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The AAFP and Payment Reform — They’re Screwing It Up, Again, Part 4 – Care Coordination

February 27, 2017

First, I’ll quote the statement in the AAFP’s Alternative Payment Model document that deals with care coordination:

“[P]rimary care is best positioned to coordinate care across settings and among physicians in most cases. Primary care medical homes work closely with patients’ other health care providers to coordinate and manage care transitions, referrals, and information exchange.”

What the heck does “coordinate care” really mean? Drive your patients to their CT scan appointments? Double check chemotherapy doses? Call the nursing home every 2 hours to be sure the stroke patient was turned? Pre-approve patient grocery lists?

The devil is in the details and this statement is so vague as to be vulnerable to the dark forces. To my ears, care coordination mostly sounds like the AAFP is saying we’re just a bunch of medical traffic cops. “You have a nose problem? I’ll coordinate care with the nose doctor.” “You had 20 minutes of sharp right-sided chest pain that was proved to not be a heart attack and you’ve had no problems since? I’ll coordinate care with a cardiologist to be sure you have every test they offer, just to be on the safe side.

Both of these statements are examples of coordinating care, but they would result in horrible care, costs, and satisfaction for patients.

Even I have to admit that there are a few times in a patient’s life when the most important aspect of maximizing her health is for her to get out of my office and see another doctor. They don’t give me the keys to the cath lab, but sometimes patients actually benefit from a cardiac cath. There is no reason for me to learn all the evidence for a rare disease (though there usually isn’t much if it’s rare), so really rare diseases should be the purview of the ologists. But I should own all the common symptoms and diseases, and, as we in family medicine like to say, commonly things occur commonly.

The most important action to improve patient outcomes and lower costs is for the family physician to OWN AS MUCH OF THE CARE AS POSSIBLE. This doesn’t mean refer patients constantly. It means refer rarely and for very specific reasons with a very short shelf life. “Hey nephrologist, I have one quick question about medications and kidney toxicity. Answer the question and DON’T DO ANYTHING ELSE TO MY PATIENT.” Care coordination doesn’t mean have your employee call the nursing home employee for information sessions that result in nothing actionable. It means see your own patients in the nursing  home, or hospital, or rehab center, or home visit.

Of course the  bureaucrats who live along the Eastern seaboard have absolutely no concept that this comprehensive care is even possible, much less beneficial, because they live in extremely siloed worlds, where every healthcare facility has a different team of doctors and their entourages. They don’t know what it’s like for a family physician to do hospital rounds, then go to the clinic, then go to the nursing home, then make a home visit, then see a patient in the ER. The places with the best outcomes and the lowest costs in the U.S. are the ones where the family physicians see patients the most, and the ologists see patients the least. Care coordination should be a rare event in a fully supported and compensated family physician’s office, because there is little care that needs coordinating.

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