[tweetmeme source=”Healthmessaging” only_single=false]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:
- Quality standards must be established that define effective physician-patient communications.
- Physicians and patients must be provided with training and tools to more effectively communicate with one another.
- 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.
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“Before primary care physicians can expect to be reimbursed for the time they spend communicating with patients, three things must occur:”
But if we wait for those to occur, there truly will be no primary care docs left. They’re grossly underpaid for what they’re doing right now.
Requiring that they improve communications skills, become PCMHs, etc., etc., BEFORE the payment issue is addressed is the kiss of death.
Thanks for your current and earlier comments! I know it may seem trite, but I feel your pain. Primary care physicians have been and continue to be in a tough situation financially. I have had the good fortune to be have first hand exposure to the Medical Home BCBS of Michigan sponsored P4P/Medical Home Initiative where qualifying physicians are being paid up to 30% more for certain billing codes. I find a couple of things interesting about the Michigan PCMH pilot. First it allows physician practices to take a slow, incremental approach implementing medical home criteria and second it is reimbursing physicians as the project evolves rather than wait until it’s perfect (whatever that is).
Sounds like an interesting program, BUT:
Isn’t the message from BCBS of Michigan something like:
“Yes, you’re terribly underpaid and overburdened with administrative chores, but we’ll only pay you more if you do all this additional work (data collection, monitoring, registries, etc) that we don’t require the more highly paid docs (derm, radiology, etc) to do.”
Seems like this approach will only further discourage med students from going into primary care.
Yeah, I guess that is a possible take away from any similar kind of incentive program. While not talked about much in the literature, Group Health in Seattle has created a real buzz with their medical home/primary care redesign project. Turns out that primary care physicians like what they are doing at Group Health
so much
that they have 10 physicians applicants for every one opening.
What I like about the who primary care redesign thing is that it is creating opportunities for that “recognize” the value provided by primary care physicians…and to expand and reward that value over time.
I can’t help it…I am just a glass half full kinda guy.
Again, yes, but . . .
Look at the details of what happened at Group Health. They originally tried to incorporate features of the PCMH from 2002-2006. The result: physician overwork, burnout, and low morale.
So, when they tried again in one clinic, they first:
1. reduced each physician’s patient panel by a 25%, and
2. increased support staff by up to 78%.
I don’t know any physician who couldn’t provide better care under those circumstances, but, with the dearth of PCPs, I don’t think it’s a model for the rest of the country.
The take home message is that the physicians’ work load was dramatically decreased BEFORE they were expected to take on any new responsibilities.
Most of the demonstration projects in place now are based on the theory that the problem isn’t that the docs are on a treadmill, but that the treadmill isn’t going fast enough. Turning up the speed may be temporarily exciting, but it’s not a valid solution to the dearth of PCPs.
You cite evidence that is used to prove the job being done isn’t satisfactory.
In the same piece, the argument is made that the same evidence isn’t good for determining if paid services are effective.
Please explain why the evidence markers you use for failure, are ineffective as markers of success.
Good point. The fact is those measures I cited (50% of patient leave the doctor’s office without understanding what their doctor told them to do, etc..) could be used as success criteria. Thanks!
I think there are patients who would be happy to pay their doctors for some teaching about how to manage chronic illness, and it could happen under the current system. IMO, a system that makes patients feel like they have choices would work best.
First, the doctor needs to develop a short curriculum designed to teach people what they should know. What is the disease? What will happen if the disease goes untreated? How is that different than what can be expected with good disease management? What can the patient do to make things better? What things should the patient avoid to prevent worsening of symptoms? If/When the patient screws up and does something that worsens the disease, what are some methods of coping with that instead of getting frustrated and giving up? What new/worsening of symptoms merit an extra dr appointment, and what symptoms can be anticipated without extra concern (so should just wait until the next appointment)? What are the treatment options, and why did the doctor select the particular one he did for this particular patient? Are there financial assistance programs if the medication is expensive? What is the doctor’s roll in supporting the patients in managing their disease? How often should the patient expect to need follow-up appointments? Why are those follow-up appointments necessary? Will there be any repercussions if patients blow-off their follow-up appts? What, if any, labwork is associated with management of this disease? Will lab results tweak the disease management plan? What should the patient be doing on a day-to-day basis to improve quality of life despite the illness? Will any other specialists/treatment be beneficial to the patient’s treatment?
The doctor probably carries all this information around in his head, not realizing that the patient doesn’t know any of it. Formally design a curriculum to teach the patient. Then give options.
Either the patient can come in weekly for short appointments to learn the material – it might take three or four appts to get through it all – and pay for an office visit every time to cover the doctor’s time and expertise, or the doctor can schedule one class per month for a group of all his patients newly needing to learn how to manage this chronic disease. Charge cash for the group class if it’s not something that patients’ insurance will cover. I pay a $20 co-pay for every office visit, so if I can pay a one-time $50 fee to attend a one-time class instead of $60-$80 over the course of a month, I’m saving both time and money. The doctor can have one or two or ten patients in every class, and not have to deal with insurance paperwork. As long as the patients understand that they’d be signing up for a group class, it shouldn’t be a HIPAA violation (after all, hospitals have diabetes education classes all the time and it’s not a privacy problem).
You could have cute little brochures available for people to take home reminding them of the information covered at the appointment/in class. You could also put the highlights of this material on the patient-information tab of your website.
It will take some uncompensated time to develop your materials, and might take more time to tweak the presentation the first few times, but once you get into a rhythm, you could end up with patients who better understand their situation and know how to manage their disease the best they possibly can. They should also do a better job of keeping their follow-up appointments if they understand the purpose, instead of thinking that the doctor’s just wanting more money.
My $.02.
Excellent thoughts Warm Socks! I agree that some patients (particularly those with painful chronic conditions like RA) would pay for what you suggested. The vast majority of patients – however expect physicians to already provide the level of service you so carefully described.