Saturday, June 4, 2011

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?

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