According to the MedScape 2014 Physician Compensation Report, 50 percent of primary care physicians spend 16 minutes or less with each patient. This is impressive because primary care physicians are now mostly responsible for treating the largest, most expensive category of diseases in the United States–chronic disease.
With the tactical obliteration of infectious disease over the last century, modern medicine is now left fighting a grueling ground war against chronic disease. Chronic disease is certainly the quintessential healthcare problem of our era. Eighty-four percent of U.S. healthcare spending is on people with chronic diseases, and 75% of U.S. healthcare spending is specifically related to the treatment of chronic diseases.[i][ii]
Unlike fighting infectious diseases with antibiotics and vaccinations, modifying patients’ behaviors and lifestyles to combat cardiovascular disease, lung disease, and diabetes is a slow, painful battle. How in the world are primary care physicians expected to radically change patients’ lifestyles and behaviors during brief 15 minute office visits?
As a result, a new character has entered into our healthcare drama. Patient navigators, community health workers (CHWs), and outreach workers are some of the relatively new titles used to identify the person that you may see after your physician leaves the room. Generally, CHWs are lay people from the community that share many of the social, cultural, and economic characteristics of the patients. They may not be nurses or technically trained medical professionals, but their job is to make sure you understand everything your physician said about your disease, treatment, and get you answers to your questions.
This new role developed as a function of necessity. Robin DiMatteo, PhD, adherence expert and professor of psychology at the University of California-Riverside, estimates that 275 million office visits per year are essentially wasted because patients either didn’t understand the information they received during physician office visits or forgot it soon after. Patients who do not understand what they are being told also tend not to ask questions.
“It is like going to Best Buy and throwing away 25% to 50% of what you buy when you leave the store,” DiMatteo says.
As a result, patient adherence to prescribed treatments are shockingly poor. Close to 40% of patients may take prescribed medications incorrectly.[iii] Adherence failure rates are almost twice as poor for dietary, exercise, alcohol abuse, and smoking.[iv][v][vi]
According to a recent article in the American Heart Association’s “Science News”, the authors boldly assert that “When it comes to reducing early deaths, medical care has a relatively minor role, potentially preventing 1 in 10 premature deaths. Rather, the single greatest opportunity to improve health and reduce premature death lies in favorably modifying unhealthy behaviors…”[vii]
They idea that 90 percent of heart disease treatment does not require the services of physicians or medically-trained professionals seems fairly radical.
The finance guys inevitably ask, “Who is going to pay for this?” There is a strong tendency not to hire any new employees or create new positions that aren’t billable to insurance. It is not desirable to add CHW staff costs if there is no new revenue to offset these new costs.
At the same time, there are new challenges, including Medicare’s Hospital Readmission Reduction Program, the Bundled Payment for Care Improvement initiative, Accountable Care Organizations, and Value-Based Purchasing payment metrics. How can these new responsibilities be shifted to practicing physicians already only spending only 15 minutes with each patient?
An emergency medicine physician recently laid out a compelling business case to me for the use of patient navigators in the emergency department. Several years ago his hospital started using patient navigators in the emergency department to schedule ambulatory physician visits for patients determined by ED nurse to be non-emergent. This hospital projected to eliminate 10 to 12 percent of emergency department visits by navigating patients to more appropriate settings. This arrangement had serious cost reduction implications because the hospital pays between $13.0 and $14.0 million per year to secure emergency department physician coverage and patient visits decreased substantially as a result of the use of patient navigators.
— [i] Robert Wood Johnson Foundation. Accessed March 2014. “Chronic Care: Making the Case for Ongoing Care.” http://www.rwjf.org/en/research-publications/find-rwjf-research/2010/01/chronic-care.html. [ii] Centers for Disease Control and Prevention. Accessed March 2014. “Chronic Disease Prevention and Health Promotion.” http://www.cdc.gov/chronicdisease/index.htm. [iii] Epstein LH & Cluss PA. A behavioral medicine perspective on adherence to long-term medical regimens. J Consult Clin Psychol. 1982;50:950–971. [iv] Brownell KD & Cohen LR. Adherence to dietary regimens: 1. An overview of research. Behav Med 1995;20:149–154. [v] Wilfley D & Brownell KD. Physical activity and diet in weight loss. In: Dishman RK, ed. Advances in exercise adherence. Champaign, IL: Human Kinetics 1994:361–393. [vi] Norman P, Abraham C, Conner M, eds. Understanding and changing health behaviour: From health beliefs to self-regulation. Amsterdam: Harwood, 2000. [vii] Barry A. Franklin, PhD; Jenna Brinks, MS; Harold Friedman, MD. Accessed April 2014. “Foundational Factors for Cardiovascular Disease: Behavior Change as a First-Line Preventive Strategy. American Heart Association.” http://my.americanheart.org/professional/ScienceNews/Foundational-Factors-for-Cardiovascular-Disease-Behavior-Change-as-a-First-Line_UCM_457215_Article.jsp