The PCMH pushers love to talk about care coordination. They believe the key to more cost-effective care is to have primary care practices hire care coordinators to keep track of patients.
I asked the leader of a large integrated network what his care coordinators actually do. He said they mostly track things like standard chronic care and preventive measures — hemoglobin A1Cs, cholesterol measurements, mammograms, etc.
As reasonable as this sounds, remember that all these interventions raise healthcare costs, except in the few patients who have such bad chronic diseases that they are prone to go to the ER or hospital when they feel bad.
A study that appeared in the Archives of Internal Medicine looked at chronic care management for high risk patients that might actually benefit from care management and result in lower costs. This was a cluster randomized trial of interdisciplinary primary care teams for patients with multiple chronic diseases. The “guided care nurse” closely monitored these patients with multiple chronic diseases in the Kaiser system in Baltimore for 20 months. This included self-management teaching, transitional care assistance, monthly monitoring of symptoms, etc. In the guided care group compared to the usual care group, there was no difference in ER visits, hospitalizations, or ologist services. There were reductions in home health use and skilled nursing use.
The reality of most models of care coordination I’ve heard or read about — boiled down to its economic essence — is that the practices spend more money on care coordinators to spend more healthcare dollars on more tests, clinic visits, and prescriptions. Quality measures for chronic disease processes may improve a little, but the cost curve is only bent upward.
Where then does the notion of “coordination” apply? In today’s mishmash of care, where so much money spent (wasted)in duplication of things like tests and where procedures are done that have not really been discussed, how does a family physician act in a proper role of coordinator? What defines good coordination, if we agree that some degree of coordination is a worthy aim in overall care?
I’m talking about some of the primary care initiatives that want to pay practices some fee per-member-per-month to track down patients. An example would be a care coordinator nurse running a quarterly mammogram report and contacting women who apparently have not had a mammogram in over a year.
Dr. Young:
As always, your scientific approach to the fads of the day is a breath of fresh air.
Over and over again, you clearly articulate what every family physician I know thinks about the direction our specialty is headed. Any chance of you running for president of the AAFP?
Robert,
Thanks for the kind thoughts. Even if I wanted the president’s job, my obvious lack of political skill would make me a poor candidate. Bluntness is not a good campaign platform.