It’s widely acknowledged that the American health care system achieves relatively poor quality outcomes compared to most industrialized nations and at much higher cost. A new survey, conducted by Nielsen Strategic Health Perspectives and commissioned by the Council of Accountable Physician Practices (CAPP), provided important insights into why this could be the case — and more ominously, why the future may be no better.
CAPP is made up of 28 of the nation’s most successful, multispecialty medical groups, all with long, proud histories and hundreds (in some cases thousands) of physicians. For example, the Mayo Clinic has a storied past dating back to the 19th century, and the Billings Clinic, in Montana, traces its roots back more than 100 years. Kaiser Permanente, founded by Dr. Sidney Garfield and Henry Kaiser a mere 70 years ago, is a relative “new kid on the block.” As large, integrated delivery systems, these medical groups and their parent organizations have embraced 21st-century technology and use it to achieve superior quality results, according to outcome data from the National Committee for Quality Assurance (NCQA).
Each year, CAPP holds an event in Washington D.C., entitled Better Together, to explore the latest developments broadly in American health care. The conference brings together the voices of patients and physicians to inform policy makers and elected officials about how to improve health care in the future. In preparation, CAPP asks Nielsen Strategic Health Perspectives, an independent and highly respected research organization, to survey 30,000 patients and 600 physicians, and during the event present the findings.
This year the research focused on three aspects of health care, all important for patients, particularly those with chronic, complex conditions. First, do physicians use technology to improve the care they give patients? Second, how do they create access to care for their patients in evenings and on weekends? And finally, how frequently do they communicate with their patients about prevention of chronic illnesses and their complications? The findings on all three questions are quite troublesome: our nation’s health care system is doing a poor job in each area. Across the nation, technology is frequently unavailable and underused. Access to medical advice and off-hours care is minimal. And physicians are relatively ineffective at communicating the importance of prevention.
The survey results broken down
Only 49 percent of doctors report being able to share medical information with other physicians. And only 50% say they provide their patients with a portal to see their laboratory and imaging results. Worse still, only 27% of the respondents let patients make an appointment online, and a mere 30% allow patients to communicate by sending a secure email. These shortcomings are unlikely to improve in the future. In a telling comment to an interviewer, the incoming president of the American Medical Association said that he refuses to use an EHR, preferring instead to “just take the penalties.” His reluctance reflects the views of many U.S. doctors.
When it comes to access to medical care in the evenings and on weekends, the results are worse. Only 32% of doctors say they make themselves available to see patients in person. Further, only 58% enable patients to obtain advice by telephone 24/7. And patients surveyed gave their doctors even lower ratings on these same questions. Only 38% of patients say they can obtain medical advice by telephone during off-hours. And a scant 2% of patients can engage in a video visit with their physicians.
These findings — that only half of physicians deliver the excellence in quality and service to patients that’s possible through modern information technology, and that only a third of patients can obtain medical care after hours and on weekends, except through an emergency room — are disturbing. But what is most alarming is the third part of the survey. There is a huge gap between what physicians believe they are communicating and what patients hear, particularly about prevention. Only 14% of patients say they are “generally reminded about preventive screenings,” even though 89% of doctors report doing so. And doubly disturbing, this disparity looms equally large for patients with chronic illness, those individuals most in need of these lifesaving tests and interventions.
This distressing gap helps explain why America’s health care system seriously underperforms. The failure of physicians to effectively communicate the importance of preventing chronic disease and avoiding its complications underlies many of American health care’s shortcomings today. And this failure explains why tens of thousands of people die each year from cancer, heart disease and stroke unnecessarily.
What’s behind the differences?
The survey doesn’t answer the question of why this gap in prevention efforts exists. Maybe patients were, in fact, reminded about screenings, but forgot what they were told or didn’t understand. On the other hand, maybe doctors said they counseled patients about prevention, but in reality didn’t take the time needed, or at least enough to do so memorably.
Whatever the reasons, these findings help us better understand why only half of Americans receive the preventive services they require to avoid or detect early colon and breast cancer. And this failure of communication shows why, just to take a single example, almost half of patients across the nation with high blood pressure fail to achieve control, increasing their likelihood of having a stroke or heart attack.
Although each part of the survey is discouraging, the combination of all three makes improvements in the future less likely. Lack of an EHR leaves the treating physician with incomplete information at the time of the visit. The doctor is, therefore, less likely to deal with care gaps that might come to light or to emphasize the importance of preventive care screening that might be necessary. And at night and on weekends, when patients with problems that a primary care physician could solve in his or her office are sent to the emergency department, care gaps and preventive services are rarely discussed.
Compounding these issues, today’s feefor-service reimbursement system, paying dramatically less to prevent complications than to treat them, gives physicians a negative incentive to invest the time needed. And with patients deprived of the opportunity to view their clinical information and laboratory findings, only a minority of them will recognize the gaps that exist, much less be empowered to try to close them. In sum, this research shows that the chasm between where most of American health care is right now and where it needs to go, preferably in the near future, remains vast.
Creating the solution for tomorrow
Patients who are healthy can have their acute problems addressed on an episodic basis, but without obtaining the preventive services they require, they still face a major risk of developing a chronic illness later in life. Patients with chronic illness, though, need medical care every day to avoid developing complications. Providing the best quality requires that treating clinicians be able to access each patient’s full EHR. Based on this survey, few patients have that today, regardless of their disease status.
In contrast, most of the nation’s large, integrated, multispecialty medical groups have implemented a comprehensive EHR and offer both advice and in-person medical care outside of Monday to Friday, 9 a.m. to 5 p.m. As a result, their patients don’t need to be sent to the local emergency department in the evenings and on weekends. And for appropriate medical problems, many of these groups provide not only telephone access but also video and secure email. Moving in this direction would greatly benefit American health care.
Make no mistake: addressing these gaps, especially the one between what physicians believe they are accomplishing and what patients experience, will require more than information technology. Doctors will need to train in how best to communicate about the importance of preventive services. And given how busy they are, they will need support from similarly trained nurses and pharmacists. Unless physicians have this assistance and can bill for the time required, they may do a poor job of explaining the importance of these tests and procedures. And, as a result, patients are likely to fall through the cracks. Of course, some patients will seek preventive services themselves — by, for example, scheduling their own mammograms and requesting colon screenings — but many will forget or just put it off. The Nielsen research tells us that 20% of the time, doctors do a good job of communicating with patients. Unfortunately, 20% is simply not good enough.
Unless the structure, technology and reimbursement of American health care are fundamentally improved, the future is unlikely to be better than the present. If the frequency of chronic disease continues to rise, our nation will experience even lower quality and higher costs than we see today. And patients, family members and our nation as a whole will all pay the price.
Robert Pearl is a physician and CEO, Permanente Medical Groups. This article originally appeared in Forbes.
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