Monday, January 23, 2012

A Novel Approach: Ask the Primary Care Doctor

The government, academics and policywonks are always in the process of "redesigning" health care.  Patients with increased health care needs are considered "complex" and these patients consume the major health resources (translate: "money").  In fact 65% of total health care expenditures are directed toward the 25% of patients with multiple chronic conditions.  Eighty percent of Medicare spending is on patients with 4 or more chronic diseases.  For the first time a study has been done and published in The Annals of Internal Medicine  that actually asks primary care physicians (PCPs) what defines patient complexity.  Who better than the treating doctor to answer this question?

The researchers asked 40 primary care physicians to rate the complexity of 120 of their own patients and to document the characteristics associated with complexity.  Over 1/4 of patients were described by the doctors as "complex".  The doctors were not told what defined "complexity", but instead were asked to describe it in their view.  Once a patient was described as "complex" the doctor was given 5 domains to chose from, developed from previously published concepts.  The 5 domains were:
  • Medical decision making (cognitive effort needed to make appropriate diagnoses and therapeutic decisions)
  • Coordination of care (overseeing care involving others and for making sure that the medical system is working for the patient)
  • Patients personal characteristics (challenging patients)
  • Patients with mental health issues (includes substance abuse)
  • Patients socioeconomic circumstances (home and work issues, inability to afford medication)
Some characteristics of PCP-defined complex patients stood out.  They were more likely to be over age 60 and women.  They were more likely to have government insurance (Medicare/Medicaid) than commercial insurance.  They were more likely to be undereducated and had many office visits.  They took more than twice as many prescribed medications.

I find it fascinating that most of the PCP identified complex patients were not considered high risk by the Medicare model and other known models.  The algorithms that guide payment and other policy decisions didn't hold up.  The patients identified as complex by PCPs affect their workday and time, yet the known models would not have called them complex.  More than co-morbidity and other case-mix definitions, factors like inadequate insurance, alcohol related problems, prescriptions for anxiety and other mental health issues were all associated with increased complexity per the physicians.  These patients generated more visits, more high cost procedures and more need for mental health services.

The fact that doctors are finally being asked about their work is promising.  It is predicted that 32 million uninsured Americans will come into the primary care system with the passage of the Patient Protection and Affordable Care Act.  This at a time when fewer medical school graduates are entering primary care and many PCPs are leaving clinical practice due to work related stress and decreased job satisfaction.

These results actually provide insight that should be considered in designing a health care system that works for patients and care-givers.  It should influence payment mechanisms, office support and allow the extra time it takes to care for complex patients.  These changes would go a long way to increasing the work satisfaction for PCPs.

The fact that this was the first study that actually defined complexity from the PCP perspective is amazing.  Let's hope it is the start of something that will ultimately improve the health care system for patients and PCPs.




5 comments:

Anonymous said...

Thanks for this, Dr. B. We need more studies like this that are practical and can be translated into policy that actually affects what happens in a physician's office. I am a PCP and understand completely these categories for complex patients. The medicare codes and payment rules do not address these time consuming patients so we are disadvantaged when we spend time with them and try to to our best to help them. Each patient that I keep out of an emergency room or a hospital saves the system tens of thousands of dollars. The entire health care system should be focused around my productivity and ability to spend time with patients. It benefits everyone.

Michael Kirsch, M.D. said...

I'd include 'coding and billing' wherever medical complexity is being assessed! I find this aspect of medical practice more confusing and challenging than practicing medicine.

Meagan said...

Thanks for posting this! I certainly hope this is a sign of the positive turn ahead!

wedding maldives said...
This comment has been removed by a blog administrator.
Anonymous said...

Complexity often serves as a euphemism for "unknowns" in medicine and for "difficult-to-assess-cost" among hospital and health care administrators. Complexity doesn't fit into neat boxes. That women over 60 fall into the category is not a surprise considering the dramatic changes in the body following menopause that leads to the need for more attention to cellular change, infection, and a boat-load of co-morbidities that baffle doctors and patients alike. Sadly, too many doctors diagnose too many of these women as having the 21st-century version of hysteria, better known as fibro-myalgia--and they are dosed on prozac, or lyrica, or any other dumbing drug that sooths the beast but does not lead to quality health. Too often I, at age 54 already, have been told that any ailment I have is thanks to my age--with no regard whatsoever to what is actually happening. A droopy eyelid might be age, when the reality is a herpes infection.

I agree with a few of the others who have commented here. The system needs to focus on care, preventative medicine, and yes, time with patients so that doctors actually know what the difference is between the healthy patient and the sick patient. In the long run, this will be more effective and cost saving--and ethical.

It's nice to see a doctor hosting such a fantastic blog as well. I'd like to see more doctors reaching out publically in this way.