Tag Archives: patient satisfaction

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?

Sources:

[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.

Wonder What Your Doctors And Patients Talk About…Or Don’t Talk About…Behind Closed Exam Room Doors?

Soon you can stop wondering…

For the most us, our first patient experience was a trip to the Pediatrician’s office with our mother. As we age things don’t change much…the doctor’s office remains the center of most people’s “health care experience” except that now we are taking our parents to see the doctor.

The physician-patient relationship is and will continue to be the key stone holding together the rest of U.S. health care system. Why? Because the primary care physician’s office is where the vast majority of health care decisions are made and where most health care is delivered. We are still 13 times more likely to visit our doctor’s office than we are to require an overnight stay in the hospital.

What happens behind the closed doors of the exam room between doctor and patient drives everything else in health care – patient health status, patient adherence, referrals, ER visits, hospital admissions and re-admissions, patient satisfaction and so on. Other than our own personal experience and some vague top line satisfaction survey data, we health care professionals (non-physicians) really know very little about how doctors in our organizations talk with and relate to patients one another once the exam room door closes.

We Know Even Less About The Impact Of Different Styles of Physician-Patient On Our Organizations

For example, what impact does a paternalistic, physician-directed communication style have on patient activation and engagement in hospital-owned physician practices? Or how successful will a physician with poor patient- centered communication skills be when it comes to managing the health of a patient population in an ACO?  Can physicians with poor communication skills hope to retain members attributed to the ACO?  How much money will your organization forfeit next year in incentives and penalties due to poor physician-patient communications resulting in preventable re-admissions and sub-optimal patient experiences?

Exciting New Research Will Soon Provide You Invaluable New Insights Into How Physicians And Patients In Your Market Communication With One Another…And The Implications For Your Organization

It is not often that one gets the chance to become involved in landmark research.  I guess this in my luck day.  Working together with a corporate partner Verilogue in the upcoming months I will be analyzing the patient communication skills of 2,500 HIPPA-compliant physician-patient interviews collected from across the U.S.  The goal of the research will be to deconstruct what primary care doctors and their patients say (and don’t say) to one another and how they say.  We will then benchmark the patient communication skills of physicians in the study against agreed upon industry best practices – aka patient-centered communications.  Ideally the results can be used by hospitals, physician groups, ACOs and health plans to improve the patient-centered communication skills of primary care physicians across the country.

Stay Tuned

As more details of this excite new research become available you will find them here at Mind the Gap first. I look forward to helping advance the field of physician-patient communications. More importantly, I look forward to doing what I can to disseminate and make actionable the finding on behalf of those who will benefits the most – patients.

What things would you like to learn from this research?  Please let me know.

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.

When It Comes To Patient Engagement…It’s The Little Things That Count

I did a dumb thing a couple of weeks ago.   I fell off a ladder on to a cement floor and broke some ribs.

I went to the local ER, was x-rayed, and went home.   There’s nothing they do for broken ribs these days it seems.   The treating Physician’s Assistant told me she had notified my primary care doctor of my fall and resulting injuries.   Mind you this is the same primary care physician who was aware of my 3 recent retinal detachments, major surgeries (Vitrectomies), and prolonged recovery from these events.

It’s been a month since I feel off the ladder….and in all that time I haven’t heard a peep from my personal physician.  That bothers me.

It’s not like I had a problem that needed follow-up…but it would have been nice – perhaps even prudent – for his office to call and see how I was doing.   Why?  The fact that he didn’t call just reminds me that my physician really doesn’t think or care very much about me – as a patient or a person.   Either that or he has yet to read the ER report of my injury from 4 week ago.

In truth everyone I have spoken to about this has had a similar experience.  This is unfortunate for patients and the medical profession.   As patient’s we are continually reminded that physicians don’t have time for us or our problems.  We chide ourselves for not looking for a new doctor in the hope that things might be better.   For their part,  medical professionals meanwhile are clueless why their patients are not as engaged in their health or adherent as they should be.

Want to Engage Your Patients?  Act Like You Care

We all know primary care physicians are very busy and not properly reimbursed for all the work they do.  We also know you all had mothers that “taught you better.”  We all had those same mothers.  Mine used to tell us kids that you “catch more flies with honey than you do with vinegar.”

If you really want to blow the socks off even the most jaded of patients….call them up and ask them how they are doing.  Start with a phone call – it’s more personal than an e-mail.  Just tell the patient that you “know there not ever enough time during office visits to show you care…so when you had a free minute you wanted to remedy that.”

Start with your chronic and frail patients – one call is all you need.  Do this one simple  albeit time consumer thing and your outcomes ill improve, patient adherence will improve, patient satisfaction and loyalty will improve…and you will feel better about yourself.  Think of it as a long-term investment.

You need more proof?  Calculate the ROI of buying and installing an EMR system and hiring a care coordinator and then compare it to the cost of making a single phone call to your sickest patients.   When you compare the saving from the EMR and the cost of your time to make the phone calls….you will be amazed that you didn’t do it sooner!

This ain’t rocket science!  Go out now and make your Mamma proud!

That’s my opinion…what’s yours?

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

Sources:

Stein, T., Nagy, V.T., Jacobs, L. (1998). Caring for Patients One Conversation at a Time : Permanente Journal, 2(4), 62-68.

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?

Sources:

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.