Coordinated Care Needed Now

Joe Cantlupe, for HealthLeaders Media , September 16, 2010

Boost the number of primary care physicians: It's a refrain we hear repeatedly in the healthcare reform debate.

A new study from the Dartmouth Atlas Project adds another layer to the debate. But here's the rub: the study authors don't expressly call for more primary care physicians. Numbers alone won't do the trick, they say. The study says neither higher amounts of primary care services nor routine visits with a primary care clinician is by itself a guarantee that a patient will get recommended care or experience better health outcomes.  What works? Coordination of care, the authors say.

"As is often the case in health care—it's not always how much you spend, but how you spend it," says one of the study's co-authors, Elliot S. Fisher, MD, MPH, co-principal investigator for the Dartmouth Atlas Project. The Dartmouth Atlas Project is run by the Dartmouth Institute for Health Policy and Clinical Practice.

The study, Regional and Racial Variation in Primary Care and Quality of Care Among Medicare Beneficiaries, examined the relationship between the per capita supply of primary care physicians and the percent of Medicare beneficiaries who had at least one annual visit with a primary care physician during 2003-2007. It "suggests that there is no correlation between the supply of physicians and access to primary care," according to Fisher.

"Achieving the benefits of primary care is likely to require both improving the services provided by primary care physicians and more effective integration and coordination with other providers," the study says. "A higher supply supply of primary care may be important in smaller areas, but unfortunately, public policy and reimbursement practices have not matched patient needs with supply at any level, local or regional."

In a study of fee-for-service Medicare population from 2003-2007, the study points out that improving access to primary care doesn't always keep people with chronic conditions out of the hospital, or improve their chances of getting optimal care. Those conditions include diabetes, and congestive heart failure, as well as screenings for breast cancer or eye examinations, and leg amputations.

Access to primary care physicians also may not be enough to overcome racial disparities in quality and outcomes, the study says. Too often, people most in need of primary care simply don't receive the necessary care as well, according to the authors.

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5 comments on "Coordinated Care Needed Now"

John Morrow (9/18/2010 at 11:44 AM)
Buz is right...the last time I checked FFS data doesn't have an indicator for who got coordinated care and who didn't, so the conclusions are quite anecdotal, and biased toward the author's business interests in the health coaching industry. I think we are all seeking better care, but if we have no access to care, coordination is way downstream as the end solution. More PCPs will address access and allow for more appropriate coordination...assuming someone will reimburse for these services. Once again another self-serving bit of folly out of Dart_mouth.

Bob Stone (9/17/2010 at 11:07 AM)
There is certainly no question that better coordinated care must be part of any solution that is likely to be effective in improving heealth and well-being, as well as reeducing cost. I find it interesting, however, that [INVALID] at least according to this report [INVALID] most call for coordianted care seem to focus on coordination between elements of the delivery system. While there is certainly room for improvement in that area, I am surprised by the absence of reference to the need for the individual's and/or caregiver's active involvement in the coordination effort. In most cases, and in particular cases involving individual with chronic disease, it is the individual who is responsible for their own care [INVALID] sometimes as much as 98% of the time. Accordingly, unless the coordination infrastructure is focused primarily on the individual and is interacting with him or her on a regular and proactive basis, the opportunity to avoid the need for coordination among the elements of the "sick system" is lost, and cost will inevitably increase.

HD Carroll (9/17/2010 at 9:35 AM)
(1) Poverty, whether you spell it with hyphens or not, is a relative term, and measuring it is trying to define a moving target - the US Government is infamous for not adjusting the income definition. Having said that, I am certain housing, shelter, education, and hygiene (which in my terms includes basic preventative medicine) deficits have a lot to do with health outcomes - it is improvement overall in those items that caused the large majority of improvements in both morbidity and mortality since 1900. For certain demographic segments of the population such improvements are likely still available, with the education/cultural shift components being the primary ones. (2) the study period involved may simply turn out to be viewed historically as a time before true primary care shortages actually came about due to failure in medical education and the sudden influx of millions of new insured persons suddenly seeking the free wellness benefits promised by the reform laws. Do the study in 15 years and let's see if the situation has changed at all. (3) Of course we need more and better coordinated care - when have we not?




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