By Kevin Moore, PsyD
In my last blog, sequestration had just begun and I questioned the moral and economic justifications of rationing. In the two subsequent months, our AIDS Service Organization (ASO) has suffered a sequestration-related cut of 11% to our primary funding. We have heard about ASOs in other cities receiving as much as 30% cuts. The logic of ration is impairing ASOs and harming the clients that we serve. There is an alternative to rationing: avoiding waste.
During his 2012 re-election campaign, Obama highlighted reducing waste, fraud, and insurance overpayments as goals of his reforms. Unfortunately, fraud and insurance overpayments together only account for a small amount of money (though these are important goals). But what about the larger – and far more abstract- concept of reducing waste? What does reducing waste mean?
A recent PricewaterhouseCoopers study places the dollar value of identified waste at $1.2 trillion dollars. They specified three types of identified waste:
Behavioral – obesity, smoking, non-adherence to medications, and excessive alcohol use.
Clinical- defensive medicine, re-admissions, poor diabetes management, medical errors, unnecessary ER visits, treatment variations, hospital acquired infections, and overprescribing antibiotics.
Operational – claims processing, ineffective use of information technology, staffing turnover, and paper prescriptions.
Clearly these are all important areas to improve and the Affordable Care Act (ACA) has elements that address essentially all of them. However, even $1.2 trillion will not fully correct our sky-rocketing health care costs and improve quality (though it would help). Fortunately, there is an even more powerful waste avoidance measure built into the ACA. It is so simple and so straightforward that it is routinely underestimated by even health care professionals: effective care coordination.
Allow me to illuminate effective care coordination by using a sports analogy. Imagine a professional sports team with a head coach, assistant coaches, and a star player. The coaches talk to each other and with the player individually and as a group so that everyone is on the same page. Important information is repeated so clarity is achieved. The work of the head coach is to insure the entire team is communicating so that the player can maximally perform.
Now let’s imagine the antithesis of this analogy. What if the head coach didn’t think it was important to coordinate the input of the assistant coaches? What if the coaches rarely talked to each other? What if they typically only spoke individually to the player and often asked the player to relay what the other coaches said? This is the state of much of this nation’s health care system. Let me give a real world example of what the current lack of care coordination looks like.
A person living with HIV sees both his primary care provider, who is an HIV specialist, and a psychologist for psychotherapy for depression. The CDC estimates that half of those living with HIV screen positive for depression. The primary care provider is prescribing a “standard of care” anti-retroviral medication that combines several medications into one pill a day. The psychologist is assisting the person cope with seemingly intractable depression. The primary care provider occasionally asks the patient how therapy is going and the psychologist occasionally asks the patient how he is doing medically. The two health care providers never speak directly, though the patient has signed releases to consent to this communication.
Were they to communicate, the primary care provider would hear that the depression was not resolving as expected and might wonder if the side effect of depression from the anti-retroviral medication might be a factor. The psychologist would be surprised to learn that a strictly “biological” cause of depression could account for the patient’s continued pain. A different medication could be prescribed and the depression might lift just as quickly. Simple care coordination could improve the life of this patient and improve the outcome of both of these providers. Care coordination might be boring to talk about, but it is intensely powerful in healing the sick. It is wasteful not to coordinate care.
In Part II of this blog, I will explain how the ACA enhances care coordination and what you can do to help.