The coordination of each patient’s care over time is another area for improvement. As patients move among providers and settings, they are subject to treatment errors and duplicative services. A recent survey revealed that patients experience problems with receiving results of medical tests and information about their medical history and that test results frequently are unavailable at the time of doctors’ appointments. Almost 20 percent of patients reported that test results or medical records were not transferred from another provider or a laboratory in time for an appointment. Nearly one-quarter of patients said their health care provider had to order a previously performed test to have accurate information for diagnosis (Stremikis et al., 2011). Similarly, care often is not coordinated with the patient. One study found that in 1 of every 14 tests, either the patient was not informed of a clinically significant abnormal test result, or the clinician failed to record reporting the result to the patient (Casalino et al., 2009). In the previously cited study of Stremikis and colleagues (2011), half of survey respondents said they had experienced waste and inefficiency in the health care system, and one-third said the system is poorly organized (Stremikis et al., 2011).
Patients also have reported poor communication between their primary care providers and specialists, and the reported likelihood of these coordination failures increases with the number of physicians seen (Stremikis et al., 2011). This trend is particularly concerning given that, as noted in Chapter 2, Medicare patients see an average of seven physicians, including five specialists, split among four different practices (Pham et al., 2007). The presence of multiple comorbidities only exacerbates this trend. One study found that while the average Medicare patient with type 2 diabetes but no comorbidity saw an average of 5.6 physicians in a year, a patient with 10 comorbidities saw 28.2 physicians (Niefeld et al., 2003). Another study found that in a single year in fee-for-service Medicare, the typical primary care physician had to coordinate with 229 other physicians in 117 different practices (Pham et al., 2009). Further, the rate at which physicians refer patients has doubled over the past decade, and the number of primary care visits resulting in a referral has increased by nearly 160 percent (Barnett et al., 2012). Coordination failures also are likely exacerbated by the wide variety of professionals in health care today (Leape and Berwick, 2005). Modern medicine includes nurses in more than 50 specialties, physicians in more than 50 medical specialties, physician assistants, pharmacists, physical therapists, psychologists, dentists, and many others, all of whom must