Curbside Consult with Dr. Jayne 11/7/16

One of the key tenets of the shift towards value-based care is the idea that physicians are increasingly graded on patient outcomes. Not surprisingly, this grates on many physicians.

There are complex issues involved when trying to get a patient to change behavior, even when it’s a relatively straightforward recommendation such as taking a medication. Conventional wisdom and multiple studies have demonstrated that close to half of all prescriptions aren’t taken as directed and many are never even filled. There are many factors involved: cost, convenience, commitment, side effects, etc. Additional factors related to specific patient populations may also include transportation, safety, health literacy, cultural barriers to care, and more.

When a significant lifestyle change is recommended, the factors involved become exponentially more complex. We live in a society that focuses on instant gratification. Health-related lifestyle changes typically challenge that paradigm and require ongoing hard work that results in slow change that can sometimes feel imperceptible. People want quick wins. Any clinician who has tried to discuss the pros and cons of moderation in diet and increased exercise vs. various celebrity-endorsed weight loss programs knows what I’m talking about. Patients see the claims of a dropping significant weight in a short time period and find the contrast of a slow, sustainable loss of a pound a week to be off-putting.

Other lifestyle changes are impacted by socioeconomic factors, including food insecurity, variable availability of healthy grocery options in the urban core, joblessness, homelessness, abuse, and more. Although physicians can refer patients to community supports and programs (assuming that the programs exist in your area and can maintain their funding in the face of increased need), there are limits to what we can do. That is where the idea of being graded on patient wellness starts to feel unwelcome.

Once you’ve considered the logistical issues involved in a change in patient health status, you have to contemplate the ethical ones. Autonomy and personal freedom are major issues in America today. Governments from the national level to the local level are trying to address issues such as the consumption of high-calorie drinks and the inclusion of unhealthy ingredients in foods. I still miss the trans-fat in my Oreo cookies, but I understand why it’s no longer there. But when you try to convince a patient to make a change, things can often get challenging.

Physicians are at the front line of trying to drive outcomes, but often our advice is often challenged. When I recommend diet and exercise for weight loss, patients want a pill. When I recommend a pill for high blood pressure because diet and exercise failed, I’m accused of being in the pockets of the drug companies. Even though 95 percent of the prescriptions I write are for generic drugs and many of those are on the $4 list at the local supermarket, it’s assumed that we’re getting kickbacks and are part of the healthcare cost problem.

Physicians have long been in a position of paternalism, although that is changing with the focus on patient-centered care. Still, there are patients who want to choose their treatments based on what I would do for myself or a family members. They don’t want to be part of their own decision-making, they just want to be told what to do.

But the next room you enter might have a patient and their entire extended family, all of whom have been all over the Internet researching treatment options, and want to discuss each one of them independently. It certainly makes one feel scattered when trying to see patients as well as a bit fragmented when you have to shift back and forth between two completely different frames of mind. Not to mention that it’s difficult to get payers to compensate physicians for the time spent in those conversations, and patients aren’t eager to pay for it out of pocket.

Then, there’s the principle of beneficence. By pushing patients to comply, are we still doing right by the patient? Where is the boundary between trying to engage your patient to take charge of their health and being pushy? At what point do you agree to disagree on the colonoscopy order the patient is never going to complete? I’m on the hook for the patient’s performance regardless of whether they go or not and regardless of how many times I’ve tried to get them to go or how persuasive my arguments might be.

Under the new healthcare payment schemes, our incomes are directly tied to our ability to motivate our patients to do what we recommend. A recent study may shed some light on which approaches are more productive in moving patients towards change. It confirmed the results of a previous study that identified potentially effective strategies for supporting patient self-management:

• Emphasizing patient ownership
• Partnering with patients
• Identifying small steps toward change
• Scheduling frequent follow-ups
• Showing care and concern

Researchers created a scale to measure where primary care clinicians stand and found that performance on the scale was associated with patient efforts. I found it interesting that they only looked at primary care physicians. Although everyone assumes we’re “most responsible” when trying to attribute certain elements of care, it really does take the proverbial village to care for patients. The study found that primary care providers who spent more than 60 percent of their time “counseling, educating, and coaching” their patients scored higher than those who spent less time in those activities. For most of us, being able to spend that portion of the visit motivating our patients would be a luxury.

I also found it interesting that some of the strategies they cite are challenging under new reimbursement schemes. Frequent follow-ups aren’t going to happen for patients on high-deductible health plans. The usual response to that concern is telemedicine, but most payers still don’t cover it. That translates to unreimbursed physician work, which is less likely to happen than actually reimbursed work.

Even something that seems relatively simple such as showing care and concern is increasingly difficult under payment reforms and technology incentive programs. Many physicians are stressed to the breaking point. Scarcity of primary care physicians in traditional continuity practice makes for long waits and short visits. When you have to spend time trying to hit as many metrics as possible in as little time as possible, it doesn’t make it very easy to get to know your patient. Adding the stress of technology issues doesn’t help.

Another factor that doesn’t help is the assumption that patient engagement is a software problem. The reality is that patient portals and online interactive education are just part of the toolkit, but it takes time to help physicians learn how to best use those tools, how to best encourage their patients to use them, and how to put processes and policies in place in their offices so that their use doesn’t increase the burden of physician work.

I’ve done formal training in motivational interviewing and healthcare coaching and know that physicians struggle with finding the time away from their practices to get that kind of training. Some of my rural colleagues have difficulty getting coverage for even a few days out of office. Regardless, having those as options for practice improvement activities under some of the regulatory requirements might have been additional motivation to move clinicians in that direction.

What are your plans for greater patient engagement? Email me.

Email Dr. Jayne.