Now Let's See What Coordinated Care Can Really Do

The results of the Medicare Coordinated Care Demonstration, as reported in the Journal of the American Medical Association, can't easily be characterized.  On the one hand, it would seem to be a failure - after all, of the 15 care coordination pilot programs that began in 2002, only 2 of them demonstrated an ability to produce better health outcome with fewer hospitalizations and less money.  But on the other, those two are a pretty big accomplishment, with ample lessons that can be applied to the future tests programs being rolled out both through Medicare and the private insurance industry.  So although by pure success standards, this is a mixed bag, the learning opportunities are huge.

By testing coordinated care, the Centers for Medicare and Medicaid were basically testing what many are calling "the medical home."  Patients have a single provider or coordinator who is responsible for coordinating all of their care, rather than bouncing on their own from primary care provider to specialist to hospital.  Entities like the Mayo Clinic and the V.A. already operate along these lines.  Groups like the Sustinet movement in Connecticut and the soon-to-be pilot program in Arizona prompted by IBM favor this approach because of its potential upside in terms of customer satisfaction and cost savings.  But the idea is even more important for those with chronic conditions and diseases like diabetes, heart disease, etc.  The chronically ill account for a large percentage of the health care dollars spent, particularly in Medicare, and are the unfortunate recipients of much of the inefficiencies and waste built into our system.  In a study by the Commonwealth Fund, 1/3 of U.S. patients "encountered poorly coordinated care, including medical records not available during an appointment or duplicated tests."  More disturbingly, 1/3 of those surveyed, "experienced medical errors, including delays in learning about abnormal lab test results."   Coordinating care, and compensating providers based on how well they coordinate, holds out the hope of reversing these trends.

Medicare gave those participating in the trial wide latitude to come up with their own program, and the JAMA article is clear that some of the programs were bound to fail the way they were set up.  For example, the two successful programs included in their mix of patients those whose monthly expenditures were $900 to $1200 - essentially, they went often enough to the hospital before the trial that it was noticeable when they were hospitalized less, but weren't so seriously ill that no new care program could decrease how often they needed to hospitalize.  That's a design flaw - easily fixed in future trials.

But the other lessons from the successful two programs are even more intriguing:

• "Relatively frequent in-person contacts maybe necessary to develop the level of trust that patients and their families need to consider the care coordinator..."  When you're trying to create a bond of trust so the patient actually follows the non-physician coordinator's advice, you can't phone it in.  It's cheaper, but it doesn't work.
• Teaching patients how to treat their medication rather than assuming they'll know how to do it counts for a lot.
• Care coordinators who worked closely with local hospitals and shared information freely and quickly had a big impact on patient care.
• Regular contact with primary care physicians and nurses by both the coordinator and the patient was essential to success.  For the patient, it validated the recommendations they got from the coordinator.  For the coordinator, working with the same physicians and developing a team relationship clearly helped them do their jobs.

These may seem like "No duh" lessons to learn, but there's an obvious incentive to have coordinators off-site, interacting by the phone and not doing the little things to establish a relationship with the patients - it saves the hospital money.  Fostering teamwork and a face-to-face rapport with patients takes time and a personal touch - time that current compensation methods don't take into account, particularly for the primary care provider, whose buy-in is crucial.  You can't do coordination on the cheap, or in the call-center model of profitability.  Instead, we need to break down the old habits of our fee-for-service system to really establish coordinated care that leads to healthier patients.

So initial overwhelming success, no.  But, to riff off Aaron Sorkin, there was a time in the history of everything that worked when it didn't work.  We've learned, as the Center for American Progress puts it, "we can't simply apply a band-aid and call it coordination."  Now we need to absorb these lessons and really see what the coordinated care model can do.

(Photo credit:  Liberal Democrats on Flickr.)