Is Care Coordination the Future of Primary Care Medicine?

It may be, but the road leading there has some challenges

As the team-based care model and its focus on care coordination expand throughout the world of primary care, so do the “coordinator” analogies. For example if you like sports, you might view the primary care physician as the quarterback of the team or the coxswain of the racing boat. If your interests run to music the PCP is the conductor of the orchestra. For cinema buffs, he or she is the director of the film.

To extend the analogy, it’s clear these particular coordinators would have a problem if, respectively, the offensive tackle decided not to block, the sweep refused to row, the first violin didn't want to tune up and the star wouldn’t memorize her lines. You get the idea. Team-based coordinated care only works if everyone involved is open to being coordinated. When it comes to primary care medicine, the coordinated team includes the patient who, if we’re doing it right, is at the center of the whole process. And that’s exactly where we’re starting to see a growing concern.

As individuals and families covered through employee health plans or other forms of public or private insurance are becoming exposed to higher out-of-pocket costs for their health care, we can expect a corresponding increase in non-compliance based on financial pressures. It’s a simple equation. Less comprehensive plans and the higher co-payments and deductibles that go with them mean more and more people will make the decision to forego needed therapies, medications and procedures because they don’t think they can afford their share of the cost.

Given this scenario, what role can physicians play to improve treatment plan adherence in the face of healthcare sticker shock? To start with, we’re not financial advisors so a direct assault on the underlying economic concerns is not going to be part of our repertoire. What can be highly effective, however, is a more open approach to talking about costs before going forward with potentially expensive diagnostic procedures or ordering medications in those instances where it may not be affordable in either the short or long term.

In an excellent article on this subject in the New England Journal of Medicine the authors contend that having this kind of discussion is as important as sharing information on the potential side effects of treatment – with the belief that the anxiety created by financial concerns is a type of negative side effect in its own right. The article goes on to suggest a number of important reasons why a greater degree of transparency and open communication in the exam room has important benefits to patient outcomes, to the patient-physician relationship and to the healthcare system as a whole.

Care coordination is an essential element in the Patient-Centered Medical Home. Likewise, it’s a critical part of the way ACOs are going to work and the foundation of our ability to provide the right care at the right time in the right place.  But without the buy-in, literally and figuratively, of the patient and often the family, without the compliance of the person who’s at the center of all the coordination resources and efforts, the full promise of care coordination won’t be realized.

Talking directly about the cost of care isn’t something we train for and is generally not the easiest kind of conversation to have with patients. Beyond the possibility that they might range from mildly awkward to downright difficult, however, these discussions are becoming part of the way we should orient our view of the whole patient. And if we believe care coordination is the future of primary care medicine, or at the very least, a big part of it, conversations related to potential out-of-pocket costs are something we need to have. There’s that much at stake.