Caring Relationships

August 27, 2014
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Small is Beautiful

Juxtapositions are thought-provoking. Comparing diverse ideas from several sources often results in new insights and perspectives. Last week’s Tao of Caring post explored the differences between physicians who have more patient-centered approaches to care and those who center their attention on technology and data.

Small is Beautiful

Juxtapositions are thought-provoking. Comparing diverse ideas from several sources often results in new insights and perspectives. Last week’s Tao of Caring post explored the differences between physicians who have more patient-centered approaches to care and those who center their attention on technology and data.

Can We All Get Along?

Three reports were published in this month about the unsexy topic of care coordination. Care coordination is the process of getting a patient’s various clinicians to talk to each other. Preferably with a rational diagnosis and treatment plan. Coordination minimizes duplicated tests, makes transitions from one care facility to another safer, and results in better outcomes. It’s such a simple notion. In theory.

Patients who have one life-threatening illness do better when all those involved in their care know what the others are doing. If the patient has two or more diagnoses, the chance of mishap seems to increase exponentially. Care coordination can head off many disasters.

Age is the biggest risk for acquiring multiple chronic illnesses. We accumulate health problems as we accumulate years. A widespread, politically correct belief says if we take personal responsibility and lead healthy lives, we won’t become chronically ill. Perhaps risks for heart disease, diabetes and stroke are reduced. Not eliminated. But there are scores of other diseases that have devastating effects on peoples’ lives. And are resistant to your lifelong broccoli intake or your exercise capacity.

A woman enduring near-blindness from macular degeneration while also suffering severe spinal stenosis that limits her mobility may lose her independence. She may develop other problems such as depression and insomnia. A man who has struggled with the effects of congenital heart disease and anxiety for many years is diagnosed with Parkinson’s Disease. Just managing his medications needs coordination among specialists. The complexities of coordinating care for these patients have multiplied dramatically.

All in health care agree care coordination is crucial. But it’s rarely done. For the usual reason. Few get paid for it. Coordinating care for one person with multiple complex illnesses is stunningly time-consuming. Matthew Press, MD wrote a piece for the New England Journal of Medicine this month describing himself as a quarterback for a 70-year old man with a newly diagnosed liver mass. He drew multicolor game-plan diagrams to chart his interactions with other providers, family and the patient. The diagrams resemble wiring schematics for Google server farms.

Clinicians may have several hundred complex patients in their practices.

Dr. Press concluded the key to care coordination is teamwork fostered by relationships. He said, “…there is only one way for physicians [and other clinicians] to confront the perilous nature of complex care: together.”

Put Your Money…

doctors coordinate careDr. Press’s account came to mind as I read the second piece; Robert Pear’s article in the New York Times. Mr. Pear wrote “Medicare to Start Paying Doctors Who Coordinate Needs of Chronically Ill Patients”, reporting a policy change approved by Medicare. Medicare, according to Mr. Pear’s article, has finally caught on to care coordination.

Medicare proposed paying for care coordination back in December 2013. (For insomniacs, pull up the Federal Register/Vol. 78, No. 237/Tuesday, December 10, 2013/Rules and Regulations. All 595 pages.) Then, in July, the Center for Medicare and Medicaid Services (CMS) issued the final rule that providers would be paid $42 per month for care coordination. Patients must agree to the plan in writing and pay 20% of the monthly cost or about an $8 fee. Doctors, nurse practitioners and physician assistants may take part in the program.

There is predictable squawking forty-two bucks are not enough to compensate clinicians for all the time, staff, and expertise required. Probably true. But it’s a start.

Small is Beautiful

The final article snagged my attention as I slogged through journal abstracts. It has the unwieldy title “Small Primary Care Physician Practices Have Low Rates Of Preventable Hospital Admissions”. The research was published online and is the collaborative work of nine authors from various institutions around the country. Using different data sets, including one that studies small and medium-sized physician practices, the researchers explored how well small physician groups performed compared to larger groups.

These authors estimate that 65% of US doctors practice in groups with five or fewer colleagues. A continuing trend has medical practices combining, forming larger groups. Hospital systems are also snapping up medical practices, turning small groups into big multi-specialty clinics. All driven by the belief that large practices offer better care. A largely untested hypothesis. The authors decided to test it.

They used preventable hospital admissions as the study benchmark. The prime goal of care coordination is to prevent hospital admissions. Hospitals are expensive, teeming with risks and patients are often in worse shape at discharge than admission.

What they found should give pause to those lobbying for larger practices and sprawling hospital systems. Patients fared best in the smallest practices. Solo practices or those with two physicians had hospital admission rates 33% lower than groups of 10-19 doctors. The authors speculate about these findings. They point out one strong reason: the patients, providers and staff know each other.  They note,  “It  is also possible… these closer connections result in fewer avoidable admissions.”

In other words, caring is about relationships. No news to Dr. Press.

The profit-driven health care system has created chaos. While trying to control the uncontrollable, such schemes as medical homes have been bolted on the ponderous structure. Perhaps we should simply stand back and quit the health care Great Leap Forward. Let doctors doctor, patients get care and see what happens.

Don’t it always seem to go

That you don’t know what you’ve got

Till it’s gone

              – Joni Mitchell