Team based care in health reform needs patient involvement

The following op-ed was published on June 7, 2011 in USA Today.

More than ever, I find myself fielding questions from patients about the health care reform law. The most common one is, “How will reform affect me?” It’s a complicated question, with a different answer for each patient. But as the law’s full effects unfold, one of the more significant changes will be in how patients interact with their doctors. This sea change became clearer in March, when the Department of Health and Human Services proposed rules encouraging health providers to operate in teams.

What will this look like in practice? A patient’s trip to the doctor might result in treatment by a clinician from the doctor’s team, perhaps a physician assistant or nurse practitioner. Getting an office appointment should be easier, and team members would be more available to answer questions and follow up with patients. This model is known as a “Patient-Centered Medical Home.”

Another variation would address the fragmented nature of today’s patient care by coordinating hospitals, primary care and specialists into networks called “Accountable Care Organizations.” Here, everyone involved would have incentive to share information, work together and be jointly responsible for the patient’s care.

The success of team-based initiatives, however, will rely on the patients themselves. And here’s the problem: Their input has largely not been sought.

Last year, the American Academy of Family Physicians released results from the first practices that were transformed into the team-based “medical homes.” Despite findings showing better quality of care, patients were unhappy with the change. Physician-columnist Pauline Chen noted in the  New York Times that many patients felt “displaced as they saw the old one-to-one doctor-patient interactions replaced with … one-to-four relationships involving not only the doctor but also a whole host of other providers.”

According to Terry McGeeney, a primary care physician who led the medical home project, “The Achilles heel of all of this is a lack of patient understanding and engagement.” Indeed, someone forgot to inform patients how their health care would change.

In its messaging, the government has sought to calm health reform skeptics by assuring them their health care will minimally change. But by endorsing team-based models, patients will need to be better informed, and policymakers and physicians, in particular, can play important roles:

  • Policymakers should do a better job preparing patients for what to expect. Inform them that they may not solely see their doctor, for instance, but other members of the health care team. Tell patients their health information may be shared among their providers.
  • Physicians also should prepare patients for changes in their health care routine. Transforming a medical practice to fit the required regulations can take years, and the process is disruptive. Involving patients and proactively soliciting their feedback can help ensure a smoother transition.

Team-based care can improve quality of care by emphasizing preventive medicine, improving communication between providers, and facilitating better management of chronic disease. Pilot studies show provider teams save money through better coordination, which reduces duplicate procedures and expensive trips to the emergency department.

We will realize the full benefits of health reform only if patients are informed and involved every step of the way.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitter, and LinkedIn.

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  • pcp

    Several comments:

    “Despite findings showing better quality of care, patients were unhappy with the change.”

    The decrease in patient satisfaction in the NDP was statistically significant; the increase in meeting certain quality standards was not. It was also reported that the practices experienced significant financial stress, but the data on that have never been released.

    “patients will need to be better informed”

    Patients need to be told the truth. In “team-based care,” the doctor will: have a much larger patient population (and much larger medical liability); spend much more time doing administrative and supervisory chores; and have much less time for each patient, resulting in shorter and less available appointments.

    “Team-based care can improve quality of care”

    No outcomes data yet; just evidence that some corporations are better than others at collecting and massaging data regarding non-significant endpoints.

    “Pilot studies show provider teams save money through better coordination”

    Translation: corporate profits are up. So far, none of the poster children for “team-based” care have passed these savings on to patients in the form of reduced premiums or lower fees.

    Sign me up!

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      Don’t be so quick to sign up. Team care saves money to payers, not to the team…. Maybe they’ll share the savings with you ($5 a month), maybe not….. patients are certainly not going to see a dime, or maybe a dime is all they’ll see.

  • Carrie

    There is absolutely value in continuity of care, in building a relationship, and in knowing what a patient’s rash looked like last week rather than trying to read it in a chart. But seeing more than one doctor/care provider means an automatic second opinion. Doctors are not perfect, and one doctor may have a new idea for diagnosis, treatment, or encouragement that is just what the patient needs.

    If patients are cared for by a team with at least some stable members, team-based care may be able to provide continuity of care and a diversity of perspectives at the same time.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    There is a big difference between informing someone on the decision, and seeking their input in making the decision.

    Decisions in health care are now made top-down with very little input from those who actually provide health care and those who receive the care.
    If we’re lucky, everybody will be happy and satisfied with these decisions. If we’re not so lucky, the decisions will have to be enforced somehow, or more likely, tossed out eventually.

  • Homeless

    “The Achilles heel of all of this is a lack of patient understanding and engagement.”

    My former doctor practices in a clinic that participated in the TransforMED Demonstation Project. The above sentence implies my negative experiences were a result of not being engaged or educated.

    I have a zebra. I know my disease, I live with it everyday. I have worked with some wonderful specialists and have done extensive research on my disease. At the time I was going through the diagnostic process, I didn’t have a primary care physician with enough time to be engaged with my health. When I learned about the PCMH, I was intrigued and looked forward to having a real relationship with my doctor, one where my needs were met and the staff was familiar with my uncommon disease.

    I had been a patient of Dr. X for 9 months when the clinic began the project. During the next 20 months of the project, I saw five different providers for a developing problem-one unrelated to the zebra. The communication was poor and things were missed. I felt I wasn’t a real person, just a chart. During that fifth visit, I was almost in tears, frightened by my worsening symptoms and frustrated to feel alone. The stranger that walked in the exam room, a physician assistant, could see I was upset. Her solution: come in next week because I hadn’t seen “my doctor” in over a year. I did get a phone call from Dr. X the next day. She didn’t inquire about my declining mental health but she did recommend I see a specialist. I was engaged and educated enough to seek the care of a psychologist on my own.

  • Homeless

    From the AAFP link above:

    “According to the NDP evaluation team, adoption of PCMH components is associated with small improvements in condition-specific quality of care. This was observed in both facilitated and non-facilitated practices. Practices that adopted more PCMH components achieved better scores for quality-of-care, chronic disease care, prevention and condition-specific outcomes included in the Ambulatory Care Quality Alliance Starter Set. There were trends for very small decreases in coordination of care in both groups. Until primary care becomes more integrated in the larger delivery system, PCMH implementation is not likely to result in statistically significant improvements to most patient quality-of-care outcomes.”

    Small improvements?

    Decreases in coordination of care?

    Not likely to result in statistically significant improvements?

    So the PCMH trashes the doctor-patient relationship for these outcomes? And where is the evidence that PCMH saves money?

    • pcp

      Excellent comment.

      Many of us feel the AAFP’s enthusiasm for a model of health care in which the doctor-patient relationship is considered to be of no value is so incomprehensible as to verge on the clinically delusional.

      • Homeless

        If direct patient contact is only done by the team of mid-levels and my doctor only knows my chart, then it seems to me the next step in cost savings is to outsource my care to a doctor in India.

  • Hexanchus

    What if the patient is not comfortable with the whole idea and doesn’t want to be cared for by a “team”?

    What then?

    • Penny

      Like homeless suggests, it will be tough luck. They will just farm his case out to India.

  • David Keller

    Interesting take on the findings. I was not surprised to hear that people don’t like change, and that the process is stressful on patients (and staff). I am a big fan of caring for patients in teams, and have done so for 20 years, as part of the American Academy of Pediatric’s Medical Home Initiative. What is missing in the current adaptation of that model, however, is the patient voice. When planning practice transformation, I think that we must include patients in all levels of the discussion in a real and meaningful way, including governance. That way, we can develop the team around their needs, rather than the needs of the medical-industrial complex.

  • enuf4me

    Hmmm, make decisions with patient input? What a concept! Next our employers will be wanting our input on our jobs. Nope, not going to happen any time soon in the healthcare industry that I can see. My insurance could be lower each year if I would just let the team of “wellness” experts at my place of employment tell me what to eat, how to exercise, and if I share my spiritual thoughts by giving me points towards earning the discount. For some reason they don’t understand why I and others find this insulting, invasive and aren’t jumping at the chance to have our jobs/employer become more a part of our lives. Now I can have another team to look after me and care for me in my “medical home?” Oh goody, more people to tell me how to live, what I should do, what I should change and why I should l like it. Will they give me points I can use to lower my copay? I have enough “teams” in my life already. What happened to people using their own good judgment to go by? There’s no “I” in team, and there’s no “U” either.

  • Deborah Bolton-Plucknett

    As a clinician for many years, I too endorse the premise of team based care. However, when you put yet another layer between the physician and patient not only do you decrease the patient satisfaction but you increase the possibility of lack of coordination rather than increase it. It has been my experience that the more complex the concept the less compliance by everyone involved.

    Not only is the patient input absent in this model of team based care but also absent is the probability of human error and differences of interpretation as well as over inflation of team member opinions, etc. In other words simply put, the human factor.

  • Kristin

    It’s interesting to watch modern medicine fumbling toward industrialization–a necessary but highly disruptive move that interferes with pretty much everyone’s profit margins–and particularly to see the main complaints associated with it from all angles. Patients, across the board, don’t like the loss of face-time with their doctors. Doctors don’t like the loss of autonomy to decide which patients have problems that need more face-time. Insurance companies don’t like actually paying out to anyone, ever, and deeply dislike being forced to take on patients who probabilistically won’t be profitable. Drug companies don’t like the pressure to move to a generics-based prescription system. Device manufacturers don’t like pressure to provide long-term safety data.

    The pressures on all parties have to be regarded as systematic. Insurance companies behave the way they do because of their legal obligation to shareholders, in addition to the personal profit incentives for high-ranking corporate officials. That system of reimbursement is driven in large part by the drug and device manufacturers, because they reap large rewards from the current system. As their rewards decline, expect their support for the status quo to decline. Hospitals are trying to act like corporations because it costs money to run a hospital and they would like to not close. Hospitals acting like corporations (taking out advertisements, etc.) means that patients are being treated more and more like consumers, but the healthcare market can’t behave like other markets. (Nobody’s going to stop mid-heart attack to research which area hospital they should go to and what cardiologist they would prefer, even if they had the background and the free-floating knowledge to understand the choices.) Doctors are working toward insurance reimbursement, and patients have virtually no power to affect those pressures on an individual level, although if patients banded together into effective advocacy groups they could… well, probably still not do very much, since the health-care market is not like other markets and the profit incentive to ignore patients is so huge.

    No wonder everyone without their own industry lobbyists feels helpless and frustrated. And no wonder the lobbyists and their pawns are so very effective at removing the teeth from legislation that might make a difference.

  • David Keller

    Interesting is one word. I’m not sure that those of us who supposedly have lobbyists always know that the lobbyists are on our side.
    The trick for any guild that is being industrialized is to figure out how to maintain the best of our traditions in the face of overwhelming economic pressures. I for one am finding it challenging.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      When guilds are industrialized, they cease to exist and their members are transformed into laborers.

  • Sharon mickan

    Team care can offer a lot of potential benefit for all… But who is going to coordinate the team’s activities? Will doctors be too busy? Will patients have to manage their own teams? How can they be assisted to do this?

    • Penny

      Some 17-year-old secretary, no doubt, who has been working there for at least a month.

  • Penny

    Didn’t doctors already decide a few years ago, who was going to live and who was going to die, or did I misunderstand those 2008 articles?

    http://www.google.ca/search?q=doctors+who+live+who+die+pandemic+decide&hl=en&num=10&lr=&ft=i&cr=&safe=images&tbs=

    The way I understood it, in any pandemic (and governments are trying to create one after another it appears, since few seem “naturally occurring”), certainly all our parents have been selected to die as well as the majority of baby boomers. So the only changes I can see from here on in, are that instead of wiping people out at age 60, they will lower the age to 55, and then 50 as budgets tighten. Anyone see it more positively?

    • David Keller

      Hmm. Don’t know anyone working on causing a pandemic. Planning for disasters seems a good idea; if the disaster is limited in time and space (pandemic, tsunami or otherwise), having contingency plans is useful.
      Doubt that anyone is planning to exterminate the elderly.
      I think that most people, including doctors, are reasonable people trying to make sense out of the world. But I always have been an optimist.

      • Penny

        Surely I have to admit I’m a pessimist, David, and proud of it too, as you likely are for being an optimist.
        You know what I think that’s kind of funny? I think that an optimist sees himself as a realist and thinks pessimists walk around wearing tin foil hats, whereas a pessimist sees himself as being a realist thinks optimists walk around wearing rose-coloured glasses, yet both are the way they they “want” to be.

        I totally can’t handle disappointment if not prepared for the worst, so in a sense, maybe that makes me weaker than you — or maybe stronger too, because I watch all of the bad things happening in the world as well as good, while a lot of optimists “cover their eyes” from the bad (and accuse pessimists of covering their eyes from good)..

        I keep thinking that those killed by Hitler were probably optimists for the most part — the type who stuck around thinking things would improve, while pessimists spared their lives by fleeing in advance, thinking things would get worse.

        Have you ever watched the movie called the Matrix, where someone had the choice of taking the red pill, (pessimist pill) or the blue pill (optimist pill)? (Yes, the colours should’ve been in reverse.).

        If there had been a purple pill in the middle, how many people do you think would choose that, keeping in mind that both pessimists and optimists consider themselves realists? Do you think both types would take it or almost none would choose it? That’s such a “fun” topic to discuss when you’re sitting with a group of people!

  • Wesley Hard

    The medical home transition will be a long and difficult process for patients and physicians. It will increase medical costs initially, but may decrease them in the future, at least in theory. I think the medical home is worth pusuing, but should not be seen as a panacea.

  • Penny

    What a sloppy mess that sounds like — 50 cooks in the kitchen trying to get to the same pot. We don’t have much of that in Canada yet, thank God. It was bad enough going through the Cancer society not long ago and realizing that when 20 people are in charge of things, you generally have to fill out the same forms and ask the same questions at least five different times. It’s just like government where so many people get paid for doing the same jobs that countries are all going bankrupt. It’s not the poor who are draining them; it’s the rich.

    When people wake up from an operation they already don’t see the surgeon who operated on them. Instead they see his assistant (who supposedly didn’t do that operation), leaving them wondering if the surgeon either lied saying he was going to do the operation himself, or flubbed up badly somehow. And instead of the surgeon training an assistant these days, the assistants are training assistants to themselves.

    These are all sure ways to ensure there is no more patient rapport or connection with any physician. From now on they will get nothing but a bunch of icy contacts from a million people who couldn’t care less if anyone lived or died.

    Getting a pap test? No need to bring in a nurse. Bring in that 17-year old secretary instead. She’s just as professional. Need to get your EKG done, ladies? They just hired a 17-year old male last week to do the job.

    Same thing with nurses in hospitals. The aides are now doing their jobs while nurses are doing doctors jobs’ and doctors are doing specialists’ jobs.

    Need someone to come into your home to look after you when you’re old and ailing? Don’t worry. They hire fly by night people all the time for a small fee.

    Need a psychiatrist? Don’t worry, hospitals have plenty just out of mental institutions themselves, the same types that are running our countries. They will assign a student to you.

    Need a prescription? Just take it to your corner drug store. They will be the ones not just filing them one day but also prescribing them. Of course you may have to pay three more though because there will be many more who will now have to buy lawsuit protection, just like all the others in the medical profession who are doing jobs they aren’t properly qualified for. What a heyday for insurance companies and big corporate North America! I’m starting to disrespect those companies more than oil companies, more than drug and radiation companies, and even more than judges and politicians. Now that’s saying a lot!

    Increasingly the entire medical system is becoming as sloppy and disorganized as government where half of the people don’t know what the other are doing and the other half say it’s the other guy’s department and no one does anything at all because they’re all out playing golf at taxpayer’s expense while working toward their early fat lifelong retirement after just a few years of golf.

    Personally this appears to be nothing but yet another government attempt to totally destroy the medical system by frustrating patients so badly with such a messy hodgepodge of treatment that they will stop going to doctors entirely. That is the name of the game isn’t it?

    The butchery and lack of patient care is becoming more brutal all the time. The real reason all of this is happening is because politicians are far too well paid, especially considering their secretaries are doing most of their jobs.
    For that they get the best salaries in the country, the best medical and dental care, and pensions so unreasonably obese they should be put on a strict diet ASAP!.

    Who do they think they are anyway? Gods versus our servants? We need to let them know they aren’t before they become delusional enough to kill us all. Sorry for my ranting but this one hits a severe nerve with patients overall.

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