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Coordinating Care: A Major (Unreimbursed) Task of Primary Care

Thomas Bodenheimer, MD
[+] Article, Author, and Disclosure Information

From San Francisco General Hospital, San Francisco, CA 94110.

Requests for Single Reprints: Thomas Bodenheimer, MD, Department of Family and Community Medicine, University of California at San Francisco, Building 80-83, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110; e-mail, TBodenheimer@fcm.ucsf.edu.

Ann Intern Med. 2007;147(10):730-731. doi:10.7326/0003-4819-147-10-200711200-00010
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For several decades, first-contact care, continuity of care, comprehensive care, and coordinated care have been core attributes of primary care (1). Of these features, perhaps the most problem-ridden is the task of coordinating the care of patients among multiple entities beyond the primary care practice, that is, specialists, ancillary services, pharmacies, hospitals, and home care agencies. Studies demonstrate that referrals from primary care physicians to specialists often lack sufficient (or any) flow of information in either direction (23). In this era of hospitalists, primary care physicians are often uninformed about what took place during their patients' hospital stay (4).

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Coordinating care reimbursement:Skating on thin ice
Posted on November 30, 2007
Edward J. Volpintesta
Conflict of Interest: None Declared

Certainly all primary care doctors would enjoy getting reimbursed for the time and energy they spend on coordinating care.

But there is a serious drawback that should be considered: The "coordinating care" function may degenerate into a dumping ground for all those time-consuming tasks that everyone else who is providing care shuns. It would become analogous to, but much more onerous, than the scut work that first year residents do. If it does, then the coordinating care function will become so burdensome that it will interfere with the actual taking care of patients. Eventually, it may be the only thing that the primary care doctor does. It would relegate the personal physician to a medical broker, acting as a go-between between specialists, nursing homes, home health agencies, physical therapists, and other agencies.

Already most primary care doctors are overwhelmed with the paperwork involved with those tasks that fall under the rubric of "coordinating care". Increasing the scope of that responsibility and paying for it may give primary care doctors some satisfaction in the short run, but any promise it holds for improving their plight carries a risk of backfiring.

For instance, can you imagine the paperwork and oversight they will be subjected to trying to prove that they indeed did the coordinating work they claim to have done? Worse, there is temptation for some to abuse this new payment code.

The best way to deal with primary care is to pay them more for their services without adding a special coordinating function payment.

Conflict of Interest:

None declared

Care Coordination: Time to make the call
Posted on December 18, 2007
Todd P Semla
President, American Geriatrics Society
Conflict of Interest: None Declared

To the Editor:

The recent article by Farber et al. (How Much Time Do Physicians Spend Providing Care Outside of Office Visits? Annals 147:693-698) and the accompanying editorial by Bodenheimer highlight a rapidly growing problem -- coordinating clinical care in an environment in which patient management is increasingly centrifugalized.

The American Geriatrics Society has expressed its concern over this issue previously [1,2] and has been working with members of Congress to develop support for the proposed Geriatric Assessment and Chronic Care Coordination Act. A key element of this legislation is a call for the development of care plans that support coordinated care for Medicare beneficiaries with multiple chronic conditions, and for reimbursement adjustments reflecting these priorities.

Addressing the need for care coordination is of increasing importance not only due to the multiplicity of professionals providing care in the current health care system -- especially in the treatment of chronic disease -- but also due to the growing need for electronic and telephone communication in clinical care. Recognition of the latter has resulted in greater emphasis on the development and use of electronic medical records.

Inefficient, inadequate coordination of care not only endangers patients, it also sets the stage for redundant testing and preventable complications and hospitalizations, and thereby raises health care costs. [ 3, 4] These consequences are of particular importance in the care of the elderly "“ in 2002 more than half of all Medicare beneficiaries were treated for five or more conditions [5]. For these patients, who are especially likely to interface with multiple caregivers, out-of-office communication and support are particularly important.

It is essential, then, to make enhanced coordination of care feasible not only between doctor and patient but also among caregivers -- and payment reform is essential to making this a reality. The proportion of the geriatrician's time spent in facilitating patient care outside the office visit underlines this need.


1. Besdine R, Boult, C, Brangman S, Coleman E, Fried L, Gerety M, et al. Caring for Older Americans: The Future of Geriatric Medicine. Journal of the American Geriatrics Society. 2005 Jun;53(6 Suppl):S245-56.

americangeriatrics.org, New York: American Geriatrics Society Public Policy Page; c2007 [cited 2007 September 11]. Available from:https://www.americangeriatrics.org/policy/iom_report040907.shtml#1.

3. Counsell S, Callahan C, Clark D, Tu W, Buttar A, Stump T,et al. Geriatric Care Management for Low-Income Seniors: A Randomized Controlled Trial. JAMA 2007;298 2623-2633.

4. Reuben B. Better Care for Older People With Chronic Diseases: An Emerging Vision. JAMA 2007;298 2673-2674.

5. Thorpe K, Howard, D. The Rise In Spending Among Medicare Beneficiaries: The Role Of Chronic Disease Prevalence And Changes In Treatment Intensity. Health Affairs 25 (2006): w378"“w388; 10.1377/hlthaff.25.w378.

Conflict of Interest:

Dr. Semla is an employee of the Dept. of Veterans Affairs Pharmacy Benefits Management. The views expressed are those of the American Geriatrics Society and not necessarily those of the Dept. of Veterans Affairs. He serves as advisor to Evercare, Inc. and on the Omnicare P&T Committee.

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