High-value care through better care coordination?

Reducing low value care or waste is gaining a significant amount of interest in different healthcare systems around the world. It refers to the elimination of spending without harming consumers or reducing the quality of care people receive. ¹ Failures of care coordination are one category of waste. Other such categories are: failures of care delivery; overtreatment; administrative complexity; pricing failures; fraud and abuse. ¹

Failures of care coordination occur when patients experience care that is fragmented and disjointed and can result in unnecessary hospital readmissions, avoidable complications, and declines in functional status, especially for the chronically ill. ¹ It has been estimated that in the United States of America (US), failures of care coordination can increase costs by $25 billion to $45 billion annually. ² If the above estimation is correct, one may wonder how much healthcare systems are willing to pay for improving care coordination.

One recently published study sheds an interesting light on these questions. In this study, conducted in the US, the relationship between physician practice prices for outpatient services and practices’ quality and efficiency of care was examined. Practices were categorized as high- or low-price based on whether its mean price for service delivery was above or below, respectively, the mean price for all practices in their geographic area. Moreover, data from (Medicare) patients were captured including their experience with regard to care coordination and management. It was found that patients of high-price practices (i.e. practices that received 36% higher prices) reported better performance on four of the six care-coordination items including ‘primary physician informed about specialty care’, ‘medication review’, ‘patient access to visit notes’, and ‘communication of test result’. As on all other measures no differences were found, authors concluded that “findings do not support claims that high-price providers deliver substantially higher-value care”. ³ Notwithstanding, high-price practices did make a difference in patient ratings of care coordination and management. Authors comment that high-price practices turned out to be much larger (on average 155 versus 11 clinicians) and have more advanced systems to support care coordination and management. They recommend that “as efforts to measure, report, and base payment on quality intensify, it will be important to monitor the relationship between price and quality and understand its implications for health care spending and quality”. ³

A few considerations to share. Comparing prices only does not provide a full picture of the cost-effectiveness between practices or services. The use of IT support systems can be less or more advanced, with more advanced use (including prediction models) potentially holding most promise. ⁴ Given the polymorphous nature of care coordination, more gains may be expected from the use of multiple tactics of which IT support systems is only one. Other tactics include shared decision making and multi-disciplinary teamwork.^5,6 It is here where the International Journal of Care Coordination invites authors to submit their planned, ongoing or recently finished work about the relationships between the context, mechanisms and outcomes of care coordination.

This double issue of the International Journal of Care Coordination starts with a provoking opinion paper by Gill who challenges the concept of ‘patient’ by stating that current health systems inadvertently promote illness. Gill explains how ‘augmented care’ can overcome currently facing shortcomings by organizing wellness and illness care around the person and making use of both conventional methods and online tools. ⁷

The findings presented in the research paper by Nilsson and Nilsson ⁸ seem to support the call for augmented care. By examining the work experiences of elderly healthcare providers as well as their patients’ individual needs, Nilsson and Nilsson ⁸ conclude that existing gaps in the organization of work and care coordination should and can be overcome by listening to those who best understand the needs of residents. Against the background of the introduction of case managers in primary palliative care in the Netherlands, Van der Plas et al. ⁹ have studied what informal care givers think about the number of professionals involved in primary palliative care. They conclude that case managers indeed have an important role to play, whilst emphasizing the importance of clearly explaining the role of each healthcare provider to patients and informal caregivers. ⁹

The challenges around the identification and assessment of the often used term ‘clinical care pathways’ are addressed by both Vrijhoef et al. ¹⁰ and Adjemian et al. ¹¹ Vrijhoef et al. ¹⁰ argue, based on a mixed methods approach, that IT-supported integrated care projects for people with diabetes reveal more heterogeneity than commonalities, hence making it impossible to define a blueprint for future IT-supported integrated care initiatives. By testing a set of five criteria to identify clinical care pathways in the field of emergency care, Adjemian et al. find that, notwithstanding the very good applicability of the criteria, the lack of clarity of the term ‘multidisciplinary’ perhaps most clearly illustrates the inconsistent use of terminology when describing and evaluating clinical care pathways. ¹¹ Busetto et al. ¹² address a somewhat similar challenge regarding the term ‘integrated care’. In their opinion paper, they argue that a universal typology of integrated care interventions should be developed to enable the comparison of interventions that are based on different understanding of integrated care.¹²

Finally, by including the names of reviewers who supported us in 2016, we would like to express our gratitude for their immensely important contribution to the International Journal of Care Coordination. We sincerely hope to continue working with all of you in the future. Thank you!