Great Deal Of Discussion

Robert P. Roca, M.D. 

As you would expect, there was a great deal of discussion about health care reform during the spring meetings of the American Psychiatric Association in New Orleans and American Medical Association in Chicago.  One conspicuous feature of the discussion in both venues was the radical diversity of opinion.  At one end of the spectrum were physicians who felt passionately that the bill was terrible for medicine and who were furious with the AMA leadership for supporting it.  At the other end were those who felt passionately that the bill was too conservative and did not go far enough to change the system.   

But beneath the clamor of words and ideas were certain unmistakably harmonious undertones.   It was clear that everyone in the conversation loved the practice of medicine and was willing to put many uncompensated hours into hashing out positions that protect the legitimate interests of our hard-working physician colleagues who serve as the anchor of our health care system.   One such interest is fair and reasonable reimbursement.  There was unanimity that the SGR problem must be fixed once and for all – despite the associated political and fiscal complexities.   

It was also clear that everyone puts great value on the doctor-patient relationship and on our duty to provide the highest quality of care.  This means not only providing the best possible care in our individual practices, but also taking the lead – through our medical organizations – in defining quality, promoting quality, and selecting quality indicators.   This is a central concern of both of the APA and the AMA.   I have had personal experience in these efforts as a representative of the APA to the National Quality Forum Steering Committee on Mental Health Outcome Measures as well as a member of the AMA’s Physician’s Consortium for Performance Improvement on the development of quality measures for dementia care.  I continue to be impressed that we physicians – despite our differences of opinion in many areas - are united by an earnest commitment to doing our best for the people we treat. 

This brings me to what is arguably one of the top practical issues in the quality of care for patients with multiple comorbidities: coordination of care.  All of us who care for patients recognize the importance of knowing what our patients’ other doctors are finding,  recommending, and prescribing, but we often have trouble getting timely information, increasing the likelihood of duplicative testing, problematic prescribing, and other wasteful if not dangerous practices and outcomes.  All of us who have ever been patients ourselves, or advocates for loved ones who were ill, know how often we felt that the treating clinicians did not know the whole clinical picture, in part because they were not closely enough in touch with each other.    Those of us involved in organizations accredited by the Joint Commission have heard that the most common root cause of avoidable adverse outcomes is the failure to communicate with our fellow clinicians.    

These issues must be of great concern to all physicians who are interested in the quality of care and who believe that physicians need to take the lead in assuring the quality of care.   The question is what steps can we take to ensure that we communicate essential information to each other accurately, in time, all the time.  This is a complex question, and the solution will almost certainly require approaches from many angles, including the smart use of communication technology, the creation of financial incentives for coordination or care, refinements in clinical workflow, and changes in medical training that would encourage physicians to work collaboratively. 

There are a lot of big ideas out there.   One of them is the Medical Home, at this point a relatively abstract idea that seeks to coordinate care by various means yet to be fully worked out.  There should be more to say about how this will take shape in Maryland as the demonstration projects called for by the Patient Centered Medical Home legislation get underway. 

Another big idea to promote coordination – and a less abstract one – is co-location, i.e, putting physicians who share patients shoulder to shoulder under the same roof.  This is an appealing idea with significant face validity as a method to improve coordination of care for patients who need to see specialists as well as primary care physicians.  It makes particularly great sense in the care of patients with mental illness and co-morbid medical conditions.  My own experience as a geriatric psychiatrist imbedded in a geriatric medicine clinic showed me the virtues of co-location.   It was clearly a boon to coordination of care between the geriatric internist and the psychiatrist.  But in addition it reduced barriers to mental health specialty care, increased early detection and treatment of psychiatric problems, and provided enhanced support to both physicians.   

This is not a specifically geriatric issue.  The National Institute for Health Care Management has produced an extensive paper on Strategies to Support the Integration of Mental Health into Pediatric Primary Care.  It stresses and illustrates the increasing role of pediatric practitioners, both pediatricians and family practitioners, in the care of children and adolescents with mental health problems.  The paper estimates that one in five children or adolescents in the U.S. experiences a mental health problem and one-half of all lifetime mental illnesses begin by age 14. Given the prevalence and complexity of these conditions, and the growing evidence that early intervention in serious mental illness improves long-term prognosis, it would make sense to locate psychiatrists in general pediatric settings so that expert care is maximally accessible and readily available. 

A special group of patients for whom co-location would be extremely valuable is adults with such conditions as chronic schizophrenia and severe bipolar illness.  Patients with these conditions die, on the average, 25 years earlier than individuals without these illnesses, and they die from chronic medical conditions that in many cases have gone untreated or inadequately treated because of very sporadic contact with primary care physicians.  For many of these patients, the mental health center is the sole contact with the health care system, and it would make great sense to provide primary care services on-site in community mental health care settings.  This is a novel twist on co–location; i.e., it brings primary care to the specialty care setting rather than the converse.  This approach has been tested in a very limited way, and it appears to increase the proportion of persons with mental illness who receive appropriate general medical care.  But it is not financially feasible to co-locate these services in the current reimbursement climate. 

One intriguing provision of the Health Reform bill is a potential game-changer in this area.  The bill creates funding for demonstration projects that would find ways to bring the services of primary care physicians into the mental health centers where these vulnerable patients receive psychiatric services.  If these demonstrations prove successful in developing effective incentives for this kind of co-location, it could greatly improve the access of persons with serious mental illness to primary care and be a great boon to the welfare of patients who have fallen through the cracks in our health care system. 

 We will not know the fate of these big ideas or extent of the funding for demonstration projects for some times.  But there are actions we can take now locally to improve coordination of care.   Discussions are currently underway between the BCMA and MedChi and the Maryland Psychiatric Society to develop systems that would make it easy for psychiatrists and primary care physicians to communicate with one another.  One idea is to create a listserv to link primary care physicians and psychiatrists.  The MPS has experience with a very popular and successful listserv for Maryland psychiatrists.  The purpose of the listserv would be to give primary care physicians access to psychiatrists when they have questions and concerns about mental health treatment and to give psychiatrists access to primary care physicians when they want general medical input.  There are details to work out, but I am hoping that we can have this up and running within the year.  Another idea – a potential low-tech, patient-centered coordination tool – would be to develop and disseminate “health passports” designed to accommodate such information as medication lists, allergies, and contact information for other physicians; patients would carry this with them when they see their doctors to make it easier for us to know what others are prescribing for our patients and how to reach them. 

These are just a couple of small communication-enhancing ideas we can work on locally while we wait for the verdict on the big ideas.  If you have ideas – big or small – about how we might improve coordination of care, I invite you to send them to me at rroca@sheppardpratt.org.   

I hope to see you soon at some of the educational and political get-togethers we are sponsoring in July.