Primary-Care and Specialists Get Their Wires Crossed - and what to do about it

What we’ve got here is a failure to communicate.

via blogs.wsj.com

"Don't you guys talk?"  Well, to be perfectly honest..... not so much, and it costs us all:

• Primary care practices spend a significant part of staff time on tracking down information from emergency departments, hospitals, and specialists, filling out forms that - if approved - would make it possible for the practice to then call to try and arrange a scan, a consultation, etc.
• Specialists are sent the wrong patient for the wrong reasons with the wrong work-up or have no information at all and a patient who has no idea why they are there.
• Patients of course suffer the most. 

A colleague of mine surveyed a high-functioning group of individuals (readers of a reputable online news service). Some of these people reported that they were receiving care from their PCP and a specialist. 

Asked "Do you know who is in charge?", 25% said "No."  Those 25% were twice as likely to report having been hospitalized within the past year.

This striking correlation has a number of possible explanations.  One possible explanation is that we in the health care system are operating in silos and are put the people we serve at risk when we fail to communicate well across those silos.  This explanation has some face validity since poor communication and lack of coordination is a near-universal experience.

What can we do about this?

1. Require seamless communication across health information technology platforms.  The rules we have in place are either inadequate or inadequately enforced.  Right now we have lip service commitment to cross-platform communication but systems almost never communicate well and the cost of bridging the gaps is completely out of reach of the average practice.
2. Require insurers to pay for care coordination by primary care.  The evidence supporting good care coordination abounds yet practices receive only lip service - requests to do more without the means to do the work.  Primary care is the weakest part of our health care system because we have systematically starved it beyond its ability to perform the basic functions of primary care.  "Help" that stipulates "do this extra work and we'll consider maybe paying you in the future if you get those pigs to fly" is a non-starter.
3. Make 'patient experience of care coordination' a core quality metric.  We over-emphasize relative trivia while mostly ignoring the core functions of primary care.  This distracts the national conversation, the work of practice transformation, and new payment models with lower impact work while fundamental benefits to the public are ignored. We don't have to give up measuring 'the percent of diabetics who have had monofilament foot exams', but we should focus first on a core set of primary care measures addressing the core features of primary care:  access, relationship over time, comprehensive services, and care coordination.

Transforming our health care system so that we may achieve better outcomes at lower per capita costs will take monumental effort.  That effort should focus first on the most important aspects of our current failures - the ones that have the greatest possible benefit for the widest number of people.

Supporting primary care transformation does just that - but only if the transformation addresses the fundamental attributes of primary care.

Comments

[L Gordon Moore]

Get the word out by writing to journals, give a talk to health policy folks, speak to your local medical society.
We need colleagues and the public to understand our willingness to engage in meaningful change, but that our good intentions are thwarted by an unresponsive and largely toxic policy and payment environment.

[Robert Watkins]

' "Help" that stipulates "do this extra work and we'll consider maybe paying you in the future if you get those pigs to fly" is a non-starter.'

Bravo! That's the fundamental flaw so many practicing physicians saw right for the start in the PCMH concept. Building a medical home on the hope of becoming enrolled in a "demonstration project" is not financially viable. Any thoughts on how we can generate more discussion on this point?