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Coordinated Care Needed Now

 |  By jcantlupe@healthleadersmedia.com  
   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.

"Primary care is the bedrock of a good healthcare system, but this report is saying just having more primary care will not necessarily fix our quality of care," says another co-author, Shannon Brownlee, MS.  Other report authors are David C. Goodman, MD, MS and  Chiang-Hua Chang, PhD. "It means that healthcare policy should focus on improving the actual services primary care clinicians provide, and make sure their efforts are coordinated with other providers, including specialists, nurses and hospitals."

While improving care delivered by primary care clinicians holds promise for a patient's wellbeing, the "value of primary care can be eroded by episodic delivery that is uncoordinated with specialists and hospitals," the study says. "Thus, simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage, may not be enough to improve the quality of care or health outcomes; nor is it likely to eliminate racial disparities."

Brownlee, a writer and senior research fellow at the New America Foundation, says she was surprised by the findings. "I think part of what is happening is the chaos factor"—primary care physicians working in isolated practices, with a lack of coordination with specialists, such as for diabetes or other medical conditions, she says.

"Was the heart attack patient prescribed aspirin and a beta blocker on discharge?" she asks rhetorically. Sometimes, or too often, that doesn't happen because of the lack of coordination, Brownlee says. "It is really crucial to keep track of a patient. If the patient only knows what is happening, you've got a big problem."  Brownlee is a specialist in healthcare writing and has written "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer."

In essence, the Dartmouth study shows that "organization of the system is a big part of the problem," Brownlee says, adding that "simply throwing more physicians at a problem is not going to fix it."

 "With lots and lots of specialists, it becomes more and more difficult for that primary care physician to really keep track on what is going on," she says. "We see simple stuff fall through the cracks, the more chaotic the care is."

So, there's the need for coordination of care, she says, more than ever. In some variations, we've heard that before, in the calls for Accountable Care Organizations. Fisher, known as one of the innovators of ACOS, wrote in Health Affairs in 2009 his proposal to "achieve more integrated and efficient care by fostering local organizational accountability for quality and costs through performance measurement and "shared savings" payment reform."

With this study, Fisher, Brownlee and their colleagues again are calling 911: coordinated care is needed now.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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