Struggles seen for Medicare care coordination

Many experts believe that better coordination of patient care by physicians could lead to a more sustainable, cost-effective Medicare program. But two recent studies demonstrate that physicians and other health professionals face serious challenges in adopting that model of care.

A typical primary care physician who wants to coordinate care for his or her Medicare patients must interact with 229 other physicians working in 117 different practices, says a study in the Feb. 17 Annals of Internal Medicine. These networking responsibilities increase when coordinating chronic care, and they are greater for physicians in solo or two-person practices as opposed to larger groups. The findings are based on a survey of more than 2,000 physicians.

"This is just one more example of the types of stressors that primary care physicians are dealing with," said Hoangmai Pham, MD, a senior health researcher at the Center for Studying Health System Change, which conducted the research along with the Dana-Farber Cancer Institute and the Memorial Sloan-Kettering Cancer Center. "The numbers were pretty discouraging, even for doctors in large practices."

Another study, in the Feb. 11 Journal of the American Medical Association, determined that only two of 15 sites in a recent Medicare coordinated-care demonstration program saw a reduction in patient hospital visits. None of the demonstration sites generated net savings to Medicare, said researchers at Mathematica Policy Research Inc.

In 2001, the Centers for Medicare & Medicaid Services chose the 15 sites -- directed by a mix of care management companies, community hospitals and a long-term-care facility, among other entities -- to study if care coordination could improve quality and reduce Medicare costs.

In comparing the two sites with decreased hospitalization rates -- Mercy Medical Center in Mason City, Iowa, and Health Quality Partners in Doylestown, Pa. -- with the rest of the sites, researchers found noteworthy differences.

Mercy and HQP had higher rates of in-person contact with patients, and they were able to increase the proportion of patients who reported being taught how to take their medications properly. In addition, care coordinators at both locations worked closely with local hospitals to ensure they received timely information on admissions, and they had more frequent opportunities to interact with physicians. The two also attempted to assign all of a physician's patients to a single care coordinator.

The researchers concluded their findings are relevant to policymakers' interest in medical homes -- a model in which each patient has an ongoing relationship with a physician who provides continuous and comprehensive care.

"Care coordination alone isn't going to solve the problems of Medicare costs, but we shouldn't throw the baby out with the bathwater," said Randall Brown, PhD, senior study author and Mathematica's vice president and director for health research. "Care-coordination programs can reduce hospitalizations and costs if they are designed like the more successful programs studied and targeted appropriately at high-risk patients."

Developing peer webs

Dr. Pham and her colleagues suggested that payment for medical home services could encourage physicians to cultivate informal groups of trusted colleagues, or "peer webs."

For instance, physicians could develop webs through service agreements that guide referrals between different practices. Medicare then could design systems to track the sources of referrals and base medical home payments on those data. Payers also could encourage peer webs by providing bundled payments to physician groups that work together to care for a patient.

"There are options out there about how to improve care, but it's just not clear which strategies are the best," Dr. Pham said.

Despite the unanswered questions, some medical experts agree the health care industry should be focused on pursuing the patient-centered medical home model. "The unification of care around a single integrated plan is the breakthrough that we're all looking for," said Gordon K. Norman, MD, chair of the board of directors for DMAA: The Care Continuum Alliance, an association of disease-management firms.

Last year the American Medical Association adopted the "Joint Principles of the Patient-Centered Medical Home" and made a commitment to continue studying the medical home model, with a particular emphasis on funding sources and payment structures.

But Dr. Norman cautioned that it could take years for such a new system to develop, if at all. The large percentage of physicians who work in practices with fewer than 10 people will face particular problems managing electronic health records, implementing workflow redesigns and dealing with other cost and management problems associated with running a medical home, he said.

"It doesn't matter if you back up a truck to their offices and drop off bundles of money," Dr. Norman said. "They don't have the time, resources or expertise right now to put this all in place."

Although Medicare has not yet achieved broad success in the care-coordination models it has tested, CMS is continuing to evaluate programs, said agency spokesman Peter Ashkenaz. These include some that offer incentives directly to physicians.