The health care safety net: Put patients first

For many of the millions of low-income families seeking quality health care in the safety net, the quest can be bewildering. They may walk into a drab, disorganized and unwelcoming clinic, with the staff, signage, and endless medical forms all using unfamiliar language, with unexplained, lengthy waiting times, and with providers burying them in information they can’t understand. On a second visit, they may feel even worse when they end up encountering a different doctor, different staff, and a renewed sense of confusion.

So it was no great surprise that when Blue Shield of California Foundation surveyed low-income Californians in 2011, many were feeling discouraged and not personally invested in their care. They said they felt disconnected and ill-informed, and would change their health care facility if they could. These sobering findings led many health centers to redouble their efforts to train staff to promote courtesy and create a cleaner and more welcoming environment. They worked to break down language and cultural barriers to provide clear information to patients about their care options.

Four years later, we are deeply encouraged that a new survey published earlier this month by the Foundation shows that after concerted efforts by safety-net providers to build more patient-centered systems, more than 50 percent of low-income Californians now rate their quality of care as excellent or very good. Overall, 31 percent of patients rated care as excellent and 22 percent very good, representing a five-point increase in just four years. Patients cited significant improvement in nine key areas, including:  58 percent said they felt welcomed at their facility, a 10-point jump; 62 percent gave top marks for staff courtesy, a 13 percent gain; and 60 percent gave top ratings for cleanliness, up by 8 percent.

These improvements are particularly remarkable because of the uncertainty created by implementing the Affordable Care Act (ACA) and bringing millions of newly insured patients into the system. The message from the survey is clear: Providers have the power to build a deeper personal connection with patients, which translates directly into increased patient satisfaction. We have long believed that the center of the health care universe is the doctor-patient relationship. And while that will always be very important, our findings demonstrate that patients are looking for a clear sense that “somebody cares about me” in their health care facility, and it doesn’t necessarily have to be the doctor. The data show that when patients feel that someone at their health clinic really cares about them and keeps them well-informed, their satisfaction level grows substantially. What’s truly exciting about these findings is that they clearly demonstrate that health care providers are taking responsibility for the outcomes.

While safety-net providers should be cheered by these findings, they must realize that these improvements are only the first step in a long journey. Going forward, creating real, lasting and meaningful change will require a massive shift in thought and actions because the most important variable is not actually medical or economic or technological. Rather it is cultural: we must work on human interactions, personal relationships, and genuine connections with a patient population that is desperately seeking vital services that meet the individual needs of their families.

Shifting the culture of health care requires some heavy lifting. More than any other system, health care has been driven by what I describe as a “supply-side model” in which the medical establishment dictates what services will be available, what the protocols are, and how the system will operate. For example, an overwhelming majority of patients would value a patient “navigator” to help steer them through the complexities of the health system, and also would prefer team-based care with a permanently assigned group of caregivers — doctors, nurses, physicians’ assistants, and specialists. And yet, less than one-third of patients have access to these vital resources today. Ideally, clinics might even have more than one navigator to meet the needs of all our diverse populations, with special sensitivity paid to ethnicity, language, age, gender, and sexual orientation.  Unfortunately, our current payment system compensates doctors to treat patients, but most often the navigators who guide patients to the best treatment are left out of the payment equation.

Going forward, in this new era created by the ACA, we must focus our energy on a more democratic approach: meeting the patient’s expectations, aspirations, and desires for what they want to achieve in their own health care. We have to put patients in the center of the conversation about their health, rather than where they’ve been: at the margins. The good news about cultural change is that it does not have to be resource intensive. In our California experience, we have seen that grants as small as $5,000 can make a big difference in beginning to train, guide, and redirect health care workers to provide the best care possible. As Nelson Mandela once said, “It always seems impossible until it’s done.” Through its actions over the past four years, the health care safety-net in California has demonstrated that high levels of patient engagement and satisfaction are eminently possible. Onward!

Peter Long is president and CEO, Blue Shield of California Foundation.


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