a safe and affordable continuum of care?

CMS is taking the lead, as it should, in an all-out effort to encourage health care coordination through various carrot-stick initiatives, aligned to ultimately base payment for medical care on value to the patient, as measured on a population level, instead of fee-for-service and no accountability for outcomes. These initiatives fall into three general categories:

  1. Health Information Technology to assist with documentation, information exchange and measurements as required in any coordination effort.
  2. Incentives and penalties for providers based on measures thought to be influenced by care coordination (e.g. preventable hospitalizations, readmission rates, etc.)
  3. Financial and structural encouragement for vertical integration of the delivery system (e.g. ACOs, consolidation, employed physicians, etc.)

Of all three categories, only Health Information Technology (HIT) is foundational. HIT is supposed to provide a toolbox for simplifying and even automating many of the tasks associated with coordination of care. The other two categories are based on series of assumptions, hope, belief and lots of other magical thinking. A brief scan of Meaningful Use regulations, which is quickly becoming prerequisite to both PCMH and ACO, reveals the following proposed care coordination enhancing features:

  • Health Information Exchange (HIE) – To paraphrase the quality measurement mantra, you cannot coordinate that which you don’t know. Most care coordination efforts today are based on faxes, phone calls and using the patient as courier for paper based artifacts. If there is one thing that computers excel at, it must be timely exchange of information. Aggregating and placing complete health information at the fingertips of all clinicians, in real time and with minimal loss of fidelity, would in and of itself eliminate most effects of geographical and organizational diversity and fluidity of care providers for any given patient. Most, if not all, remaining features are just elaborations on the information that needs to be exchanged, the actions to be taken following the exchange and the tracking of both the actual exchange and the activities surrounding such exchange.
  • Planning Care – Care plans are not a new idea, but now they will have to be composed with patient participation, and shared between physicians, hospitals and other care givers. The vision is to eventually have one collaborative plan of care accessible to all involved.
  • Managing Transitions of Care – Here you find the multitude of documents to be shared when care is transferred between facilities and/or physicians. There are care summaries, discharge notes and instructions, medication lists that need to be reconciled, and the PCMH standard adds careful tracking of referrals, appointments, test results and consultation notes.
  • Measuring Results – Meaningful Use lists 48 clinical quality measures, and more are being developed, ranging from weight measurement and dietary counseling to inpatient medication administration. At this point, this is mostly about measuring care process metrics.

What we have here is nothing more than classic Project Management: Planning, Collaboration, Change Management and Measuring. The project is health and the project owner is the patient. There are millions of such small projects executing every day around the country. In the current system, many are executing with no project management. Sometimes the owner assumes the role of project manager, sometimes a conscientious primary care physician takes on that role, but most often we all step in and out of a management role as the project heats up during events such as birth, acute disease or trauma, chronic disease diagnosis and terminal illness.  Most of us, including physicians, have no resources, no training and no decent tools to manage our health projects. In the business world, professional project management is part of every (successful) project, with purpose built tools and adequate budget allocations for this coordinating function.

Perhaps this realization is the main driver behind the expert advocated, and government endorsed push to consolidate health care into large business entities. The viewing resolution from Washington, and from equally removed academic departments, renders all our pixel-size individual health projects indistinguishable from each other in the large picture of population health. This is one case where the forest is obscuring the trees. So with the best of intentions, the government is proposing to create a handful of Project Management Offices (PMO), which is what ACOs really are, and make them fiscally accountable for operational profit and loss (P&L) at a population level. Instead of dealing with hundreds of thousands of small contractors, the government will be stepping into its familiar role of contracting with large corporations as the prime contractors for goods and services. These prime contractors, similar to their counterparts in the defense industry, will be at liberty to subcontract with smaller entities or employ their own resources, and together they will completely dominate all aspects of the market.

This massive reengineering of the health care delivery system is deemed necessary in order to begin eliminating the excesses and fragmentation brought on by the centuries old fee-for-service model of medicine. But if we learned one lesson from the fee-for-service model, we certainly learned that if we pay by the yard, we get more yards. So common sense begs the following question: if we want more care coordination, why not pay for care coordination (by the yard)? Unlike quality of care and outcomes, care coordination processes are easy to define, easy to measure and widely understood by all stakeholders. If CMS could define a set of CPTs for Evaluation & Management which entail counting all body parts being examined and accounting for all diseased relatives, couldn’t it define a set of Coordination CPTs to track care planning, exchange of care summaries, referrals, results, instructions and whatever else is deemed to contribute to care coordination?  Computers, HIT and the Internet are greatly enabling these activities, both inside and across organizations of all sizes, and are automating their documentation in the medical record. If physicians and hospitals were allowed to bill these Coordination CPTs at various levels for each encounter, and they were paid at attractive rates, we would see a flurry of activities leading to HIT adoption, health information exchange, collaboration and ultimately coordination of care.

Paying for care coordination on a fee-for-service basis will allow a unified definition of services and individual customization per patient. Some patients will need more, others will need less, and different people will need different coordination services at various times. Unlike a capitated fixed fee per patient per month, there will be no temptation to skimp on services and it is really hard to argue that too much coordination is even possible. Indirectly paying for a finished product, such as paying for outcomes, is very difficult in health care since the product is only finished when we are dead, and retrospective measurement of expenditures for dead people is nothing more than crying over spilled milk. If we maintain the granular fee-for-service system of levers, we can recoup coordination expenses by carefully reducing payments here and there for services we want less of.
So instead of punishing hospitals for failing to coordinate care, instead of penalizing doctors for lack of technology, instead of incenting everybody to do the right thing in roundabout ways, and instead of faith-based reengineering of the entire system from the top down, why not try to achieve our goals the American way, by paying a fair fee for an honest service?

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

11 replies »

  1. A spokesman for a large physician group in Texas, that is run by family docs and has shown dramaticcost savings through aggressive “care coordination,” says it takes $40-50 dollars per patient per month to really work. It can’t be done for the $1-2 that most payers are offering.

  2. John, I think the various schemes attempting to calculate how much physicians need to be reimbursed based on diagnoses of their patient panels are inherently inaccurate for several reasons, as you describe above.

    Not all patients with chronic conditions are willing to accept “coordination”, and those that do, will need various levels of effort. Trying to somehow average this over the entire panel, will effectively require the physician to accept a certain level of risk. Moreover, the temptation to do less and the temptation to upcode diagnoses so the panel looks sicker (as in Medicare Advantage) are in my opinion best avoided.

    I don’t think physicians should bill like lawyers, for every email and every phone call, but just as we have various levels of billing for office visits and it is up to the doc to choose the level based on the needs of each particular patient at each particular point in time, why not allow them to do the same for the amount of “coordination” needed? Sure, there could be abuse of the system, but these “coordination” activities are as easy to audit in an EHR as the complexity of the encounter and probably a lot easier.

    And if we figure out a way to fix the billing, perhaps they can concentrate more on the healing.

    I am not sure if this will work, but if we are dabbling in all these pilots and experiments as ACA requires, why not try this simple thing too?

  3. From the peanut gallery:

    Working as a non-medical caregiver in my post-retirement life I have observed several different types of medical attention. Some clients need transitional help recovering from a hospital stay or other condition that may resolve (such as moving to what is politely called a “higher level of care.”). Others are chronically in need of help and will not improve. And in the case of hospice, palliative care is what is left until the angel of death pays that final visit. The categories are temporary (or transitional) long-term or permanent. (I will never learn to appreciate the term “custodial” when referring to Medicare beneficiaries beginning at day #101 in rehab or hospital. It sounds so much like attending farm animals or prisoners.)

    Your post mentioned “the handoff of patients to the next provider of care” and “patients with multiple chronic conditions” suggesting at least two or three broad categories in combination of care, acute and chronic, both of which can have an identifiable beginning, middle and end as far as additional charges are concerned.

    ►At this point it is easy to confuse billing with healing.

    Even a straightforward “chronic” condition may go into remission or remain identifiable for years without additional professional attention. (In my case a chronic bone condition in my left wrist has been part of my life over forty years and only in the last few years has caused any discomfort. To date I am still ignoring it, but I’m certain if I went to an orthopedic doctor he would want to go to work on it immediately. There is no way to know how many thousands I have saved either myself or some insurance company over the years.)

    It seems to me most cases can be compartmentalized in the same way that home health care, tests and medications are billed by the hour, procedure or market rate.

    But the actual physician’s and/or PA/nurse practitioner’s attention should be rated by the week, month or quarter (as appropriate) regardless of what is required in actual hours in the office, on the phone or even (dare I say it) at the patient’s home.

    The patient with a chronic condition needing variable but never-ending attention — insuring an income stream of long duration — should not be proportionally out of balance with the ER charges for a broken hip or stroke, which can be expected to be costly but “one-time only” events. .

    Just my two cents.

  4. pcp, I do understand your concern and I actually share most of it. However, I believe that two things have changed in recent decades and those require that primary cares responds accordingly, precisely so it remains relevant.
    First, the medical care system, technology and financial included, has become prohibitively complex for the average patient. Second, people are much less anchored than they used to be and many have no family support.
    In view of the above, I think the doctor must, again, step out of the office and into patients’ lives. It is similar and very different than the “olden” days where most care was actually delivered at home, only “home” has a much larger meaning right now.
    Yes, it is labor intensive, but medicine (and technology) has advanced enough to enable some delegation down to non-physicians. This is why, I likened care coordination to project management. Project managers are not experts of any particular industry. They need to have some knowledge, but their contribution is in doing those things that don’t require a professional, and tie the project together, allowing the professional folks to achieve more than if they had to do everything on their own.
    Dr, Coburn’s model is one and Dr. Brenner’s model (Gawande-New Yorker-Hot Spotters) is another. What both have in common is an intensive intervention in the patient’s life outside the office. Perhaps this is the modern adaptation to Marcus Welby. Whatever it is, and however it is performed, and I assume that there will be many different ways, it must be reimbursed appropriately, or it will not happen the way it should happen.

  5. Great post that strikes at the root of the problem in US healthcare. Today I end a practice I have been in for nearly 6 years and move to another 250 miles away from my lifetime home primarily because of a compelling personal and professional need to practice in a coordinated care environment. As I have stated previously (and as this article illuminates indirectly), it is time for healthcare to move categorically and disruptively into a system most analogous to the US airline industry – with standardization, coordination, and accountability. As others have posted, this would more likely cause costs to decrease, not increase – and quality would improve; safety would improve infinitely (airlines’ safety record in the US is near-perfect in recent history). There is a need for a system whereby physicians are akin to well-trained pilots; where each position / role is ‘do-able’ because of defined standards; and where patients can feel safe and have consistent care. There will still be a role for the personal provider, and the ‘rules’ can be broken when needed – but there must be a rule first, to define what the exception to the rule must be. Right now, there are few rules, and a system built on exceptions. I fully agree with the call of this post to begin studying system re-design in earnest…along the lines of ‘project management’ and care coordination.

  6. Good news is that there is an effective alternative. Leading models of nurse led community-based care coordination can appropriately support primary care providers and run largely in parallel provided that collaboration with the PCP is available on a high-value, as needed, basis. That’s what we’ve done at Health Quality Partners (HQP), with good outcomes seen in rigorous evaluations of the model undertaken by Medicare in a long-term randomized controlled trial.

  7. Nice analysis. One challenge is that there is a wide array of activities described as “care coordination” which together or alone are often not implemented in ways that are effective in improving care and outcomes. Never mind that the generic, abstract concept of coordination is accepted as inherently good by all. This reality is highlighted by the results of efforts like the Medicare Coordinated Care Demonstration (MCCD) in which my team has participated. Of 15 reasonably strong models of care coordination for chronically ill older adults, only one, (our program at Health Quality Partners, HQP) has been continued by CMS for its impact on hospitalizations, cost, and outcomes (lower death rates). Most people would consider our model ‘intensive’ compared to the current widely held notions of care coordination with attributes not shared among the other demo programs, but maybe that’s what it takes to be effective. Paying for more of something that sounds good, but isn’t actually effective on the ground, will just set us back further. Rigorous study and evaluation, with replication and scaling of what actually works … and paying for THAT seems more promising.

  8. Fascinating post, with lots to think about.

    Coordination of care is still quite poorly defined, but, to be meaningful, it will be expensive and labor intensive. Everyone seems to assume that the 5 or 6 remaining primary care docs will the ones to take this on, managing the “team” if not actually doing the work themselves. This will significantly reduce their patient care time, and, I feel, make primary care even less attractive to med students than it already is. Who wants to through the rigors of med school and residency to spend all day sitting in front of a computer “managing” population health needs?

    I’m not sure this is the way we want to go.