Paying Doctors More For Communicating With Patients – Have They Earned It?

I often hear from physicians that they would do a better job communicating with patients if they were adequately reimbursed for the time it took to do so.  Given that certain types of physician-patient communications (patient education, care planning, etc.) can have quantifiable, therapeutic benefits for patients, I can see their point.

I have no problem with physicians asking to be adequately reimbursed for services they provide.  Just as long as they are high quality and add value. For example, teaching chronic disease patients how to care for themselves at home takes time and is critical to effective patient self care.  In this role physicians are called upon to be a provider of necessary information as well as a coach to encourage and support patients.

But as the evidence below suggests, many physicians don’t communicate effectively enough with patients, chronic or otherwise, to seem to merit additional reimbursement.

According to the evidence:

• Physicians typically spend <1 minute of a 20-minute visit discussing treatment and planning with patients.
• Up to 5o% of patients leave office visits not understanding what their physician told them to do.
• Physicians do not ask patients if they have any questions in more than 5o% of outpatient visits.
• Physicians prescribing new medications did not tell patients the number of tablets to take 45% and 42% of the time respectively.
• Physicians tended to underestimate their patient’s desire for information in 65% of encounters — and overestimated the patient’s desire for information in only 6% of encounters.

If we are ever going to see significant improvement in patient medication adherence rates, greater levels of control of patient A1C levels and blood pressures, we are going to have to find new ways to pay physicians.  But in so doing, physicians will have to be held as accountable for the quality of their patient communications as they are for the quality of their clinical care.

Before primary care physicians can expect to be reimbursed for the time they spend communicating with patients, three things must occur:

1. Quality standards must be established that define effective physician-patient communications.
2. Physicians and patients must be provided with training and tools to more effectively communicate with one another.
3. We will need to move beyond basic patient satisfaction surveys and develop more sophisticated approaches to measuring the quality of the physician-patient interaction.

Sources:

Kaplan, S. et al. Assessing the Effects of Physician-Patient Interactions on the Outcomes of Chronic Disease. Medical Care, Vol. 27, No. 3. 1989.

Heisler, M. Actively Engaging Patients in Treatment Decision Making and Monitoring as a Strategy to Improve Hypertension Outcomes in Diabetes Mellitus.  Circulation. 2008.

Focus on Team Care May De-rail Patient Centered Medical Home Efforts

“Team care” has become a rallying cry for those who think that the Patient Centered Medical Home is bad for health care reform.   Comments on a recent blog post in the New York Times provide a good example of this.   When patients get sick, as the argument goes, they want to see their doctor…not some nurse or PA that they do not know.   I agree.

There are a whole bunch of things wrong with all the current focus on team care in the Patient Centered Medical Home.

1. Team care is not patient-centered care…at least not for those patients who want to see their doctor and not nurse, PA, etc.  By definition patient centered care respects, and where possible, honors the patient’s wishes, beliefs, expectations, etc.
2. Team Care is not one of the founding Joint Principles of the Patient Centered Medical Home agreed to the American Academy of Family Physicians and other professional groups.   In fact it is counter-intuitive to the first of these founding principles.  That is that “each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.”
3. Team Care is seen by many patients and physicians as a way to cut cost – not improve the quality of care.
   
4. Team Care is not conducive to good provider-patient communications. Each person that comes between the patient and physicians complicates the communications process and will lead to increased risk of medical errors.    Just look at the provider communication problems in hospitals associated with “handing off” a patient from one provider to another.
5. Team Care and expert patients often do not get along.   Many people who have effectively lived with and managed their chronic conditions don’t want to “match wits ” with someone (non-physician) that probably does not know as much as they do in terms of living with their condition.

I have nothing against nurses, nurse practitioners or physician assistants.   I just prefer to discuss my person health with my physician of many years. Other people may be quite happy working with physician extenders.   The point is it should be my choice who I see for care and not the choice of the physician, physician group, insurance company, government or anyone else.

For some consumers, the term “medical home” conjures up visions of nursing homes and end of life.   The term Team Care also apparently carries a lot of unwanted baggage.

My advice to aspiring Medical Homes?    Tread carefully when it comes to telling everyone that they are going to get “Team Care” in their new Medical Home.

What’s your opinion?

Patients Want This or That…Don’t Believe It

Anytime you come across a health care article that implies that every patient wants this or that, i.e., electronic access to their medical record, patient centered care, etc.,  you can safely assume that the claim is wrong. Why?  Patients are not a monolithic group – they don’t all share the same motivations, preferences, beliefs or experiences when it comes to their health.

But let’s face. If you are trying to push an agenda, just saying some people want this or that is not the same as implying that everyone wants it.

Take the issue of patient access to physician notes in their medical record.
Robert Wood Johnson recently announced their OpenNotes study. The OpenNotes project will evaluate the impact on both patients and physicians of sharing, through online medical record portals, the comments and observations made by physicians after each patient encounter. OK…so far so good.

Things begin to fall apart however when RWJ cites “a recent study“ in the Journal of General Internal Medicine, as part of the basis for the OpenNotes research. According to the RWJ that study found that “most consumers want full access to their medical records.” Since when did six focus groups (64 people) constitute a representative sample, e.g. most people?

The authors of the Journal of General Internal Medicine make the following claims about what patients think and want:

• Patients are very comfortable with the idea of computers playing a central role in their care.
• Patients want computers to bring them customized medical information.
• Patients expect that in the future they will be able to rely on electronic technology for many routine medical issues.

Oh…I should mention that recruitment for the focus groups was limited to people who:

1. Were concerned about health matters
2. Were less than completely satisfied with services and information currently available to manage their health
3. Used the Internet at least once a week for at least four different transaction types (e.g., banking, e-mail, and travel reservations).

The focus group participants tended to be younger (average age of 39 years old), well educated (67% college educated) and presumably healthier participants than the typical primary care patient panel.

Given the recruitment criteria, the attitudes and opinions expressed by these groups might reflect about 1/3 of adult patients at best. They certainly don’t reflect the opinions of my 88 year old mother or a lot of others people I suspect.

Don’t get me wrong. I think anyone who wants access to their medical record or patient centered care should get it. What I object to is when researchers attempt to justify a position or agenda when the evidence clearly does not support it.

Source:

Delbanco, T., et al. Insights for Internists: “I Want the Computer to Know Who I Am.” Journal of General Internal Medicine 24(6):727–32.