How many health coordinators does it take to screw in a lightbulb?

Four. But none actually do any screwing. One is your point of contact for screwing lightbulbs. One helps the bulb get screwed. One goes between those two. And one manages the other three, raises funds and writes reports.

My office strives to cut all barriers between the patient and provider. The patient calls me to schedule and comes in, or even better, walks in without an appointment, bypasses the front desk, and just sits down next to me. There was a day when most practices were closer to this flow, even for specialists.

When a doctor wanted to refer to mental health, it looked like this:

Sure, you can add a front desk staff to each provider, but still, you will get nowhere near the complexity I faced last week in scheduling a patient for mental health:

I’m not part of a big provider system, but I drew it in, because unfortunately that is how most doctors in underserved medicine choose to practice. Accessing these big systems is so complex, that we are now paying millions to care coordination agencies to help untangle them. Also, any patient with barriers of language, education or disability (i.e., most Medicaid patients) need a less disadvantaged family helper just to figure out the chaos. This diagram doesn’t even include medical directors, managers of care management (I’ve met two), coordinators of coordination (I just made that up), CEOs, or the insurance companies.

I know a number of care managers, health navigators, health coordinators, and similar titled folks, all of whom are wonderful hard working people. I am not making personal attacks on them; their work is needed with such a complex system. I just wish the system was less complex.

John Brady, president of Ideal Medical Practices, famously applied the {N(N-1)= #lines of communication} formula to primary care, arguing that an office with two staff (my assistant and I) has only two ways for conversation to flow, while even just five staff results in 20 paths for communication. Each additional staff means more dropping the ball, not knowing patients, wasting money, and doing anything but actually seeing a patient. We’ve now scaled up this Brownian chaos with multiple make-work positions as shown above.

In the worst cases, multiple entities will come together in a partnership that looks good on grant applications, but results in harmful care that is so fragmented even the state medical board can’t assign responsibility. Miscommunication between teamist entities is unavoidable with so many lines of communication, and the resultant “lawyer” in the above diagram is an actual part of my recent experience.

Last month I had one refugee health coordinator (I work with refugees) manage, by phone, to scare a mom with a sick kid out of my office, stating that her care was arranged elsewhere already. The mom had come to my office on a friend’s suggestion, and I could have treated that kid in seconds. The health coordinator resulted in worse health.

Let’s simplify this crazy making by returning to small entities. Even if doctors don’t want to hang their own shingle, the big systems can break themselves into two-provider doc-in-the-boxes, each with their own phone line, personality, and decor. This means the doc may have to do some things besides just medical decision making, but the more hats worn by the provider, the more your care is intimate and cost effective. Get rid of the big system chaos and you can get rid of the coordinators.

For every few coordinators eliminated, you could fund one more provider. Less care coordination means more care.

P.J. Parmar is a family doctor at Ardas Family Medicine and blogs at P.J.! Parmar.