By Norman Chenven, M.D., CEO, Austin Regional Clinic
Vice-chair, Council of Accountable Physician Practices

A recent 10-nation Commonwealth Fund study of primary care physicians (PCPs) published in Health Affairs revealed that physicians surveyed struggled with care coordination, and that the U.S. has a higher percentage (about 25 percent) of primary care doctors who report that they are not prepared to care for patients with multiple chronic conditions. Additionally, 84 percent of American PCPs felt that they are not able to manage patients with severe mental illness or substance abuse.  As the CEO of a physician-led multispecialty medical group that is committed to and values good care coordination, I believe that the reasons that PCPs responded in this manner is because the majority of American physicians still work in organizations that do not provide them with adequate support.

Even though integrated systems and large multispecialty medical groups are increasingly investing in the infrastructure required to better coordinate care around patients with multiple and complex conditions, barriers created by our fragmented system of disconnected healthcare providers incentivized by a fee-for-service payment structure continue to hinder progress. The Affordable Care Act and the Centers for Medicare & Medicaid Services have been implementing incremental changes (Accountable Care Organizations, Patient-Centered Medical Homes, Bundled Payments for Care Improvements, etc.) under the banner of value-based payment programs, which in theory could spur increased coordination. However, the underlying fee-for-service payment system used in many of these models does not adequately support or reward providers to invest in the technology and staffing necessary to manage the care of our frailest and sickest.

Evolving technologies could be used to enhance care coordination but the lack of incentives and rewards to do so is a problem. A recent study conducted by Nielsen Strategic Health Perspectives revealed that American physicians still do not utilize readily available technology — such as video, email or text messaging — to communicate with their patients and more than half are still skeptical of the value of telemedicine. We all intuitively understand that educational, social and financial issues are significant factors in influencing health care outcomes for patients for complex problems, yet our health care system does not encourage or support strong communication using existing technologies or integration with our equally fragmented social service system.

While those of us in the health care and social service sectors struggle to manage and coordinate the way we deliver care, tech innovators and venture capitalists are (not surprisingly) developing ways for consumers to get care outside of traditional channels (i.e., stand-alone urgent care centers, episodic online virtual visits, do-it-yourself lab testing, etc.). While innovation is good, when it comes to health care, good outcomes for the larger system (and for patients with complex problems, in particular) are unlikely to be enhanced by further fragmentation of an already fragmented delivery system and payment mechanism. Caring for patients with complex health and social needs requires more coordination and communication with providers who know the patient well.

The article further states that America’s efforts to manage the care of high-needs patients are “nascent.” That may be true for doctors and facilities just starting their accountable care and medical home journeys. But, the members of the Council of Accountable Physician Practices and the American Medical Group Association have been delivering coordinated, accountable care for years.  Many of our physician-led, integrated, and technologically enabled organizations were the first to step forward to test new models of care and payment under the Affordable Care Act, yet improving care delivery under these new arrangements remains a complex endeavor even for us.

The U.S. is lagging in its ability to manage complex care for many reasons other than purely medical/technical ones, for we already have the training, medical technology and facilities that should support good outcomes. The challenge lies elsewhere in a multitude of legal, regulatory, financial and market barriers.