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)
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.