On paper, care coordination looks simple: primary care physicians and specialists collaborating to provide the best treatment for patients.
Virtually all primary care physicians engage in coordinated care to some degree, but the extra emphasis placed on it now by healthcare policymakers, along with new reimbursement models and reporting requirements, has primary care doctors looking for ways to improve how they coordinate care.
Policymakers say care coordination can cut costs and improve patient outcomes, but if it is to realize its promise, primary care doctors will have to overcome a number of obstacles to implementation, such as incompatible electronic health records (EHRs), poor communication with specialists, egos, a lack of resources and polypharmacy.
And those are just the things they get paid to do.
“It would be fair to say more than 50% of my time is spent in uncompensated care coordination,” says Susan Osborne, DO, a solo primary care physician located in Floyd, Virginia.
Here are five major obstacles regarding care coordination and how primary care physicians can overcome them.
1. EHRs and coordination
Sharing medical records among providers is essential to coordinated care, but the promise of seamless digital exchanges is still far from reality.
In a recent survey from healthcare research firm Black Book, 41% of hospital medical record administrators report difficulties exchanging records with other healthcare providers and 25% say they are unable to integrate into their EHRs any patient information received electronically from outside sources.
The problem is particularly acute for independent primary care doctors, who are less likely to be tied into larger digital networks. “Physician groups continue to lack the financial and technical expertise to adopt complex EHRs, which are compulsory to attain higher reimbursements by public and private payers,” according to Black Book.
Some physicians have upgraded their EHRs to improve interoperability and their resulting ability to collect and analyze the patient data they need for care coordination and coding and reporting. If doctors find themselves referring patients mostly to a single healthcare system, they should make sure their EHR is compatible with the one that system uses.
Some physicians rely on their accountable care organizations (ACOs) for help collecting, analyzing and exchanging data. Melissa Weakland, MD, a physician in a small primary care practice in Seattle, pays $900 a year to a neighboring hospital to use its EHR system to get emergency department notes and discharge notices, but she and others say they still routinely print out paper records for patients to take with them when they see specialists.
Primary care doctors also can, where available, join Health Information Exchanges, which allow member providers to securely exchange patients’ data. These can be expensive, however. The Healthcare Information and Management Systems Society offers a calculator (visit bit.ly/HIE-HIO) for practices.
2. Dealing with specialists
One of the greatest challenges to care coordination, primary care physicians say, is working with specialists.
“Many of the specialists I work with are great to collaborate with. There are other specialists who don’t want to collaborate and think they know it all and don’t understand my role as a primary care doctor,” says Weakland.
A 2011 study of specialty referrals found numerous problems, including varying thresholds among primary care physicians for making referrals, poor communication, incomplete data transfer and missing follow-through. “PCPs and specialists also frequently disagree on the specialist’s role during the referral episode (e.g., single consultation or continuing comanagement),” researchers noted.
Primary care doctors should negotiate and formalize the terms of their interactions with specialists, says Bert Miuccio, chief executive officer of HealthTeamWorks, a practice consulting firm in Golden, Colorado.
He recommends written agreements between doctors and specialists, detailing terms such as who is in charge of coordinating a patient’s care, when it’s appropriate to refer, what records must be exchanged and when the patient returns to primary care.
He recommends primary care doctors and specialists negotiate these in person, if possible. “It’s just a matter of hammering these things out and coming to an agreement. It’s really easy to get the teams focused on what’s in the best interest of the patients,” Miuccio says.
If a referral is anything more than routine, Jeffrey Kagan, MD, an internist in Newington, Connecticut, and a member of the Medical Economics editorial advisory board, says he tries to talk to the specialist on the phone or communicate via text. “Nothing beats doctor-to-doctor communications,” he says, adding that specialists want his input.
While care coordination is collaborative, primary care doctors should never forget that they, not the specialists, have the greatest overall responsibility—and the most authority, says Pamela Ballou-Nelson, RN, MSPH, Ph.D., a senior consultant with the Medical Group Management Association Health Care Consulting Group in Englewood, Colorado.
Primary care doctors too often defer to specialists; they should be the ones laying down the law instead, she says. When referring a patient, they should let the specialist know what information they expect to receive, and how and when. If the specialist doesn’t share test results, ignores care plans or otherwise doesn’t comply, send future patients elsewhere, she says.
3. Getting paid
Besides getting better results, primary care physicians hope care coordination will lead to better reimbursements from payers.
“It’s been an unofficial mandate for decades, and it’s only now that the primary care physician is being recognized for all the work they do in coordinating care,” says
Emily Briggs, MD, who has a primary care practice in New Braunfels, Texas.
Reimbursement, as always, takes work. Ballou-Nelson says practices should begin with a self-assessment. “Many practices think they’re doing more care coordination than they actually are,” she says. Practices should classify patients by condition, age, gender, healthcare coverage and need for care coordination, she says.
The next step is to evaluate payer contracts to determine what coordination activities they pay for and how to bill for them. “As we move into value-based contracting, you must know the ins and outs of your contracts,” Ballou-Nelson says, noting that contracts with the same payers can differ according to patients’ employers. Practices can find that they’re not being reimbursed for all they could be, she says.
Medicare’s Quality and Resource Use Report is a good source for determining how effectively a practice is delivering coordinated care compared to its peers. While the Centers for Medicare & Medicaid Services (CMS) is reimbursing now for more care coordination, such as handling patients’ transitions from hospitals and skilled nursing facilities back into the community, careful coding is essential.
Kagan says his practice bills for some elements of care coordination but not others, because the reimbursement is not worth the effort in every case. Weakland says she doesn’t bill because she doesn’t like the reporting system: “We’re being required now to spend time collecting the data, analyzing the data and reporting the data rather than spending time with patients.”
4. The polypharmacy problem
An additional challenge of care coordination is the risk of harmful polypharmacy—adverse interactions caused by drugs prescribed by different doctors.
Physicians say they rely on their EHRs and government resources such as the federal Electronic Prescribing Initiative Program and state-run prescription drug monitoring programs, to alert them to adverse drug interactions. The website drugs.com is another resource.
However, problems with EHR interoperability pose a challenge here, too. Osborne sends her patients to specialists with a list of the medications she provides and asks them to bring in the bottles of the medications specialists prescribe so she can check them. If they don’t, she asks them to contact her office with that information.
Weakland says she relies on her EHR for warnings, but still reviews her patients’ medications, whether prescribed by her or a specialist, at every visit.
“One of the most important ways of avoiding polypharmacy is to talk with our patients about their meds so we are all thinking together about that they take and is it needed, Technology helps with this, but it’s just a tool,” she says.
5. Coordinating with patients
With all the emphasis on collaboration among primary care physicians, specialists, and other caregivers, the role of the patient is sometimes overlooked. But without the patient’s cooperation, coordination does not work.
Paying for specialty care is one obstacle, as is the patient’s mental health, family support, understanding of the need for primary care and ability to travel for additional care.
“It’s all based on the patient’s sociological situation at the time. If you’re not looking at those things, you’re not a [primary care] physician,” says Briggs.
Osborne, the solo physician in rural Virginia, says many of her patients can’t or won’t travel four hours to the nearest major medical center, so she winds up delivering care that she would refer to a specialist if she worked in a city. For example, she draws blood samples from cardiac patients and mails them to cardiologists and removes cancerous skin lesions.
Dealing with a lack of transportation or homelessness are outside the scope of traditional medical care, but doctors sometimes must address such issues in order to coordinate care, says HealthTeamWorks’ Miuccio.
Practices should look to outside resources for help, including charities and government agencies, he says. HealthTeamWorks sometimes organizes meetings between physicians and community resource groups.
“Often, those on the primary care team don’t know what exists in the community. They might not know there’s a nonprofit three blocks away that offers the service they need,” he says.
Care coordinators can help by identifying obstacles to successful care. Jennifer Brull, MD, a primary care physician in Plainville, Kansas, could not figure out why a patient was unable to manage his diabetes until her care coordinator learned the man had no electricity and the heat was rendering his insulin inert. The coordinator intervened to get the man’s power back on and get him a refrigerator to keep his insulin cool.
Of course, even the most seamless coordination between providers means little if the patient can’t afford to see a specialist. So primary care doctors need to consider the patient’s financial situation before making a referral.
“We incorporate a patient’s coverage into care collaboration on a patient-by-patient basis. It is an ever-changing target and we have to be creative,” Weakland says, adding that she might hold off on ordering studies or making referrals until late in the year when a patient’s deductible has been met.
Brull says she compares specialists’ prices before referring a patient. “You look at the prices and you might ask yourself if one specialist is really the best guy to send your patient to,” she says.
For some doctors, the answer is to provide specialty care themselves, whenever possible.
“I will try to work out a way of finding out how to deliver the care without actually sending the patients (to specialists). Fortunately, as a [primary care] doctor, I’ve been well-trained and am fully capable of handling a lot of these things myself,” Briggs says.