Concerns over the cost of health care and apparent lower health outcomes in the United States compared to other developed countries have significantly influenced program development by the Centers for Medicare and Medicaid Services (CMS). New reimbursement strategies intended to address cost and drive quality—specifically the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)—are placing new clinical and operational demands on the health care industry.
So in the era of MACRA, providers need to balance reporting requirements (which can be time-consuming) while continuing to put patients first. One of the best ways to do this is to ensure patient care is well coordinated.
Moving Forward with MACRA
MACRA made fundamental changes in the way health care providers are paid for Medicare patients. MACRA included the repeal of the Sustainable Growth Rate (SGR) and moved toward rewarding providers for performance through the Merit-based Incentive Payments System (MIPS) and, ultimately, the Advanced Alternative Payment Model (AAPM).
Thomas James, III, M.D.
Under these rules, providers have to take on more financial risk, including bundled payments in a system reminiscent of capitated payments from the 1990s. The capitated model from the 1990s resulted in a system negatively perceived in part for its “gatekeepers” and resulting decreased access to services.
Providers have an opportunity with this new system to do the right thing by coordinating care so that patients get the services they need and don’t fall through the cracks—to avoid repeating history from decades ago.
Care Coordination Goals
Delivering “coordinated care” involves having mechanisms in place to ensure that information about the patient diagnosis and treatment is shared with the patient and all participants concerned with the patient’s care. This enables the patient to receive necessary health care in a timely manner. The primary goals of care coordination are clear:
- Patient Centeredness: Improve health outcomes by empowering patient participation in determining case priorities to achieve greater engagement in diagnosis and treatment.
- Health System Focus: Enhance sharing of clinically actionable information among all care providers engaged in the care of an individual patient.
Patient preferences should be part of the decision-making process and “participants” include patient caregivers and the full range of providers across relevant health care settings (e.g., referring physicians, specialists, diagnostic centers, pharmacies, home care agencies, acute care hospitals, skilled nursing facilities and emergency departments).
Coordination of care is especially important as patient health issues increase in complexity and include multiple providers. Centers for Disease Control and Prevention (CDC) data indicate that there are 297 office visits per 100 patients and slightly more than half (53 percent) are primary care provider visits. This information indicates it is likely that a significant number of patients are seeing both primary care and specialty providers, highlighting the importance of coordinated patient care.
Care Coordination Management
Care coordination can be managed by a single person, usually a nurse or medical social worker. A care coordinator may be the employee of a physician group, a hospital or health care facility, a payer, or social service agency. Virtual care coordination, whereby physicians participating in the care of the individual patient use a common electronic medical record (EMR) to share information on diagnosis and treatment with other participating providers, is another option.
Studies indicate there is room for improvement in the coordination of care among multiple providers, and there are many tools to help providers accomplish this, such as:
- Tracking systems for patient tests
- Referrals and follow-up appointments
- Automated reminders regarding scheduled care
Tracking systems can be a key component in care coordination as they reduce the chances of patient care falling through the cracks while also increasing patient satisfaction, according to study in the Joint Commission Journal on Quality and Patient Safety. Simply offering tools such as online tracking systems as part of electronic health records (EHRs) without guidance through an implementation process is often insufficient. Providing guidance tools and assessing the success of implementation using a rapid-cycle quality improvement activity may be effective in improving laboratory test preparation, tracking of laboratory tests and patient notification, according to a study published in the journal of the American Board of Family Medicine.
Another asset for care coordination management is performance benchmarking and standards that guide quality improvement. The National Quality Strategy identifies “promoting effective communication and coordination of care” as one of six priorities to target the triple aim. Accrediting organizations—such as AAAHC (Accreditation Association for Ambulatory Health Care)—have care coordination standards requiring documentation in the clinical record of consultations and referrals, as well as missed, after-hours and follow-up appointments. AAAHC Standards also require that transitions of care are proactively planned, coordinated and documented in the clinical record.
In the surgical/procedural setting, AAAHC Standards require organizations to have written guidelines for the transfer of care from one provider to another that includes information about the patient’s care, current condition, and any recent or anticipated changes. These Standards are comparable to those required by other accreditors/regulators.
To assist care coordination managers in developing processes, measuring performance and implementing quality improvement strategies to meet requirements, there also are several toolkits available including:
- An upcoming AAAHC patient safety toolkit, Tracking Patient Tests and Referrals, summarizes the evidenced-based research on the topic and includes resources for providers in both the primary care and ambulatory surgical/procedural care settings.
- The Agency for Healthcare Research and Quality (AHRQ) PCMH Resource Center offers online resources to help clinicians, clinical teams and health care administrators measure care coordination and learn more about how to incorporate care coordination into routine primary care practice.
- An American College of Physician (ACP) High Value Care Coordination (HVCC) Toolkit contains out-patient referral request templates and response checklists. ACP also has developed two care coordination agreements templates. One template is an agreement between the primary care practice and the hospital and the other is an agreement between the primary care physician and the specialist. These templates define the expectations and responsibilities for the providers involved in a referral relationship.
New regulation doesn’t mean having to repeat past problems; instead, this is a continued opportunity to put patients first, hear their input and help them navigate the different components of their care to ensure there are no gaps. Providers have a growing number of resources available to assist them in all aspects of care coordination and if they haven’t already, this is the time to use these resources to their fullest.
Thomas James, III, M.D. is corporate medical director for Medical Management and Quality for Highmark, Inc. In this role, Dr. James provides clinical oversight to Highmark’s quality and wellness departments. He is actively involved with organizations working to improve the quality of health care including the National Quality Forum and AAAH. Prior to joining Highmark, Inc., Dr. James served as senior medical director for such organizations as Baptist Health in Kentucky, AmeriHealth Caritas, Humana, Anthem, Traveler’s Health Network, Sentara and HealthAmerica. He has experience with commercial, Medicare and Medicaid health plans. Dr. James is board certified in internal medicine and pediatrics. He received his medical degree from the University of Kentucky and served his residencies at Temple University Hospital, Pennsylvania Hospital, and Children’s Hospital of Philadelphia.