Fastsummary of Redesigning the Practice Model for General Internal Medicine. A Proposal for Coordinated Care

Health care has grown more complex: more patients have more chronic illness that requires coordination by a highly trained specialist in adult medicine. In 2005, 133 million Americans (45% of the population) had a chronic condition; approximately 60 million (24% of the population) suffered from multiple chronic conditions, and this number is projected to increase to 81 million (25%) by 2020. 1 , 2 Care for this type of patient is complex and expensive. Total yearly medical expenditures for a person with a chronic condition ($6,032) are more than 5-fold higher than for a healthy person ($1105) (Fig.&x000a0; 1 ).

Redesigning the Practice Model for General Internal Medicine. A Proposal for Coordinated Care

A DISINTEGRATING HEALTH SYSTEM FOR PATIENTS WITH CHRONIC ILLNESS. CREATING A PRACTICE MODEL FOR CHRONIC ILLNESS THAT WORKS&x02014;COORDINATED CARE. PRINCIPLES OF COORDINATED CARE THAT IS EFFECTIVE,. A PROPOSED MODEL FOR PROVIDING COORDINATED CARE. PAYMENT FOR COORDINATED CARE. THE SPECIAL ROLE OF SGIM. References. Abstract General Internal Medicine (GIM) faces a burgeoning crisis in the United States, while patients with chronic illness confront a disintegrating health care system.

Reimbursement that rewards using procedures and devices rather than thoughtful examination and management, plus onerous administrative burdens, are prompting physicians to pursue specialties other than GIM. This monograph promotes 9 principles supporting the concept of Coordinated Care&x02014;a strategy to sustain quality and enhance the attractiveness and viability of care delivered by highly trained General Internists who specialize in the longitudinal care of adult patients with acute and chronic illness.

This approach supplements and extends the concept of the Advanced Medical Home set forth by the American College of Physicians. Specific components of Coordinated Care include clinical support, information management, and access and scheduling.

PRINCIPLES OF COORDINATED CARE THAT IS EFFECTIVE,.

A DISINTEGRATING HEALTH SYSTEM FOR PATIENTS WITH CHRONIC ILLNESS

Some academic medical centers are eliminating primary care from their organizations altogether.

Total yearly medical expenditures for a person with a chronic condition ($6,032) are more than 5-fold higher than for a healthy person ($1105) (Fig.&x000a0; 1 ). 3 From a national perspective, direct medical costs of chronic diseases were $510 billion in 2000 and are expected to rise to more than $1 trillion by 2020, and nearly 80% of this is apt to be spent on patients with chronic illnesses.

4 Health care spending for a person with one chronic condition is 2 1/2 times greater than spending for someone without any chronic condition, while spending is almost 15 times greater for someone with 5 or more chronic conditions, translating into more than $15,000 per beneficiary annually (Fig.&x000a0; 3 ). Thus, care for patients with multiple chronic conditions demands a level of support and a working environment that is vastly different from that required for less complex acute care or prevention.

Health care in the United States is extraordinarily expensive, consuming nearly 15% of the United States gross domestic product in 2002 and projected to grow to more than 18% in 2013, with annual expenditures of $3.4 trillion. 5 Despite this vast expenditure, the health care received by most Americans is at best mediocre compared with the rest of the developed world. In a study of approximately 4,600 randomly selected adults from 12 U.S. cities, only slightly more than half received recommended preventive, acute, or chronic care.

6 Moreover, these deficiencies respect neither ethnic nor socioeconomic boundaries and are equally pervasive throughout the population.

Heavy demands for productivity, micromanagement by insurers, and limited practice support have eroded continuity and opportunities for truly personalized care. Performance of Generalist Physicians is measured in terms of numbers of visits, patients, or relative value units (RVUs), rather than results or quality. Current attempts to address these problems, such as typical disease management programs, that are external to the physician&x02019;s practice rather than integrated with it, may produce targeted improvements but also lead to more fragmentation and disease-centric care.

These circumstances can easily lead to higher use of medical services (including procedures), lower quality, and higher costs. It is for this reason that every other developed country in the world has a health care system that links each patient to a generalist provider. Accumulating evidence supports the model of care where the patient has a strong relationship with a primary care physician as improving quality of care and lowering costs.

Continuity of care is a prime determinant of patient satisfaction. 9 Ironically, wealthier patients have recognized these problems and now often seek out &x0201c;boutique&x0201d; physicians who have divorced themselves from the systems that pay for disease care and offer a more comprehensive model focused on maintaining health. This reflects the fact that practically no patient wants production line, generic care, and that when substantial economic incentives exist, personalized, continuous care is available.

. The United States has reached a crossroad. Unless the decline in cognitive specialists is reversed and new approaches to care for chronic illness are made readily available to all who need them, our health care system will continue to disintegrate and grow unaffordable to the majority of Americans. Patients will undergo an endlessly growing number of expensive procedures for a diminishing benefit.

The elderly, who use most of the health services in this country, will continue to find themselves increasingly adrift in a complex system, required to shuttle on their own between single system specialists, each armed with a procedure.

In the early 1970s, it was recognized that the rapidly increasing specialization of physicians was leading to care that was fragmented and focused on specific organ systems rather than whole patients. Furthermore, the care was expensive and lacked sufficient emphasis on prevention.

. There are numerous ways in which the office or clinic of a General Internist might be restructured to facilitate coordinated care. The physician might work side-by-side with one or more clinical assistants who are not independent clinicians but have substantial training and experience in clinical settings. For each patient, a clinical assistant completes an initial intake, reviews medical records, assesses the patient&x02019;s status, solicits agenda items, obtains vital signs, and performs any necessary point of care testing.

The clinical assistant confers with the physician to review this information and joins the physician with the patient. The physician confirms and supplements key aspects of the history in an efficient and directed manner. During this process, the patient, clinical assistant, and physician formulate a plan and the clinical assistant simultaneously completes documentation.

Moreover, the EHR is specifically designed to support this model of practice. When collecting and compiling clinical data, a clinical assistant is easily able to assemble prespecified reports that display all relevant information about patients, irrespective of the source (e.g., history, laboratory results, procedures, etc.) in a readily understandable, standardized format. This facilitates information exchange and eliminates time that would otherwise be spent searching through multiple sections of a record.

The visual interface and format or presentation of information is critical.

Promotion of Quality Improvement

Patient Involvement Modern EHRs also provide the opportunity for patients to access and supplement their health records. They can verify and amend, when warranted, personal health information.

The modern General Internist must simultaneously manage three basic sets of issues: evaluation of acute symptoms, management of chronic illness, and disease prevention. The typical practice relies mainly on routinely scheduled visits plus a variable number of acute or drop-in visits, although some practices are beginning to commit a substantial proportion of visits to open access. Advance planning for either type of visit is often minimal, but in a setting in which coordinated care is practiced, the staff carefully manage schedules to optimize efficiency.

In the Coordinated Care model, staff assembles necessary data from other providers or the laboratory before the visit to facilitate management of chronic illnesses and to provide opportunities to enhance preventive health.

A DISINTEGRATING HEALTH SYSTEM FOR PATIENTS WITH CHRONIC ILLNESS. EFFECT OF THE DYSFUNCTIONAL PAYMENT SYSTEM ON COGNITIVE SPECIALTIES. CREATING A PRACTICE MODEL FOR CHRONIC ILLNESS THAT WORKS&x02014;COORDINATED CARE. PRINCIPLES OF COORDINATED CARE THAT IS EFFECTIVE,. EFFICIENT AND REWARDING. A PROPOSED MODEL FOR PROVIDING COORDINATED CARE. PAYMENT FOR COORDINATED CARE. THE SPECIAL ROLE OF SGIM.

References. PAYMENT FOR COORDINATED CARE Implicit in all of the foregoing discussion is that few, if any, of these changes can occur without a change in the method of paying for care. The present evaluation and management system reinforces an inefficient and expensive care delivery system that rewards piecework yet ignores the finished product. Unless and until the payment system is revamped, providers will be motivated to provide high volumes of visits without investing the time, energy, or resources into improved approaches to delivering health care to all people, but especially those who are chronically ill.

In particular, there must be a mechanism to fairly reimburse physicians who provide leadership to teams that deliver high quality coordinated care. Payers must recognize that teams can provide better care than individuals and provide a mechanism to reasonably support this type of care. By furnishing a mechanism to provide coordinated, longitudinal care, payers will ultimately reap benefits by avoiding preventable complications and unnecessary care.

References. . THE SPECIAL ROLE OF SGIM.. . As the premier organization for academic General Internists, SGIM has a critical role to play in discussions regarding the future of GIM and the role of General Internists in caring for patients in the 21st century. In particular, SGIM must lead the way by. working in close partnership with other organizations such as ACP to advocate for the importance of concepts such as coordinated care and the &x0201c;advanced medical home&x0201d; and by seeking new mechanisms of payment and funding for pilot projects.

. seeking to develop coalitions with other cognitive specialists through organizations such as the Association of Specialty Professors (ASP).

1. Anderson G. Chronic conditions. The cost and prevalence of chronic conditions are increasing.

National Institute for Health Care Management.

7. President&x02019;s Information Technology Advisory Committee. Health Care Through Information Technology.

Continuity of care and other determinants of patient satisfaction with primary care. [ PMC free article ] [ PubMed ] .. 10. American College of Physicians. The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care Policy.

The quality of health care delivered to adults in the United States.

Continuity of care and other determinants of patient satisfaction with primary care.

Building a better quality measure: are some patients with 'poor quality' actually getting good care' Med Care.

Resources .