Prescription for a broken system

A missing ingredient in the U.S. health care system: coordination

The United States has the best-trained doctors, the best-equipped hospitals and rehabilitation centers. It has access to the best medicinal and diagnostic technologies and pays three times as much for health care per capita than any other country. Yet we rank last in health care among industrialized nations and somewhere between 37th and 48th overall in various international surveys.

One of the reasons the United States has the lowest-ranked health care system of the modern industrialized world is its lack of health care coordination.

As a primary care physician, I see an enormous variety of health-related problems daily. Making the diagnoses and determining the treatments is often the easier part of my job. The real challenge begins after that. Each health care plan has its own set of formularies. If I prescribe a medication that is not on that patient’s formulary, it may cost the patient tens to hundreds of dollars more. Since I tend to prescribe generic medications first, I find that not all generic medications are covered. That could make the difference between the patient taking the medication or not.

The same principle applies to other parts of health care as well. Certain insurances will allow access only to specific laboratories for blood draws. Some specialty care doctors are only contracted with some insurance companies and not with others. Rehabilitation facilities, short- and long-term care facilities, mental health counseling and social services counselors all require time and special consideration(s) before the patient can implement the prescribed treatment.

Many patients need help even before they get to the doctor’s office. Transportation problems and insurance coverage are two of the most common reasons that most patients cancel their doctor’s appointments at the last minute.

Doctors’ offices are not the only places where health care coordination is needed. Quite a few patients miss their recommended follow-up from a hospital stay or emergency room visit for precisely the same reasons that they are unable to follow up from their primary care physician – a lack of health care coordination. Most emergency departments are good at instructing patients about what they need for follow up, but they lack the expertise and personnel to show patients how to follow up.

The absence of health care coordination means that much of the work done in doctors’ offices, hospitals, emergency rooms and long- and short-term care facilities is lost. It is one of the reasons that there are so many readmissions, and it greatly adds to the cost of medical care. Private insurance companies, Medicare and Medicaid would all save significant sums of money if they actually paid to coordinate patient health care.

Here in New Hampshire, our local hospitals and health clinics have made some inroads in an attempt to coordinate health care, but by definition, they work only within their own system.

They lack the scope and depth needed to access resources on a statewide or regional scale to meet the needs of our patchwork health care system that often requires resources outside a local community.

Ironically, the few health care coordinating organizations that exist are underused precisely because each hospital, insurance organization and health clinic tries to set up its own system within its own network. One such organization, SeaCare, has lacked both recognition and funding, despite saving Seacoast residents millions of dollars in readmissions and lost follow-up visits.

When we take the steps needed to see that patients actually get the medication their doctor has prescribed, have access to the healthy foods recommended by their health care team, or have access to the therapy or specialty care referrals, the quality of health care in the community improves while the overall cost decreases.

For more information, I would invite you to go to the SeaCare website,, or call them at 772-8119.

Dr. James Fieseher of Portsmouth is a member of SeaCare’s board of directors.

Categories: Opinion