Tag Archives: patient attitudes and beliefs

ACO Success Will Depend Upon The Patient-Centered Communication Skills Of Providers

Accountable Care Organizations (ACOs) and “bundled payments” are set to play a central role in the Affordable Care Act.  Under accountable care, physicians and hospitals would be paid out of a “single payment” from CMS or health insurers for all the care needed to treat a clinically defined “episode of care” like a heart attack.   The premise is that bundle payments will incentivize physicians and hospitals to deliver more efficient, high quality care.

Much has been written about the health information technology infrastructure needed to support ACOs.  Experts also underscore the need for providers (physicians and hospitals) to get patients with conditions like heart failure more engaged in prevention and self-care.  After all, as much as 90% of the “care” for chronic conditions like heart failure is provided by the patient and their care givers at home.  But effectively engaging patients has been a difficult nut to crack for health care providers.

What Can ACO Providers Do To Increase Patient Engagement?

Here’s the short answer – improve the quality of communications between physicians and patients.  After all, physician-patient communications is how most patients are diagnosed and treated.

The degree to which patients and physicians agree on key aspects of the diagnosis and treatment is said to be an indicator of communication effectiveness.  Disagreements such as the nature or severity of a medical condition or the need for a new medication represent a breakdown in physician-patient communications.  Such breakdowns are common and are closely associated with patient behavioral issues such as non-compliance, excessive health care use, and decreased satisfaction.

High levels of physician-patient agreement are linked with more desirable patient outcomes and behavior.  Physicians that use a patient-centered style of communication tend to report much higher levels of agreement with their patients on critical diagnosis and treatment issues.

The Current State of Physician-Patient Communications

A 2011 study of patients diagnosed with a heart condition, and being seen in a public hospital cardiology clinic, illustrates the scope of the communication problems facing not just ACOs…but all health care providers today.

In the study, 55% of patients diagnosed with heart failure did not recognize (nor agree with their doctor) that they had heart failure.  Even more disconcerting was the finding that “only 15% of those with hypertension agreed with their doctor’s diagnosis.

Physician-Patient Disagreement And A Lack of Patient-Centered Communication Are Greatest Amongst Population Groups That Are The Sickest And Most In Need

African-Americans experience heart failure at a rate this is 20 times higher than their white counterparts.  Physicians that treat blacks are less likely, according to researchers, to use a patient-centered communication style.

Numerous studies have revealed that when treating black patients, as opposed to white patients, physicians tend to “provide less health information, are more physician-directed (versus patient-centered), spend less time building a rapport with patients, and are more verbally dominant.“  In other words, the patients that are in greatest need for patient-centered communications, and the benefits it provides, are presently the least likely to receive it.  The lack of high quality patient-centered communication is not limited to minority groups.  An estimated 60% of practicing physicians use a physician-directed communication style.

 The Take Away?

Needless to say, the quality of physician-patient communications in the U.S. does not bode well for the success of ACOs.  Health plans, physician groups and hospitals looking to realize the financial benefits of bundled payments and accountable care should give serious consideration to investing in benchmarking tools and communications interventions that will measurably improve the quality of physician-patient communication both in the office and hospital.

That’s my opinion…what’s yours?


Cené, C. et al. The Effect of Patient Race and Blood Pressure Control on Patient-Physician Communication. Journal of General Internal Medicine. 2009. 24(9):1057–64

Sarkar, U. et al. Patient-physicians’ information exchange in outpatient cardiac care: time for a heart to heart? Patient Education and Counseling. 2011. Nov;85(2):173-9.

Johnson, R. et al. Patient race/ethnicity and quality of patient-physician communication during medical visits. American Journal of Public Health, 2004. 94(12), 2084-90.

Patient Portals. PHRs, & On-line Decision-Support Tools Alone Will Not Lead To Greater Patient Engagement

Patient engagement is getting a lot of attention these days, particularly in the health information technology press.   Anticipation of Stage 2 Meaningful Use criteria is certainly is driving much of the “talk.”  So too are the promises of improved patient outcomes and satisfaction associated with the adoption of patient engagement tools like EMRs, PHRs, web portals, and on-line decision support tools.

But if the mere availability of such health information technology was all there was to engagement…member use of health plan web portals, which have been around for years, would be a lot higher than they are now, e..g., often < 10% of members.

Patient Engagement Begins With The Patient-Physician Relationship Not Technology

If you were to take everything you read at face value, all physicians and hospitals need to to engage patients is patient or member web-based portal.  I guess the idea is if you build it…they will come. But there is a HUGE FATAL FLAW in that logic:

 Successful patient engagement is predicated upon the existence of a strong, trusting, mutually satisfying relationship between the patient and their physician.

Strong, trusting physician-patient relationships are becoming harder and harder to develop and maintain these days…for both patients and providers.   Poor physician communication skills, e.g., physician-directed communications, have been cited in the literature over last 30 years as a major barrier to more satisfying and productive physician-patient relationships. Poor communications also tops the list of patient complaints about their doctors.  Not surprisingly,  many patients find it easier to “get by” in an OK relationship with a primary care provider than seek a provider with a more engaging demeanor

What Are The Three Traits Patients Find Most Engaging In Their Provider?  Check out our latest White Paper

The Link Between Patient Use Of Engagement Tools And The Physician-Patient Relationship
So What Does A Strong, “Engaging” Physician-Patient Relationship Look Like?

Here’s my short list;

  • Patients and providers like, respect, and trust each other
  • Patients and providers are interested in and take the time to listen to where each other is coming from, e.g., their beliefs, concerns, etc.
  • There is a high degree of agreement between patients and providers as to the visit agenda, diagnosis, treatment, and self-care options.
  • Providers’ employ patient-centered communication skills

Imagine yourself in a relationship with a provider who simply doesn’t seem to dedicate much time or place much importance on the above traits. How likely would you be to spend your valuable time-sharing personal health information with someone who has never exhibited any interest when you attempted to share the same information in the past?

The Take Away

Don’t get so wrapped up in the promise of the latest health information technologies that you lose sight of what’s really important to patient engagement, outcomes and patient/provider satisfaction – the physician-patient relationship

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

If you like this post you will love my White Paper on Patient Engagement send me your email and I get you a copy.

Challenge #1 For Health Care Providers – Way Too Much Information And Way Too Little Communication With Patients

One of the biggest problems with health care today is that there is way too much information and way too little communications going on between providers and patients.

Here’s a great quote that explains what I mean:

The two words information and communication are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through.

Sydney Harris,  Journalist

I was reminded of this and the quote from “Cool Hand Luke” quote in an exchange I had with a primary care physician on LinkedIn recently.   In that exchange, which dealt with long-term physician-patient relationships, I hypothesized that intentional non-adherence may be the by-product of situations in which physicians and patients in long-term relationships simply grow to distrust each other.

The good doctor commented as follows:

In the end, it is the patient’s decision to be compliant or not, yet many physicians continue to care for these patients because someone must. Would the patient comply better with a new doctor? I doubt it.

I replied to the good doctor’s comment as follows:

True…the decision to comply or not is up to patients.  But the evidence shows that compliance is not a product simply of bad patient behavior. Non-compliance is an outcome for which both physician and patient have shared responsibility.

I suggest that most people would be a lot more likely to comply if they: 1) understood and agreed with the need for the prescription and 2) believed that the benefits of taking the medication outweighed the risks and concerns. But these issues are seldom brought up by the physician or the patient, due to limited time, provider attitudes and beliefs about patient, and so on.”

Then he dropped the A-bomb – a move intended to silence anyone who would dare challenge physician authority and learnedness:

A professional who deals with this on a daily basis can explain meds, conditions, etc. very quickly and to the satisfaction of the patient.

That’s when it occurred to me…too much information and not enough communication

No doubt most providers today are proficient at quickly giving information to patients (including telling them what to do).  What most providers (and people in general) are not good at is effectively communicating, e.g.,  getting through, with patients (or each other).   Anyone who has ever been married knows the difference between information giving and communicating.

And how would the good doctor know that his patients understood the information he gave them…not to mention their being satisfied with it?   Surely he’s not banking his revenue going forward under P4P on his patient satisfaction surveys alone.

If anything, the weight of evidence suggests that his patients probably do not understand the information he quick doles out and probably are not particularly  satisfied with it.   Like many of us, his patients probably do not want to confront the good doctor choosing instead to ignore his recommendations or seek advice elsewhere, e.g., no-adherence.

But as with any good relationship, effective spouse-centered (I mean patient-centered) communications is key.   To truly engage the other party, you have to know where they are coming from, what’s important to them and never, never ask them to do more than they are willing and able to do.  I had to say that since my wife “proof reads” my blog posts…lol).

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

Patient Engagement Infographic

Check out other recent posts on the topic of Patient Engagement:

Patient Engagement Is Very Important – It’s Just That No One Agrees On What It Is…Or How To Do It – Infographic

Patient Engagement From The Patient’s Perspective

Patient Engagement Versus Physician Engagement – Which Comes First?

Patient Engagement – Here’s The Key To Success

Patient Engagement – Here’s The Key To Success In Case You Are Interested

Primary care physicians are the point of first contact that people like you and I have with a hospital or health systems.   We are 13 times more likely to visit a primary care physician in any given year than we are to need a hospital stay.

Primary care physicians are very important.   Yes they are they the first line of care for many people.   The primary care physician’s office is also the  “make or break” point for “engaging the patient.”  

What people experience have experienced in primary care physicians’ offices  in the past tends to “shapes and frames” their expectations of future health care experiences.    Patient complaints about doctors that don’t listen, long waits, etc. are as much a reflection  of our collective life-long experience as they are the reality of any one physician.   So it is with the tendency of patients  to stay disengaged from their health care.   That’s what we as patients are taught from childhood.

This post is the 3rd in a series of posts on Patient Engagement.  Be sure to also check out:  Patient Engagement Versus Physician Engagement – Which Comes First? and Patient Engagement From The Patient’s Perspective.

What’s the Point?

The point is that the medical exam – the most frequent point of contact between patients and the health care – was never designed to engage patients.  This is the same “medical exam process” taught in medical schools to this day.

The medical exam is a highly structured affair.  It doesn’t just happen.   It consists of 6 steps or processes that physicians move the exam through with the single goal of diagnosis and treating the medical problem

The most important “take away” from this graphic is that patients – people – are invited to freely speak only during the 2nd step – the patient’s opening statement.  This is where people tell the doctor the reason for their visit.   Even then…patients are often interrupted before finishing their story.

From this point of the medical exam on, the patient’s role – aka the sick role – is to answer yes or no to their physician’s questions.

How can physicians, hospitals or health systems ever hope to truly engage patients in their own health  care when the heart of the heart of the health care system – the medical interview – is so un-engaging?

The Key to Patient Engagement – High Quality Patient-Centered Communication

Patient-centered communications by definition is tailored to the patient – their beliefs, fears, concerns and past experiences.   It invites patient input and participation.   It engages us in important conversations with our physician that would not otherwise occur.   When practiced over time, patient-centered communications will enable physicians to accomplish more…in shorter visits…while creating exceptional patient experiences.

Hospitals, health plans, and ACOs looking to engage patients should begin by looking to ways to help their physicians adopt more patient-centered communication skills.   Simply providing them with EMR systems and care coordinators is not enough.   Going forward, those physician groups and hospitals most successful at engaging patients will be the ones that are the most patient-centered where it counts – physician-patient communications during the medical exam.

That’s my opinion…what’s yours?


Haidet, P., & Paterniti, D. A. (2003). Building a history rather than “taking” one: a perspective on information sharing during the medical interview. Archives of Internal Medicine, 163(10), 1134-40.

Cegala, D. J., McClure, L., Marinelli, T. M., & Post, D. M. (2000). The effects of communication skills training on patients’ participation during medical interviews. Patient Education and Counseling, 41(2), 209-22.