Want Your ACO To Succeed? …Then You Better Focus On Improving How Your Doctors & Patients Communicate

The basic premise of the Accountable Care Organizations is simple enough.  By incentivizing providers (physicians and hospitals) to assume financial responsibility for coordinating the health care of a defined patient population, it is possible to increase the quality of care while decreasing the cost of care delivery.

For ACOs to succeed, experts tell us that 3 things are required: 1) health information technology is needed to track and manage patient populations, 2) redesigned care delivery processes are needed to support patient care coordination, and 3) the right set of provider financial incentives must be in place.

do thisBut The “Experts” Have Overlooked Perhaps The Most Important Requirement

The improvements in quality and cost effectiveness in large part are predicated upon providers being able to engage patients with the goal of changing their health behavior.  

The problem is that most physicians lack the patient-centered communication skills needed to engage patients in their own health care not to mention persuade patients to change their health behavior. 

An Example – Physician and Patient “Meeting of the Minds” 

I think we can all agree that “telling patients what to do” is not an effective patient engagement or behavior management strategy.  After all, if patients don’t agree with or understand the rationale for a recommendation from their doctor, they are not likely to comply with it.

Rather, a meeting of the minds by physicians and patients is needed…and that requires physicians  understanding the patient’s perspective.  The evidence bears this out.  Higher ratings of trust, satisfaction, and intention to adhere occur when patients see themselves as similar to their physicians in personal beliefs, values, and communication.[1]

The problem is that physicians and patients often disagree on even the most fundamental issues…and herein lies the problem:

  • Doctors & patients disagree on the principal reasons for office visits 53% of the time.[2]
  • There is “substantial discordance” between the problems patients describe to physicians and the symptoms that physicians document in the EMR.[3]
  • For diabetic patients who cited pain or depression as their top health concern their physicians rated these conditions “as likely to affect the patient’s health outcomes” in only 9% and 32% of cases respectively. (Remember, 95% of the treatment for diabetes is patient self care). [4]
  • 41% of patients disagree with their physician as to whether their presenting symptoms represented a psychological versus a medical problem. [5]
  • Physician perceptions of “how pleased, cheerful, relieved, worried, angry, and disappointed” they thought the patients were during office visits differed significantly from patient rating of how they actually felt. [6]
  • Physicians tend to underestimate the patient’s desire for health information in 65% of visits.[6]

So What’s The Take Away?

Many physicians today are ill prepared to assume the role or financial responsibility of care coordination (or care management) given their lack of patient-centered communication skills.  Notice I didn’t mention lack of time since effective use of patient-centered communication skills over time can actually save providers time.

Unless and until medical groups, hospitals, health plans, CMS, and ACOs address this critical shortcoming through providing physicians with the  training, tools and resources needed to develop and refine patient-centered communication skills, ACOs will not deliver on their promise of more effective and efficient medical care.

That’s my opinion. What’s yours?


[1] Street, R. et al. (2008) Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity. Annals of Family Medicine. 6:198-205.

[2] Greer, J. and H. R. (2006). Predictors of Physician-Patient Agreement on Symptom Etiology in Primary Care. Psychosomatic Medicine, 282, 277-282.

[3] Stein, T. et al. (1999) Inaccuracies in physicians’ perceptions of their patients. Medical Care.  Nov;37(11):1164-8.

[4] Keulers, B. J., Scheltinga, M. R. M., Houterman, S., Van Der Wilt, G. J., & Spauwen, P. H. M. (2008). Surgeons underestimate their patients’ desire for preoperative information. World Journal of Surgery, 32(6), 964-70.

[4] Street, R. et al. (2008) Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity. Annals of  Family Medicine, 6:198-205.

[5] Freidin, R., et al. (1980). Patient Physician Concordance in Problem Identification. Annals of Internal Medicine, (93), 490-493.

[6]Stein, T. et al., Inaccuracies in Physicians’ Perceptions of Their Patients.  Medical Care. 1999 Nov;37(11):1164-8.

[7] Pakhomov, S. et al. (2008). Agreement between Patient-reported Symptoms and their Documentation in the Medical Record. American Journal Of Managed Care, 14(8), 530-539.

11 responses to “Want Your ACO To Succeed? …Then You Better Focus On Improving How Your Doctors & Patients Communicate

  1. Stephen — good comments about the shortcomings of physician communication. If you had to list 10 ACTIONS either the patient or physician could do today to improve patient-centered communication what would they be? I would propose one as a start: patients should bring a WRITTEN list of three concerns or questions they want addressed to every healthcare interaction (and expect a response to each). Others? Better ideas? Chuck this one in place of another?

  2. There seem to be some pretty cool looking technologies coming out to help keep the patient-provider relationship engaged. Coordinating care across the continuum of the patient experience, though, will require some similarity across these tools because providers will pick and choose which ones they like resulting in a variety of deployed tools (as has been the case with everything else related to IT in healthcare). I’m hoping within 5-10 years every physician office in the country will be armed with automated kiosks for documenting their patient information, speeding up the registration process, managing medications and other critical patient information ripe with errors, etc. Something like Patient Point comes to mind: http://patientpoint.com/. I agree that the communication between provider and patient need to improve. Quickly the question becomes, though, even if this communication improves, are the right systems in place to capture this improved communication and use it to the collective advantage of all stakeholders? I’d say no, unfortunately.

    Interested in your thought of my take at the gaps in ACO-IT readiness as well.

  3. Steve, very well said! Physician-patient communication affects ACO performance directly… and outcomes–no doubt. I hope you’ll take a look at my new book (with Carla Rotering, MD) called The Language of Caring for Physicians: Communication Essentials for Patient-Centered Care (available on Amazon—and I put a copy in the mail to you). It’s a handbook that describes in concrete detail evidence-based physician communication practices key to patient-centered care.

  4. Nicely said, Steve. I think you and your blog readers would find very useful my white paper on patient-centeredness in the real world of ACOs, which requires understanding patients in an ethical, economic and clinical context; following careful patient-centered guidelines in the Medicare regs; and learning from role models. It was done with the National Partnership for Women & Families and has garnered a fair amount of attention. See: http://acochasegroup.com/content/universal-american-corporation-now-has-31-aco’s.

    And, of course, we at the Society for Participatory Medicine applaud what you’re doing, as well. Are you a member? (www.participatorymedicine.org)

    • <ichael,

      Thanks for your comments and kind words. Thanks also for sharing the link to your wonderful resource.

      I guess when it comes to the Society…I subscribe to to old Grouch Marx saying that "I would never be a member of a club that would have me as a member." Plus I never felt welcome by the management…

      Steve Wilkins

  5. Patients should not only come in with a written list of questions, complaints. They should also have list of RXs and other doctors patient sees. I have been with elderly patients who go to urgent care clinics and they can’t name medications or names of doc who prescribed.

  6. Cheryl nails a key topic with her comment that “I have been with elderly patients who go to urgent care clinics and they can’t name medications or names of doc who prescribed.” That looks like a waving flag marking that health is a regional population (whole population) matter. Hospitals need to work with regional walk-in sites as well as classic primary providers in a region in order to be the main regional supplier of high-end remedial care and regional quality engagement. For how far this can add value to regional results, see Atul Gawande’s New Yorker article on the QA topic (and by extension also on the topic of reducing the variance in regional specialist performance) at http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande?printable=true&currentPage=all#ixzz22xYXytCr .

    Also need to connect regional hospital EMR with traffic at regional walk-in sites (Retail Health Clinics-RHCs, Urgent Care Centers-UCCs, Community Health Centers-FQHCs, and employer-located worker clinics). The first connection goal is to enable the walk-in person to check a HIPPA OK box for downloading from the regional hospital (head of regional care supply chain) to the walk-in site (via kiosk or a workflow resource like Amazing Charts) a real-time snapshot for morbidities trended with meds, labs, and vitals. After walk-in bumps, scrapes, and colds are addressed and any necessary triage to primary or other care, the walk-in site uploads work done to the regional hospital EMR. The best system and tele-health gold standard as a care-focused EMR (as opposed to a billing tool forced to handle health info) is the VistA system and its stable and blazing fast MUMPS core code serving some 175+ VA hospitals. The largest firm migrating VistA to the civilian world is Medsphere at http://www.medsphere.com/company/about .

    This topic covers so much more than the above encounter scenario — e.g., regional funding sources and flows, regional and hospital support for pt navigation, care coordination, structured hand-offs/discharges, meds management, common semantics to ensure terms and concepts cohere so participants clearly can connect ideas with actions in speech and in practical workplace queries and references, and more. The facets to a regional re-do cover much ground, but can be addressed if approached with mutual respect and energy.

    But it all comes back to what Charyl said above — in effect, the need to put the pieces together is a regional, whole-population opportunity to do better.

  7. Stephen et al, I agree with the notion that patients are told what to do rather than involving them in their care. To add more challenges to the system: the patient is even more confused when doctors, nurses, care managers, dietitians, pharmacists, WebMD, friends and family are inconsistent with their messaging.
    Which source do they trust most? The doctor? OK, but the seed of doubt has been placed. A coordination and standardization of health communication is also required for the new influx of care teams, patient centered medical homes and accountable care organizations. Clear communications and a standardized message will be important for an engaged patient.

    • Friso,

      Thanks for you comments. The reality is that the majority of physicians today are physician-directed (aka paternalistic) and not patient-centered (either by choice or lack of know how). Put another way, physicians in PCMHs and ACOs today are no more patient-centered (the communication gold standard) than their non-PCMH or ACO counterparts. I expect to be able to validate this is s big research project I will be embarking on soon.

      Absent a focus on improving clinician patient communication skills (as well as patient skills), many clinicians will be no more successful at coordinating care in an ACO or PCMH than they before entering such arrangements.

      I think many established patients are past “believing” everything their doctor tells them for the reasons you mentioned (inconsistency,inaccuracy, lack of time) and have taken to requesting diagnostic tests that they read about or hear about from friends. The challenge is now one of rebuilding lost trust for many patients.

      Steve Wilkins

  8. Hmmm-Getting sick and needing medical care is worse than hearing a clanking noise in your engine or transmission and being forced to go to a car mechanic or transmission shop. No wonder many Americans do not proactively manage their disease(s). They are treated worse than an unscrupulous mechanic at their most vulnerable time of sickness and illness.

    This provides and an OPPORTUNITY on a silver platter for those healthcare providers willing to provide transparency, trust and customer service for customer patients however…this will build loyalty and is the right thing to do.

    TIME Magazine: Bitter Pill: Why Medical Bills Are Killing Us

    Read more: http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/#ixzz2M6bZmbpe


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