The Case Manager
Who’s responsible for care coordination? It depends.
In theory, the primary care physician (PCP) is the quarterback of people’s healthcare. But if the patient is injured on the job, the treating physician assigned by the Insurance Company would be responsible. In mental health, it might be the psychiatrist or psychologist who is seeing the patient. In reality, many people are part of the process.
In this article, I want to focus on who is responsible for care coordination in today’s complex healthcare system, regardless of the payer.
It’s the individual person who is the key to effective care coordination.
Managed care was designed so that every person had a PCP who knew them, followed them over time, and helped manage their health. In return, the managed care company paid the PCP a per-member, per-month fee to support this work.
It was a good idea—but the healthcare system forgot to tell people what their role was in the process. People were led to believe they only needed to see the PCP when they are sick. As a result, most PCPs saw patients intermittently, keeping their caseload manageable but not supporting long-term health and wellness.
Over time, this combination of episodic care and an uninformed public contributed to a growing population with high-cost chronic conditions. Today, an estimated 129 million people in the U.S. have at least one major chronic disease such as heart disease, cancer, diabetes, obesity, or hypertension. Five of the top ten leading causes of death are linked to preventable or treatable chronic conditions. Prevalence has steadily increased over the past two decades and is expected to continue rising unless we act.
Many people now live with multiple chronic conditions: 42% have two or more, and 12% have at least five. These conditions account for roughly 90% of the nation’s $4.1 trillion in annual healthcare spending. As costs rise, managed care plans have reduced payments to PCPs, leaving them overwhelmed and under-resourced. Instead of partnering with patients to manage chronic conditions, PCPs often refer to specialists because they simply don’t have the time.
So what’s the solution? It comes back to YOU and ME—and understanding what we can do to help our PCPs and specialists manage our care more effectively.
There are three essential strategies: be prepared, communicate clearly, and follow through. Each one reduces friction in an overburdened system and gives clinicians what they need to truly coordinate care.
Be Prepared Before Appointments
- Keep an updated medication list including prescriptions, OTC drugs, supplements, doses, and prescribers. This prevents errors and helps your PCP spot interactions or duplications.
- Track symptoms and changes over time. Brief notes on what’s happening, when it started, and what affects it help your PCP quickly understand the timeline.
- Bring recent labs, imaging, and specialist notes, especially if done outside your PCP’s system. These records often don’t transfer automatically.
Communicate Clearly During Visits
- State your top 1–2 priorities at the start of the appointment so the most important issues get addressed.
- Share your health goals, not just symptoms. Goals guide care plans more effectively than problems alone.
- Be honest about barriers such as cost, transportation, caregiving responsibilities, fear, or confusion. Your PCP can only adjust the plan if they know what’s in the way.
Follow Through Between Visits
- Use the patient portal for updates, questions, refills, and document uploads.
- Schedule recommended follow-ups and preventive care such as wellness visits, screenings, and vaccines.
- Tell your PCP when you see a specialist and ask that notes be sent back.
- Monitor chronic conditions as instructed and bring your data to appointments.
When people (patients and caregivers) do these things, PCPs gain what the system often fails to provide: complete information, continuity, and context. That leads to safer, more coordinated care—and better health for YOU.
Take Care of YOURSELF!
