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The transition to value-based health care is already fraught with challenges. But it will be that much more difficult if the primary stakeholders use conflicting maps to try to get there. Unfortunately, a recent survey suggests that that may be exactly what’s happening. Patients and providers who are asked to pinpoint the meaning of high-value care have some very different ideas about where it is and what it looks like.
Patients will tell you they want low or no out-of-pocket costs, timely appointments and conveniently located offices. They also want to be confident that their providers know what they’re talking about, and what they’re doing.
Their providers, meanwhile, will tell you that value means ordering the right labs and exams, spending enough time with their patients that they get to know and care about them, and improving patients’ health. Presumably, many would be shocked to learn that the survey, which was commissioned by University of Utah Health, found that fewer than a third (32%) of patients saw improved health as a top priority.
“The value narrative effectively splits patients and physicians into separate teams,” says Lisa Rosenbaum, MD, in a 2013 article in The New England Journal of Medicine. For physicians, she says, “value means mitigating overuse, increasing efficiency, and providing incentives to deliver evidence-based care.” For patients, she says, “value means enhancing [their] experience, honoring patient-centeredness, and catering to outcomes that matter to patients.”
The disconnect can constitute a conundrum for providers who are increasingly compensated not just on the basis of quality outcomes, but also on the basis of patient satisfaction scores.
“Patient satisfaction almost has a negative connotation when you start to think about it in terms of the medical setting,” says Alison Lemay, the associate vice president of patient and family experience at UMass Memorial Medical Center. “It’s the focus of making patients happy.”
“A lot of those things that patients value, like the ability to schedule an appointment or a convenient location, those are what traditionally physicians would view as patient experience,” not patient care, adds Robert Pendleton, MD, chief medical quality officer of the University of Utah Health.
It’s no surprise that patients respond favorably to convenience and amenities, but shiny floors and brightly decorated rooms can’t make up for subpar care and lack of engagement. A 2010 study of patients and their families who’d had experience with intensive care units found a single unifying thread: “In all focus groups, communication was the dominant theme of the discussion by patients, families of ICU survivors, and bereaved families.”
In the push for efficiency and value, are provider groups adequately recognizing the importance of communication? In the eyes of the American College of Physicians, high-value care is care that balances clinical benefit with costs and harms, while maintaining the goal of improving patient outcomes. The Institute of Medicine says it’s “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.”
One result of the emphasis on outcomes is that to meet quality metrics, providers are forced to collect massive amounts of data. That puts a computer and a steady series of tap-tap-taps between patients and their providers. Providers may be doing what they feel they have to do to follow the path they’ve been given, but patients may feel neglected and poorly understood as a result.
To align patient and provider goals, removing the computer would be a big step in the right direction, say Ms. Lemay and others. “How do we get those who are on the frontlines to be able to take their hands off the computer and ask patients about their lives?” asks Deborah Blazey-Martin, MD, a primary care physician and the chief of Internal Medicine and Adult Primary Care at Tufts Medical Center. “How can we expect our caregivers to be compassionate when the system isn’t being compassionate to them?”
“If we want to simultaneously improve quality and cut costs, we must first stop creating incentives that effectively split patients and physicians onto different teams,” says Dr. Rosenbaum, adding that “shared decision making is just that: shared.”
On the road to evidence-based quality care, computers aren’t going away, but medical scribes can help bridge some of the gaps that both patients and providers see as obstacles to high-value care. By handling data entry and other communication-related tasks for physicians, scribes create an opportunity for providers to look patients in the eye and engage on a level that may elicit important details that might otherwise be missed, while simultaneously demonstrating the care and concern patients yearn for.