Jan Greene

Health policy wonks have been sounding the alarm for decades that the American health care system won’t get better until it is less fragmented and better coordinated. Vulnerable patients stay sick because the system is so hard to use, so care coordinators are in great demand to ensure the chronically ill get to the doctor, take their meds, and report new symptoms. So now that everyone has seen the light and unleashed legions of care coordinators to check up on patients, it would be unseemly to complain about this welcome development. Wouldn’t it?

Not necessarily. Clinicians and caregivers who focus on high-risk patients report that the enthusiasm has gone a little far. They increasingly find their care coordinators bumping into others assigned by another practice, agency, or organization. Or, worse yet, they don’t even know about their counterparts until a patient has been given conflicting advice by one of them. The potential for mixed signals, confused patients, and wasted time and money is real.

“Sometimes [our clients] will have multiple case managers,” notes Maria Raven, MD, an associate professor of emergency medicine at the University of California–San Francisco, who oversees a care management program for San Francisco Health Plan, which provides city-sponsored coverage to low-income residents. “They may not know about each other and there’s no formalized way for them to coordinate. Sometimes they want to [work together] and sometimes they don’t.”

Health care, an industry particularly vulnerable to the promise of silver-bullet solutions, has embraced care coordination in a big way. And it only makes sense that high-risk patients—those with severe, chronic, or multiple conditions, and maybe some economic and social issues as well—shouldn’t just be chucked out the door when they are discharged. Someone should check up on them, make sure they are healing, taking their meds, getting to their follow-up medical appointments.

The question is, who? The hospital, fearing a penalty if the patient ends up readmitted within the month, assigns a care manager. The ACO, whose very existence is based on care coordination, is a natural for this job. The insurance company wants a hand in because their bottom line is at stake. The primary care doctor’s office has been told it’s their ultimate responsibility that the patient stays well, so there’s pressure to follow up. The specialist who performed a procedure in the hospital may get dinged financially by a poor outcome, so it’s in her interest to track the case. There are probably medications involved, so the pharmacy benefit manager wants to be sure drugs are used cost effectively. The pharmacy is probably by now associated with an insurer or provider in some way, so they’ll give a jingle to be sure the prescription gets filled.

Lost count yet? Some patients may enjoy—some may even benefit from—all the attention. Or they may be like the recently discharged patients the Advisory Board followed; they had received, on average, 9.5 calls from care managers in the week after their hospitalization. Most got annoyed and ignored all but the primary care doctor’s office.

“Everyone is kind of fumbling over each other, particularly because the demarcation lines about who is responsible for the patient at what time are undefined,” acknowledges François de Brantes, director of the Center for Payment Innovation at the Altarum Institute. But he sees the fumbling as temporary and the surge in care coordination as an indication that the system is, at long last, responding to patient needs. “It’s really a positive sign because it means the delivery system is adapting and adapting in the right way.”

Some of this coordination comes from a sincere intention to do the right thing. It is also fueled by payment models that are handing financial responsibility for a patient’s health to more parties. Insurers—they have always had a financial motivation for coordinating care. Now so does everyone else—primary care physicians, oncologists, ACOs—taking on financial risk in the form of bundle payments, shared savings, or pay-for-performance of one kind or another. Even drug manufacturers are being pulled into the risk-taking business by signing contracts that offer refunds if their products don’t perform.

Primary care doctors tend to find the scrum irritating because they have the most to lose and the least time and resources to deal with it. “If you have a pharmacy benefit manager and hospital case manager and an insurance plan care manager, you have three different care managers involved,” says Lynne Lillie, MD, a family physician in Rochester, Minn., who sits on the board of the American Academy of Family Physicians. “It’s hard to recognize any improved outcome from their involvement.”

PBMs: Personae non grata

Lillie has worked in settings where care management is coordinated well and in those where it’s not.

In her well-organized ambulatory care practice, she can go down the hall and ask a care coordinator to help the patient in her office with logistics of managing his illness. “We have the ability to send a community health worker to the home and make assessments and check whether there is food in the fridge,” Lillie says.

On the other hand, she used to work in a small town where the practice couldn’t afford an in-house care coordinator; the task was being carried out by others, such as insurers, who did not check in with her on protocols. “I might tell my congestive heart failure patient to call my office if they gain five pounds overnight,” she says. “An insurer might tell them if you gain two pounds a day for three days call your primary care doctor.”

Lynne Lillie, MD

The intrusion that most annoys family practice physician Lynne Lillie, MD, is when a PBM sends a patient a letter questioning a doctor’s decision without first talking with the doctor.

When multiple players get involved, it just furthers fragmentation of care and invites the potential for miscommunication and patient harm, says Lillie. Her least favorite intrusion is from pharmacy benefit managers, who may send a letter to the patient questioning the doctor’s medication choice without consulting with her. “It’s not coordination to get a fax from the pharmacy benefit person who looked at the care out of context,” she says.

Raven, at San Francisco Health Plan, sees the multiple care managers and coordinators as meaning well, but potentially causing confusion. Because her program invests a lot of time in tracking down frequent ED visitors, who often have thorny and time-consuming housing and transportation problems, SF Health Plan care coordinators are trained to consider themselves the “accountable person” and take the lead in figuring out who else has been in touch with the client.

Kelly Craig

Confusion often happens when there is overlapping coverage of patients by multiple players whose lists don’t jibe, says Kelly Craig of the Camden Coalition.

The care coordinators with Camden Coalition in New Jersey, an early leader in innovating population health for vulnerable populations, say part of the confusion happens when there is overlapping coverage of patients by multiple players whose lists don’t jibe. “They’re getting a list based off of different algorithms, and it can be overwhelming to figure out which of those patients overlap,” says Kelly Craig, chief strategy and information officer for the coalition.

As part of a program to reach super-utilizers of medical services, the coalition sponsored a monthly meeting with partner organizations across the city, carrying out root-cause analyses of each patient and identifying any overlap among their services. But that meeting has become untenable as the program has grown and more participating organizations are using population-health methods. “Now there are so many more entities, [the regular meeting] has become less effective and it’s harder to get everyone in the room.”

The lack of coordination, she says, “has definitely gotten worse over time.”

Some of the overlap is from well-meaning not-for-profits offering solutions to social ills, but a lot of it is fueled by organizations newly incentivized to save money on high-utilizing patients. Asking an organization whose financial viability may be decided by its care coordination program to back off and let others take the lead may be a hard sell.

That kind of friction can appear when payment models overlap, notes de Brantes. He offers a scenario: An ACO shares a patient with a partnering specialty practice—oncologists, for instance—who are working under a separate specialty payment model. They are both trying to provide efficient care for the same patient. Who gets precedence?

“This is something we’re just starting to work on with a couple of the large national payers,” de Brantes says. The solution, he says, may be in writing contract language with payers that is explicit about which overlapping organization has responsibility for plan members when they get specialty care covered by another contract.

HIEs … if only

De Brantes believes another answer lies in health information exchanges providing a central repository of patient data. “It starts by having an unfettered flow of clinical data between all the providers that touch a patient,” he says. Easy, secure electronic messaging among providers would also help.

Those seemingly simple goals have been elusive in most health care markets because of conflicting software and competing providers who lack incentives to share patient information. Recognizing those challenges, the Camden Coalition has invested in legal and technical staff to iron out information-sharing difficulties and privacy concerns. Still, says Craig, it’s frustrating.

“Even when we make a concerted effort to make the information available online, people don’t use it,” she says. “It’s only as helpful as someone’s willingness to use that system. Folks may not have time or the right workflows to access that, and then you’re not improving quality and duplication of effort happens.”

De Brantes’s organization, when pulled in to get a population-health effort off the ground, often finds itself working with health care organizations and social service agencies that are serving the same patients but have utterly different information systems. Altarum will manually set up an electronic registry that lets the systems share information.

Integrated delivery systems that act as provider and payer may have a head start on coordination because care delivery and money flows are already joined at the hip in information systems. “We can align far better than other organizations with the use of a technology platform that tracks the roles and tasks of each provider along the care continuum,” William Shrank, MD, medical director of UPMC’s health plan, wrote in response to questions from Managed Care. “We place care manager ‘quarterbacks’ within communities who get to know the patients they manage personally.”

A team sport

So who should coordinate the coordinators? Not surprisingly, family physicians think they should be at the center of the spokes. And many in population health agree that if the patient has a primary care doctor—particularly one who runs a medical home-style practice that is prepared to coordinate care—medical decision making should be run through that practice.

But what about the social determinants of health—the welter of transportation, housing, and family problems that can affect health, directly and indirectly? Isn’t it too much to expect a primary care office to take responsibility for that, too?

Primary care practices don’t need to be afraid to take on the social determinants, argues de Brantes, particularly because emerging payment models will require it. But they can outsource the work. “You have to feel comfortable as a primary care physician to delegate social needs to organizations that can take the relay,” he says. Primary care practices need to see themselves as being part of the community, not just the medical system, and be willing to lean on not-for-profits that can help their patients with problems that affect health but haven’t been traditionally seen as the province of health care providers.

But is this all too pie in the sky? It will depend on the relationship between health care providers and their social service partners, notes Melinda Abrams, vice president of delivery system reform for the Commonwealth Fund. “It requires a lot of trust because I’m relying on the social service provider to meet my financial bottom line,” she says. But relationships are what all of value-based care relies upon, she says. “Trusting relationships between patient and practice, health care organization and social service provider, payer and provider … this needs to be a team sport.”

Another likely central coordinator is the insurer, because each patient is likely to have just one at a time. The insurer can gather information through claims from a variety of providers and so has a bird’s-eye view of the whole care landscape. The problem, of course, is that providers and patients are wary of insurers and their cost considerations getting too involved in health care decisions.

Natasha Dravid

“Collaboration with insurance providers can be a really powerful solution” for tracking high-needs patients, says Natasha Dravid, director of the Camden Coalition’s redesign initiatives.

The Camden Coalition works closely with its insurer partners to share information and track high-needs patients, says Natasha Dravid, director of the organization’s clinical redesign initiatives. “Collaboration with insurance providers can be a really powerful solution,” Dravid says.

De Brantes believes health plans should be stepping forward to help make sense of it all. “It is incumbent on the health plan to say, ‘You guys are sharing the same patient. We get it, you have an incentive to care for the patient, but you all should be talking to each other so you don’t end up with three different people calling this poor plan member.’”

Another option is to add a layer of coordination such as the one developed by the Advisory Board that it calls a population health services organization (PHSO). The PHSO, usually based within a provider organization, takes the lead on care coordination and offers all the care coordinators assigned to the patient a common care plan.

Others are sanguine and figure it will work itself out as everyone gets used to new relationships and workflows that population health brings with it. “We are in the middle of this evolutionary process to better coordinate care,” says Abrams at the Commonwealth Fund. “It is a massive paradigm shift and we need to give it time.”

Jan Greene is a veteran health care journalist based in Northern California. Her work has appeared in the Los Angeles Times, Health magazine, Hospitals & Health Networks, and other publications.

But sometimes, there’s a lack of a needed care coordinator

A Commonwealth Fund survey of 1,805 “high-need” patients found that many (43%) have needs that a care coordinator might help with but they didn’t have a care coordinator. Others (15%) who did have a coordinator considered the person uninformed. Most of the high-need patients surveyed had multiple complex chronic conditions, some were under age 65 and disabled, and a minority were frail elderly.

Less than half of high-need patients who might need an informed care coordinator have one:

Source: Commonwealth Fund, “How High-Need Patients Experience Health Care in the United States,” December 2016

The survey also found:

  • 37% of high-need patients often feel socially isolated or lonely
  • 62% are stressed or worried about material hardships, such as paying for housing, utilities, or nutritious meals (compared with 32% of other adults)
  • 59% are somewhat or very concerned about being a burden to family or friends
  • 44% delayed care in the past year because of an access problem, such as lack of transportation, limited office hours, or inability to get an appointment quickly enough
  • 35% report it is easy to get medical care after hours without going to the ER (compared with 53% of other adults)