Article

Setting the Health System Up to Fail

What Really Works in Care Coordination

It’s no surprise that most of the Medicare demonstrations failed, writes Ellen-Marie Whelan; the useful lessons are in the two that succeeded.

A Medicare recipient receives advice from a representative from the Federal Centers for Medicare and Medicaid Services. (AP/David Zalubowski)
A Medicare recipient receives advice from a representative from the Federal Centers for Medicare and Medicaid Services. (AP/David Zalubowski)

We should be neither surprised nor unduly distressed by the Medicare Coordinated Care Demonstration results released yesterday in the Journal of the American Medical Association. The study found that most of the 15 approaches that Medicare was testing to improve care or lower costs for chronically ill patients had little or no impact. JAMA’s editorial described the results as “sobering,” but based on what we know about what works and what does not in care coordination, most of these demonstrations were designed to fail from the get-go.

Most of these demonstrations delegated care coordination to someone located away from the practice and relied on telephone contact to “coordinate” the care. Not surprisingly, this approach failed across the board.

The good news is that two projects using a different approach were actually successful in reducing hospitalizations. These projects applied methods supported by a substantial body of other evidence on effective care coordination. The successful demonstrations employed the following provisions:

Onsite coordinators working closely with primary care doctors. Care coordinators in the two successful programs were on site in the primary care practice. They also worked consistently with the same physicians, developing a team approach to patient care. Coordinators in other programs were off-site and randomly assigned to patients, developing no relationship with physicians.

Face-to-face contact with a real person. The care coordinator in both successful programs relied more on in-person than on telephone contact with patients—a mechanism known to be more effective. Coordinators also actually taught patients how to take their medications rather than simply writing prescriptions. Evaluators concluded that face-to-face access is essential to a patient’s acceptance of and trust in the care coordinator’s advice and guidance.

Coordination of care across settings. The two successful programs worked closely with local hospitals that in turn provided timely information back to the primary care practice. Evaluators found that regular contact allowed the practice to help manage patients’ transitions out of the hospital and ultimately prevented some unnecessary readmissions.

These characteristics of successful demonstrations together are part of what the health care field recognizes as “good” primary care—the first point of entry into the health care system and the provision of basic, quality, coordinated health care. According to the Institute of Medicine and others, effective primary care assures that patients have direct access to their providers when they need it, focuses on the person rather than the person’s disease, involves a comprehensive set of services, and assures communication across the multiple providers patients often need. The successful demonstrations applied these principles of good primary care; the failures ignored them.

Next steps

The demonstrations show that using a coordinator who has face-to-face patient contact, works across settings, and is an integrated part of a primary care practice can make a difference in improving care. But a coordinator, even a good one, can only do so much. We need to make additional changes to our health system in both the way health care is delivered and how health services are reimbursed in order to really improve the health of the chronically ill. The vast majority of our health care dollars are spent caring for the chronically ill, and at best our attempts are all too often sub par. The good news is that there are changes we can make to improve both patient outcomes and our long-term fiscal outlook.

Research tells us that primary care clinicians, perhaps with the assistance of a coordinator, must take greater responsibility for assuring their patients receive appropriate, quality care. It also shows that primary care clinicians can achieve better than today’s norm in both quality and costs as part of a team with social workers, nurses, dietitians, and pharmacists—as well as a coordinator.

Today’s payment systems are inherently flawed, rewarding volume, not value, which does not encourage effective primary care delivery. For the most part, practitioners want to do the right thing. But good practice will too often go by the wayside if it is not rewarded. Targeted changes to how we finance medical care will begin to reverse current perverse motivations and create the real incentives to deliver efficient, quality care. Changes to the financing system, including payment for coordination of services, episode-based payments, and linking payment to outcomes, will help create a system where primary care can be practiced—and rewarded more fully.

If we want better care, we can’t simply apply a band-aid and call it coordination. We need more fundamental change in how care is provided and how we pay for it.

For more on how to improve the health delivery system, see:

The Health Care Delivery System: A Blueprint for Reform

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