Docs challenged by growing need to coordinate care

Marion Davis

02/28/2009

Dr. Diane Siedlecki is part of a fairly large medical practice – Anchor Medical Associates, with three offices and a large team of internists, pediatricians and several specialists. She uses electronic medical records. As local doctors’ practices go, hers is high-tech and efficient.
Yet Siedlecki, who is also president of the Rhode Island Medical Society, can barely keep up with all her patients. It’s not just that she has a heavy schedule, as most primary care physicians do these days; it’s all the imaging and lab results, and notes from other doctors.
On a recent Monday night, she said, she worked and worked until her electronic inbox was completely empty – a coup in itself. But the following morning, she came in to 51 new notes from consulting doctors and more than 150 lab reports.
Siedlecki’s days didn’t use to be this daunting. Life was simpler when she worked for Harvard Pilgrim Health Care of Rhode Island, under a single roof with all her HMO colleagues. Her patients are also living longer now, but struggling with as many as seven or eight diseases.
“It’s way more complicated than it was, and it’s more difficult,” she said. “I can’t put my finger on it, but I can tell you one thing: It’s absolutely and utterly exhausting.”
Here’s how exhausting, a new study shows: A typical primary care physician who treats elderly Medicare patients, the Center for Studying Health System Change found, must coordinate care with 229 other physicians working in 117 different practices.
The study, co-authored by researchers at HSC, Memorial Sloan-Kettering Cancer Center and the Dana-Farber Cancer Institute, was published in the Feb. 17 Annals of Internal Medicine. The bottom line, the authors said, is that the system needs to change to make it possible for doctors to truly coordinate care, for the sake of their patients’ health.
“The logistical challenges to care coordination are daunting given the fragmentation of care and the large number of peers that physicians must interact with when treating Medicare patients,” said Dr. Hoangmai H. Pham, of HSC, the study’s lead author, in a news release.
The underlying phenomenon is well known, driven by several factors, including the aging population, huge advances in medicine, a major increase in medical specialization, and changes in health insurance that have made it easier for patients to seek specialty care.
In addition, low reimbursement rates have gradually driven primary care doctors out of hospitals, leaving patients in the care of hospitalists, not their regular physicians.
For many policymakers, insurers and doctors, the trends have been troubling enough that they’ve worked hard to reverse them, developing new models such as the “advanced medical home” that recast primary care doctors as the coordinators of each patient’s care and the leaders of a multidisciplinary team that aims to meet the full scope of the patient’s needs.
The HSC study acknowledges those efforts but says that to be successful, they may need to be backed by much more substantial delivery system reforms – or else, as Pham put it, “care coordination is likely to remain an ideal but elusive goal in Medicare.”
The study is based on HSC’s nationally representative 2004-05 Community Tracking Study Physician Survey. It combines survey data from 2,284 primary care physicians and with Medicare claims data for 576,875 of their patients.
The average primary care doctor, the study found, treated 264 Medicare fee-for-service patients, and for every 100 Medicare patients treated, he or she would typically have to communicate with 99 physicians in 53 practices to coordinate care.
Doctors who treated patients with more chronic conditions – in the top 25 percent – typically had to interact with 134 physicians in 62 practices for every 100 Medicare patients. Doctors in solo or two-person practices generally dealt with more practices to coordinate care, as did doctors in regions with a particularly large supply of specialists.
Siedlecki said in many cases, she does not believe a second doctor is needed to treat a patient’s condition, but patients go to specialists, quite simply, “because they can.” Others do need the extra care because of the severity of their condition, she said, and there’s also the fact that she just can’t make enough time to fully address patients’ questions and concerns.
But specialists, in turn, create more work for her, both because she has to follow up on their consult notes, and because they wll send a patient back to her if they discover something that is beyond their purview – say, if an endocrinologist finds a person has heart problems.
The “advanced medical home” model, which some local practices are trying under a project called CSI Rhode Island (the Chronic Care Sustainability Initiative), holds a lot of promise, Siedlecki said, though it does remind her a lot of the HMO staff model she was part of a decade ago, and which she noted failed, though for financial, rather than clinical reasons.
“The pendulum keeps going back and forth, and until someone gets it stuck in the middle, it’s not going to work,” she said. But no matter what, she added, coordination is urgently needed. “I think it’s necessary if you want to keep primary care alive and thriving.” &#8226