Do Medical Home Physicians Really Communicate Any Better With Patients?

Probably not yet…

I thing everyone would agree that Group Health of Seattle probably has a pretty good “take” on issues dealing with primary care redesign and the Patient Centered Medical Home (PCMH).   That’s why I surprised by a recent comment on a Group Health blog from by Matt Handley, MD in response to an earlier post here about Patient Question-Asking.  Dr. Handley is an Associate Medical Director for Quality and Informatics at Group Health.

Dr. Handley writes:

“While doctors often take pride in how open they are to patient questions, our self assessment doesn’t match up very well with empirical evidence. A recent post on Mind the Gap summarizes a small study that is relatively terrifying to me – the take home is that doctors spend very little time explaining their recommendations, and that patients rarely ask questions. “

I picked up the phone and talked with Dr Handley about his comments and work being done on PCMH at Group Health.   Then it struck me.  If a medical home project on the scale of Group Health hadn’t substantively addressed improving the way physicians and patient communicate (i.e., encouraging patient question asking, etc.) what’s the likelihood that any other PCMH pilot would be addressing this problem?

The truth of the matter is that it does not seem that the problems of physician-patient communication are being substantively addressed (at least publicly) by any PCMH pilot. Nor are they addressed to any significant degree (beyond reference to having written standards and, recording the patient’s communication preference and having a web portal) by NCQA’s Medical Home Certification Criteria.

Yes Group Health has extended the length of the office visit from 15 minutes to 20 minutes.  Yes Group Health and many other PCMH pilots have implemented e-visits, along with electronic patient record technology.  Yes NCQA certification criteria requires written standards addressing patient “access and communications.”   But nowhere along the way have these initiatives taken steps to systematically improve the quality of the physician-patient dialog. As I cited in a previous post, simply increasing the length of the office visit will not automatically turn an otherwise autocratic physician into an empathetic, patient-centered communicator.   Physicians will need new tools, training and help from patients to become better communicators.

I think the Patient Center Medical Home, and its funding partner the Accountable Care Organization (ACO), hold great promise for both patients and physicians.   Like any innovation, their success or failure will rests on people’s ability to effectively communicate with one another.

Paying Patients to Take Their Medications Is Stupid

The New York Time reported recently on efforts by providers and payers to increase patient medication adherence through the use financial incentives paid to patients.  The article cited the use of small financial payments (<$100), awarded via lotteries, to patients that take Warfarin – an anti blood clotting medication.

There is certainly nothing wrong with financial incentives.  Incentives have been proven successful in changing selected provider (quality and safety improvement) and patient behavior (stop smoking, weight loss and taking health risk surveys).   But paying patients to take their medication is different.  Actually, the evidence suggests that it is a just plain stupid idea for a whole lot of reasons.

Why Paying Patients to Take Their Medications is Wrong-headed

According to published research, physicians only spend 26 seconds of the average patient visit on discussing new medications with patients.  26 seconds! That’s not enough time.  Studies show that physicians often do not discuss important aspects of new medication, such as how to take the medication and how long to keep taking it.

In a previous post, I cited a study that demonstrated that poor physician-patient communication not recalcitrant patients, resulted in poor patient adherence with taking Warfarin.  As I reported, 50% of all patients in that study differed from their doctor in term of understanding how they we supposed to take the medication.  In other words, one half of the study population was taking a Warfarin incorrectly.

These finding are not new.  Numerous studies over the years have shown that many patients often don’t know the name of the medications they are taking, not to mention how to take them, or when to stop taking them.

The odds of patient medication adherence are 2.16 times higher if a physician communicates effectively with the patient.

Rather than paying patients, why not pay primary care physicians more for taking the time to: 1) explore the patient’s beliefs about medication-taking and 2) make a more compelling case for how and why patients should taking needed medications in the first place.

Sources

For Forgetful, Cash Helps the Medicine Go Down, New York Times. June 13, 2010.

Zolnierek, K., et al.  Physician Communication and Patient Adherence to Treatment. Medical Care 2009;47: 826–834.

Tarn, D., et al. How much time does it take to prescribe a new medication? Patient Education and Counseling 72 (2008) 311–319.

Like It Or Not – Patients Have Their Own Expectations Regarding “Needed” Care

In Less is More, the editors of the Archives of Internal Medicine make the case that too much unneeded care is being delivered in physician’s offices these days.   According to the authors, “patient expectations” are a leading cause of this costly problem.

Their solution? Get physicians to share with patients the “evidence” for why their requests are crazy, wrong, ill informed or just plain stupid.  But getting patients to buy into the “Less is More” argument is a daunting task as most physicians already know.

The problem is complicated by the fact that patients have a lot good reasons for not buying into the “Less is More” message.

Here are some examples of those reasons and how people come by them:

Direct personal experiences with current or previous providers

• Doesn’t seem to know who I am or what problems are from one visit to the next
• Doesn’t have lab test results at time of visit
• My doctor can’t know everything
• Medications don’t work for me
• Too busy – feel rushed
• No time for questions/interrupted

Indirect health care experiences of family or friends

• My aunt died from diabetes…insulin didn’t help
• My friend with cancer received radiation and lived…that’s what I want

What people read/hear

• 50% of US adults don’t get recommended care
• Guideline always changing – example: mammography screening
• Medical errors/quality problems
• US health care system broken
• Rationing of care and death panels
• Doctors don’t have enough time and aren’t paid enough

In truth, before physicians can change a patient’s mind about what constitutes “needed care” they need to understand the patient’s health beliefs and expectations.   But that’s not something physicians are very good at.  Nor are they paid to do it.  So until we can create the right incentives for physicians and patients to talk about such things, patients are welcome to and entitled to their own expectations of needed care.

Source:

How Less Health Care Can Result in Better Health.  Archives of Internal Medicine.  May10, 2010.