A coordinated, patient-centered health care system is one of the main promises of health care overhaul.
Most health care analysts think coordinated care — where all the doctors treating a patient work together to meet his or her needs — is good for patients. If done right, advocates say it would also save money by reducing duplicate testing and hospitalizations, though there isn't much definitive evidence on this.
But the House bill passed by three committees falls short of requiring health care professionals to coordinate care. It's a tricky thing to legislate, and all insurance providers work differently. Instead, the legislation calls for pilot studies within Medicare and a grading system for insurance companies that may or may not motivate insurers to offer coordinated systems.
The Advantages Of Coordinated Care
Coordinated care offers the promise of reducing hospitalization and emergency department visits, says Dr. Anne O'Malley of the Center for Studying Health System Change. Primary care doctors would act as the managers and front-line caregivers, so people see specialists when they need them, duplicate testing does not occur, and medication confusion does not occur, she says.
Coordinated care is a broad term and can mean different things in different medical settings. One element of coordinated care is disease management, in which insurers or hospitals set up programs for people with chronic conditions such as diabetes. For example, in a diabetes disease management program, patients see a nutritionist, an educator and a doctor who all work together, though they only coordinate in treating that one medical condition.
There are also "medical homes," where doctors or hospitals create systems in which the patients see the same set of doctors, and the doctors share records.
A third option is fully coordinated care like the type available at some HMOs, such as Kaiser Permanente.
Insurers That Already Provide Coordinated Care
Kristen Batten of Alameda, Calif., used to be a member of Kaiser until her employer switched plans. With an 11-month-old son and a 3-year-old daughter, Batten says getting care is more involved now. At Kaiser, the pediatrician would write a vaccination order, Batten and her children would go down the hall to the vaccination center, and that was it.
"Now when we go to the pediatrician, we're given paperwork, which we have to take to a clinic off site, a few blocks away from the pediatrician's office," she says. "It's a matter of bundling the kids back up into their clothes, and getting them into the stroller and to the new site. It adds another level of complexity that is a little frustrating."
Why Don't More Providers Prioritize Coordinated Care?
Most health care analysts think coordinated care is good for patients. The reason there's not more of it is money, says Dr. Alan Garber, who directs the Center for Health Policy at Stanford University.
"The biggest obstacle to establish coordinated care in routine clinical settings in the U.S. is not so much that doctors and hospitals aren't organized to provide it," says Garber. "It's that very often they have no financial incentive to do so."
Most doctors don't get paid for talking to one another, or to you. They don't get paid for tracking down an X-ray or biopsy result; they do get paid for doing new ones.
And coordinated care is a problem for hospitals, too, says O'Malley. "Guess what? It's fewer hospitalizations and revenue for them."
Effects On Spending
Whether coordinated care would save money is unclear. A recent analysis in the Journal of the American Medical Association of 15 Medicare projects showed no significant reductions in hospitalizations, no net savings and little improvement in quality. An analysis done in 2004 by the Congressional Budget Office found that there was insufficient evidence to say that disease management programs reduce health spending.
But recent studies of people with congestive heart failure treated by a team show better care and a 30 percent reduction in costs. Proponents of coordinated care say it's a matter of designing the right kind of program.
Garber says writing legislation to directly require some type of coordinated care would be too prescriptive. What's in the House legislation is not prescriptive, just suggestive. The Medicare pilot program would try bundling payments together so that doctors and hospitals make money by keeping people healthy.
The House bill also sets up an insurance "exchange" in which people could buy health insurance. The exchange would collect and distribute data on how well patients do on each plan, and some health strategists say they hope that plans that offer coordinated care would have better results, and thus attract more buyers, and that the Medicare pilot programs would set a good example, as well.
"If care coordination works as well as we think it does, it certainly will be higher quality and lower cost," Garber says.
If the legislation doesn't pass, coordinated care may find a life of its own. Some Medicaid programs have already set up "medical homes" where Medicaid recipients see the same doctor, or group of doctors, each time they come in, and the doctors focus on preventing patients' illnesses. And some insurers already are running their pilot projects on their own.