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Care coordination needs greater emphasis
Submit responseThe authors’ description of the numerous evaluation and management (E&M) also called coordinating functions, that fall on the shoulders of primary care doctors is timely but, insufficiently emphasized(1).
The intensity and scope of E&M activities are underestimated by most health insurers, not just Medicare. They need greater emphasis than that given by the authors. Referring to evaluation and management functions merely as “E&M” as commonly occurs, without going into detail, trivializes them. Policymakers reading the authors’ report may infer that evaluation and management activities are of minor importance. If this happens, as has happened for decades, payment for these activities will continue to be greatly disproportionate to the time and energy primary care doctors put into them.
Imagine someone saying that the evaluation and management (E&M) that went into painting the Sistine Chapel required some thought about mixing colors and preparing surfaces to accept paint but, not mentioning that Michelangelo spent hours poring over sketches and planning the overall harmony of his composition and working with his craftsmen.
As part of evaluation and management esponsibilities, the authors didn’t include the many reports to home health care agencies and visiting nurse associations that have to be reviewed, signed and returned. Or the numerous nursing home and hospital discharge summaries and medication lists that have to be read and explained to patients. Or the many CAT scans that demonstrate “incidentalomas” that need further testing and explaining. Or the responses to mail-order pharmacies explaining why patients cannot go on generic drugs. And the many telephone calls and walk -in visits that are the hallmark of primary care practices.
One of the hardest yet least recognized of all the E&M functions to describe which explains why it rarely is is spending time with patients, just letting them go on with the narrative of their illness or their life story or how their illness affects those around them and their life situation. This requires energy and compassion and commitment. Most veteran clinicians know that it helps the therapeutic response. Yet, listening to patients, like other activities that fall under the rubric of E&M because it is unquantifiable, almost always is under emphasized. Sometimes these indirect medical functions consume a major portion of a physician’s day.
Many well-intentioned apologists for primary care fail to go into the details of evaluation and management. Not mentioning the details, however well- intentioned their reports may be and regardless of the amount of statistical material they may contain, renders them less effective. And primary care’s apologists need to be as effective as they can be.
References
1. Pham HH,O'Malley AS,Bach PB,Sainotz-Martinez C,Schrag D. Primary Care Physicians' Links to other Physicians Through Medicare Patients: The Scope of Care Coordination. Ann Intern Med 2009;150:236-242.
Conflict of Interest:
None declared