Tag Archives: financial incentives

Ten Reasons Why Hospitals, Health Plans And Medical Groups Should Invest In Developing Their Physicians’ Patient-Centered Communication Skills

“Patients are, in fact, overly patient; they put up with unnecessary discomforts and grant their doctors the benefit of every doubt, until deficiencies in care are too manifest to be overlooked.  Generally speaking, one can assume that the quality of care is, actually, worse than surveys of patient satisfaction would seem to show.  Patients need to be taught to be less patient, more critical, more assertive.”

Avedis Donabedian, MD.   Father of Health Care Quality

Black Woman and DoctorIt’s no secret that poor communication tops the list of patient complaints about their physicians.  Who hasn’t heard a physician or an enabling administrator say that they “don’t have time to talk to patients” or that they “don’t get paid for talking to patients.”  While understandable, that kind of a response seems to demean the interpersonal exchange which is the very essence of the physician-patient relationship.

Contrary to what most people think, the quality of a physician’s patient communication skills impacts far more than the patient experience.   The quality of your physicians’ patient communication skills drives the quality of the patient’s diagnosis, treatment, outcome and cost.   And that my friends should get your attention.

If 30+ years of evidence is to be believed, there is a practicable solution to today’s physician-patient communication funk everyone finds themselves in.   It’s called patient-centered communications

Here are 10 evidence-based reasons why providers and payers should go beyond useless global measures of patient communication and give serious thought to assessing and improving their physicians’ patient-centered communication skills.

  1.  Improve visit productivity – collaborative setting of a visit agenda and negotiation of visit expectations by patient and physician have been show as a way to reduce the “oh by the way” comments at the end of the visit and to allow more to be accomplished often in less time.  1
  2. Improve the patient experience – the duration of the visit is not nearly as important to patients as the quality of time spent face-to-face with the physician.  Visits in which the physician invites patient participation and makes the patient feel heard and understood produce higher satisfaction and experience scores. 1
  3. Increase patient engagement – patients come to physicians for a reason(s).  They are already engaged otherwise they wouldn’t be there.  Patient-centered physicians solicit the patient’s reasons for the visit, their ideas about what’s wrong and their thoughts regarding what they want the physician to do.   It helps eliminate guessing and unfulfilled patient expectations.
  4. Improve patient adherence –  “Patient beliefs about medication were more powerful predictors of adherence than their clinical and socio-demographic factors, accounting for 19% of the explained variance in adherence. ”  By understanding where the patient is coming from physicians can avoid wasting time recommending treatments which patients will not adhere to, i.e., prescribing a new Rx when patient would prefer life style modifications. 2
  5. Fewer requests for expensive tests – strong physician-patient relationships characterized by effective patient-centered communication skills report higher levels of patient trust in the doctor and lower levels of patient requests for expensive diagnostic tests commonly found in physician-patient relationships reporting lower levels of patient trust in physician. 3
  6. Fewer ER visits and hospital readmissions – patients in strong patient-centered physician relationships are more likely to engage in the kinds of self care management behaviors which preclude ER visits and rehospitalizations.  3
  7. Better patient outcomes – Chronic disease patients of physicians with strong patient-centered communication skills are consistently found in studies to report better A1C scores, better controlled hypertension and asthma, and so on. 4
  8. Reduce malpractice risk – The majority of malpractice claims involve some form of communication breakdown between physician and patient.   Patient-centered physician-patient relationships are characterized by a high degree of relevant and timely information exchange which greatly reduces the risk of physician-patient communication errors. 5
  9. Reduce disparities in care – The evidence shows that physicians tend to be more paternalistic and directive when talking with ethnic patients, including sharing less information, compared to when communicating with white patients. 6
  10. Increased reimbursement – CMS and many commercial payers now offer incentive payments for outcomes linked to patient-centered communications. i.e., patient experience, reduced ER visits and hospital readmissions, use of generic vs. brand drugs, lower levels of expensive diagnostic tests, etc.

Note:  Later this Summer, Mind the Gap will be organizing a communication challenge called Adopt One! TM.   The goal of the event will be to challenge physicians and their care teams to adopt one new patient-centered communication skill within the next 12 months.

As part of the Adopt One! Challenge physicians and their care teams will have the opportunity to sign up for a free evaluation of their patient-centered communication skills, have their skills benchmarked against best practices and  receive a report detailing their findings and recommended steps for improvement. 

 Sources:

1        Dugdale, D. C., Epstein, R., & Pantilat, S. Z.  Time and the patient-physician relationship. Journal of General Internal Medicine, 14 Suppl 1, S34-40.  1999.

2       Horne, R., & Weinman, J.  Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness.  Journal of Psychosomatic Research, Vol. 47, No. 6, pp. 555–567, 1999.

3        Thom, D. H., Hall, M. a., & Pawlson, L. G. (2004). Measuring Patients’ Trust In Physicians When Assessing Quality Of Care. Health Affairs, 23(4), 124-132.

4       Stewart, M. . et al. (2000). The Impact of Patient-Centered Care on Outcomes. Journal of Family Practice, 49(No. 9), 1-9.

5        Levinson, W., Roter, D. L., Mullooly, J. P., Dull, V. T., & Frankel, R. M. (1997). Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA : the Journal of the American Medical Association, 277(7), 553-9.

6       Johnson, R. L., Roter, D., Powe, N. R., & Cooper, L. a. (2004). Patient race/ethnicity and quality of patient-physician communication during medical visits. American journal of public health, 94(12), 2084-90.

What Kinds Of “Patient Experiences” Are Occurring In Your Doctors’ Offices?

Hint: They Aren’t As Good As Your HCAHPS Scores Suggest

Now that over 50% of physicians are employed by hospitals, this is a question that should be on the minds of progressive hospital executive teams.  With good reason. Patient-reported outcomes, including satisfaction and loyalty, are going to play an increasing role in determining how much hospitals and physicians are paid. This means that astute hospital marketers will be able to build a strong business case for investing in programs aimed at creating superlative ambulatory and inpatient experiences for patients.

But Our Physicians Already Have High Patient Satisfaction Scores

Health care executives should take little comfort in the global patient satisfaction and loyalty ratings found uniformly in HCAHPS  and every patient satisfaction survey.

Generally speaking,  “one can assume that the quality of care is, actually, worse than surveys of patient satisfaction (suggest)”according to Avedis Donabedian, MD, the father of today’s quality movement.   Donabedian goes on to say that “patients are, in fact, overly patient; they put up with unnecessary discomforts and grant their doctors the benefit of every doubt, until deficiencies in care are too manifest to be overlooked. ”

Just look at the quality of physician-patient communication, a key ingredient of the “patient experience” in the physician’s office.

  1. In only 26% of the visits are patients allowed to complete their opening statement (agenda) without interruption (by the doctor); in 37% the physicians interrupted; and in 37% physician never asked about the patient’s visit agenda.
  2. Studies suggest that patients do not express their health concerns, expectations or opinions in up to 75 percent of physician visits principally because their doctor never asked.
  3. Primary care physicians typically spend less than 60 seconds informing patients how to take new medications…or why.
  4. Primary care physicians and patient disagree about the diagnosis, treatment, and cause/severity of their condition over 50% of the time.
  5. Over 50% of patients walk out of their doctor’s office not understanding what they were told, including why or how to take their medications.

For their part, patients today are hard pressed to rate the effectiveness of their relationship with their doctor.  The evidence shows that poor physician-patient communications is the norm rather than the exception.   As such, most patients do not appreciate all the ways in which their doctor could in fact do a better job communicating with them.

Why Is Any Of This Important?

Simple.  Hospital and physician reimbursement is increasingly determined by things that are closely linked with the a physician’s patient communication skills:

  • improved patient outcomes
  • fewer hospital re-admits
  •  fewer medical errors

So if hospital chiefs of staff or health plan medical directors are looking for a way to improve these types of metrics consider improving the way your physicians and patients talk to each other.   In the long run patients and physicians will thank you for doing so.

That’s what I think..what’s your opinion?

Sources:

Dyche, L., & Swiderski, D. (2002). The Effect of Physician Solicitation Approaches on Ability to Identify Patient Concerns. Family Medicine, 267-270.

Lang, F., Floyd, M. R., & Beine, K. L. (2000). Clues to patients’ explanations and concerns about their illnesses. A call for active listening. Archives of family medicine, 9(3), 222-7.

Howard Waitzkin, MD, P. (1984). Doctor-patient communication – Clinical Implications of Social Scientific Research.  JAMA, 252(5), 2441-2446.

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

Patient-Centered Care – We Aren’t Ready for It

The follow is a guest post by Aanand D. Naik, MD  @empoweringpts.

We hear lots of discussion nowadays about Patient-Centered Care.  Most legislation for health care reform proposes innovative models of care such as Accountable Care Organizations and the Patient-Centered Medical Home (PCMH) with “Patient-Centered Care” at the core.  Given all the attention: Who could possibly be against Patient-Centered Care?

In this wake, I forward the controversial contention that many patients, probably a majority of health care providers, and every major health plan and health insurer really doesn’t believe in Patient-Centered Care.  Or at the very least, they aren’t ready to change the basic paradigms of health care to cultivate what Patient-Centered Care truly is and what its requires.  Simply put, we aren’t ready for Patient-Centered Care.

To clarify my argument, a clear understanding of Patient-Centered Care is needed.  The first consensus definition comes from the 2001 Institute of Medicine Report, Crossing the Quality Chasm.   The IOM report defines Patient-Centeredness as, “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”  The report clarifies several principles of health system redesign that will better align health care along 6 quality dimensions.  The principles most closely tied to the dimension of Patient-Centeredness include: a) customization of care based on patient needs and values; b) the patient as the source of control; c) shared knowledge and the free flow of information, and d) the need for transparency.

When fully realized, these are powerful principles–they can and will transform health care.  But, they must all occur together to ensure that transformation happens.  If only one or two of these principles are accomplished, especially if only the principles of free flow of knowledge and customization based on patient-need; then there will be little positive change at all.

Don Berwick wrote a wonderful essay in Health Affairs in 2009  in which he describes the lively debate that occurred on the IOM panel that defined Patient-Centered Care.  He defends the “extremist” position and adds his own parameters for patient centeredness: (1) “The needs of the patient come first.”(2) “Nothing about me without me.”(3) “Every patient is the only patient.”   These are compelling additions to the original IOM definition.  What I fear is that without the coexisting principles of transparency and patient control, the “needs of the patients” will be defined by doctors, providers, hospitals, health systems, and insurers rather than patients themselves.

My further belief is that the types of reforms gaining momentum, like PCMH, will actually precipitate and worsen the problems of supply-driven demand and hyperinflation because they will simply increase patients’ acceptance of doctors’ recommendations through “free flow of information and knowledge” and enhanced patient-centered communication.

Without truly making information transparent and giving patients real control of the ends and means of health care, then it’s simply patient-friendly talk and involvement in discussions related to what the doctor thinks is best.

Transparency is more than the free flow of information and patient-centered communication.  Transparency occurs when patients understand “in their gut” the meaning of the health problem and how health care will impact their daily lives.  Patients have control when they choose not to pursue a course of action the doctor might recommend because those outcomes are not consistent with their values or the desired course of their lives.  In the non-transparent form of PCMH, access to health care improves but health costs will continue to skyrocket.

What we need now is real discussion of patient control and transparency rather than platitudes about Patient-Centered Care.  What does it mean to give patients control and can control be helpful and lead to health outcomes that are consistent with our needs and values?  What does transparency really mean?  I wish Steve Jobs was still around to teach us a thing or two about the importance of design and the patient-interface in health care.  As a physician, I know the patient-doctor encounter is sacred and the doctor’s role is indispensible; but I am also fully ready to embrace transparency and patient-control over the ends and means of their health.

Aanand D. Naik is a medical geriatrician and health services researcher at the Michael E. Debakey VA Medical Center and Baylor College of Medicine in Houston, Texas.  Follow him on twitter @empoweringpts  The views expressed here have not been endorsed by either institution.

Sources:

Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001, National Academy Press, Washington, D.C.

Berwick, Donald. What “Patient-Centered” Should Mean: Confessions of an Extremist. Health Affairs. 2009, 28:w555-w565.

Accountable Care and Effective Physician-Patient Communications – You Can’t Have One Without the Other

[tweetmeme source=”Healthmessaging” only_single=false]Accountable Care Organizations (ACOs) figure prominently in the new Patient Protection and Affordable Care Act.   The concept behind Accountable Care Organizations is that by tying both physician and hospital compensation to outcomes via a bundled fee (say for pneumonia), we can expect to see an improvement in quality and value.

In principal accountable care makes a lot of sense.   Practically speaking however, doctors and hospitals must address a huge challenge before they can expect benefit financially.

Before doctors can be held accountable for the care they deliver, they first must be held accountable for the quality of their communication with patients.

Take hospital re-admissions which are a big cost-driver today.   According to a recent study in the New England Journal of Medicine, 20% of all Medicare patients discharged from hospitals were readmitted within 30 days, and 34% percent within 90 days.

The Joint Commission and others believe rightly believe that inadequate communication between physicians, as well as between physicians and patients, is a major contributing factor.

Here’s an example.   In a small study of 47 patients surveyed at time of hospital discharge (Commercial and Medicare), 72.1% of patients were unable to list all their discharge medications.  86% were unable to describe the common side effect(s) of all their medications, and 58.1% did not know the diagnoses that put them in the hospital in the first place.  These trends are consistent with the findings from a number of similar studies, including studies of discharged ER patients.

Physician-patient communications shortcomings abound in the doctor’s office as well.    Approximately 20–50% of patients do not take medications as prescribed.  It’s not necessarily because patients are non-compliant.  Patients don’t take medications out of fear of drug interactions, perceived lack of effectiveness, adverse effects, misunderstanding regarding necessity, or concerns about costs.

Patients who report better general communication with their doctor, i.e.,  better instructions on how to take a medication, and who receive more medication information, are more likely to take medications as prescribed.

The success of new financing and delivery models like Accountable Care Organizations and Medical Homes depends heavily upon significant address the quality of the current state of physician-patient communications. I wonder when today’s physician and hospital leaders will get a clue.

Sources:

Makaryus, A., et al. Patients’ Understanding of Their Treatment Plans and Diagnosis at Discharge.  Mayo Clinic Preceedings, 2005.

Coleman, E., Rehospitalizations among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine. 2009.

Kripalani, S., et al. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians.  JAMA 2008.

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

[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:

  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.

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