An issue that I have been interested in for most of my career is coordinated care, especially in terms of older adults who utilize the most care resources and typically, have multiple providers (physicians in particular). Fragmented, uncoordinated care is the primary driver of over-treatment or inefficient treatment. The outcomes of over-treatment include polypharmacy, test redundancy, unnecessary diagnostics, and rehospitalization/readmissions.
In 2017, I did a presentation (with a number of colleagues) at a Leading Age Annual Meeting on care coordination. The primary focus of the presentation then was on post-acute patients in skilled facilities, principally for a short stay for rehabilitation. The presentation focused on achieving high quality outcomes and shorter, more efficient stays via the implementation of coordinated care processes, algorithms, and interdisciplinary care teams. That presentation is here: https://rhislop3.com/wp-content/uploads/2023/05/care-coordination-updated.pptx
Yesterday, in my reading “pile” (virtual as it typically is), I am across a JAMA Viewpoint article from JAMA Internal Medicine on the difference between care coordination, care continuity, and care fragmentation. The article approaches analysis of these subjects via physician care yet, the applicability of concepts is highly similar to what I (and my group) spoke about at our Leading Age session in New Orleans. The JAMA article is available here: jamainternal_kern_2024_vp_230019_1706170677.62898
For years, what I have been working on in various capacities, I have labeled care coordination and continuity. The article really sharpens the issues and defines the problem as care fragmentation – a problem that produces errors in treatment, over-treatment (unnecessary tests, drugs, visits), and avoidable hospitalizations. Per the article: “Health care in the US is characterized by fragmentation, with many patients seeing multiple physicians. Indeed, 35% of Medicare beneficiaries saw 5 or more physicians in 2019.1 Having multiple physicians may be appropriate, but it may also lead to medical errors, unnecessary visits, avoidable hospitalizations, and suboptimal care if all of the physicians do not have complete information about the patient and each other’s care plans. Even after widespread dissemination of electronic health records, 34% of primary care physicians in a national study reported that they do not always or most of time receive useful information from specialists about the patients they referred.”
What I found interesting is that the article concludes that improving continuity (fewer physicians or fewer outlets for care for a patient) would necessarily, decrease the number of physicians involved in a person’s care. For an older adult, this is problematic as often, each key comorbidity comes with a treating physician specializing in that disease state (cardiologists, urologists, orthopods, etc.). In short, coordinated care which is the outcome of reduced or eliminated care fragmentation can’t really be achieved until care fragmentation is solved. A conundrum for sure.
“Similarly, there is no consensus on whose responsibility it is to design, fund, implement, or participate in interventions to address fragmented care. National dialogue and more federally funded research on this issue are urgently needed. Patients are experiencing avoidable harm from fragmented care, and they deserve better.”
While I generally agree with the statement above from the article, there are steps or interventions that could significantly reduce care fragmentation and move the system forward, toward a more coordinated approach.
- Achieve the full standards of the HITECH Act and interoperability. More here: https://rhislop3.com/2018/06/27/interoperability-and-post-acute-implications/
- Achieve claim standardization that was the significant goal of HIPAA. One standardized claim for all Medicare, Medicaid, and hopefully, commercial insurance products would reduce coding and documentation errors as well as documentation duplicity to support multiple claims.
- Return to bundled payments and move forward, additional value-based care initiatives.
- Simplify encounter-based coding systems such as Meaningful Measures which, bears little value for patient care. The more time a physician has with a patient that is not redundant, bureaucratic driven paperwork, the more time is spent on coordination.
- Increase primary care physicians via controls on medical school costs or subsidization for education for primary care. The U.S. has a shortage of primary care physicians and thus, more care is being handled by extenders.