By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD
ROB Professional Editors
August 16, 2017
Patients and doctors can experience frustrations with one another, but it turns out their priorities are well aligned, according to a report by Forbes.
Every year, the Council of Accountable Physician Practices (CAPP) sponsors a meeting in Washington D.C. where it invites patients, elected officials, healthcare leaders and policy experts. The day focuses on examining the voice of the patient and the physician. To prepare for the event this year, CAPP sponsored focus groups across the country to compare the perceptions of patients with those of physicians about what is most valuable in healthcare delivery. Focus group participants were asked to rank 22 healthcare delivery attributes, including coordinated care, evidence-based medicine, access, preventive services, value-based care and technology, and categorize each as either most important, of moderate value or of minimal value.
Physicians were asked to do the same ranking. Unexpectedly, they chose the same highest priorities as the patients: The doctor-patient relationship, evidence-based medicine and care coordination.
The doctor-patient relationship can be described as when data are gathered, diagnoses and treatment plans are created, support is provided, compliance is monitored and healing is encouraged. But the doctor-patient relationship no longer exists independently. Third-party “insurance” companies have inserted themselves into the middle of the doctor-patient relationship so that it now may be represented as the doctor–third party–patient relationship.
This invasion impacts the doctor in many ways. As an example of this invasion, the doctor must document patient interactions according to third-party rules. This causes the doctor (and/or the staff) to spend significant amounts of time documenting the patient encounter. And there are stiff penalties if the doctor does not follow the third-party documentation rules exactly.
Another example of how doctors and patients are impacted is that third parties do not cover all treatments. The most common example is that third parties have formularies. Doctors no longer can only think of what treatment plan is the best for the patient. If a treatment, or drug, the doctor wants to prescribe for the patient is not covered by the third party, patients often resist paying out of pocket and, therefore, may not follow the treatment plan.
Doctors and patients then must have a conversation about an alternative treatment, or drug, that may not be as effective, but is covered by the third party.
How do third parties justify not paying for treatment plans that the doctor prescribes for the patient? Evidence-based medicine is the most common answer heard. There is a good side to evidence-based medicine. Both doctors and patients should want to know what treatments are most effective for the problem being encountered. But there is a bad side to evidence-based medicine. The bad side is formularies.
It’s one thing to talk about the average patient; it’s another thing to deal with the unique patient in front of the doctor. If your unique patient needs a treatment that is not on the formulary, this situation requires more time on the doctor’s part and increased medical decision-making. The patient experiences increased encounter time, increased stress, and even negatively impacted healing.
An interesting thing to note is that when this situation occurs, the doctor is not paid more for the encounter even though additional time and medical decision-making is required, and the patient does not pay less for their third-party coverage because the third party increased their encounter time, increased their stress and negatively impacted their healing.
Care coordination has also been impacted by third parties. Care coordination is a consideration in every treatment plan created by doctors. The patient showing up in an eyecare office with the chief complaint of blurry vision and a medical history of out-of-control diabetes is not well served by just a new pair of glasses. Doctors need to consider the entire patient’s situation and coordinate care to get the diabetes into control first.
Coordination of care was impacted by third parties by the introduction of gatekeepers. With gatekeepers, patients cannot go directly to the doctor they need to see, they must first visit the gatekeeper to get permission to see the specialist. This extra step clearly delays care. Delayed care is best thought of as undelivered care. In a gatekeeper system, care is delayed so that third parties can “manage” care.
We should take heart that patients have the same concerns that we do: the doctor-patient relationship, evidence-based medicine and care coordination. But let’s not stop there. Let’s take this week to do the following:
Improve your doctor-patient relationship by…
a. Mastering your job.
b. Studying personality literature to better understand how to meet patient needs.
c. Improving your skill set in breaking bad news.
d. Focusing on how to increase trust with patients to increase their follow-though with your treatment plans.
Improve your understanding of evidence-based medicine by…
a. Studying what is expected protocol for conditions you will encounter. Both the American Optometric Association and the American Ophthalmologic Association have standardized protocols you should know by heart.
b. Creating scripts for explaining when a treatment plan is not covered by a third party. The focus of the scripts should not be talking negatively about the third party, but positively on how to help the patient get the care they need.
Improve your coordination of care by…
a. Simplifying your internal processes for care coordination.
b. Improving your written communications with other providers.
Lipkin M Jr, Putnam SM, Lazare A, editors. The Medical Interview: Clinical Care, Education, and Research. New York, NY: Springer-Verlag; 1995.