If you haven’t read Moneyball or seen the movie, the story tells how the Oakland Athletics and New York Yankees both won 103 games in 2002, while Oakland’s payroll was $41 million and New York’s was $125 million. In baseball, this is called playing Moneyball.
To identify how health systems, ACOs, and medical groups around the U.S. are creating Moneyball-like results, HCTA recently interviewed Robin DiMatteo, Ph.D., to gather intelligence from the cutting edge of healthcare delivery.
During the last four years Dr. DiMatteo has been invited to speak at over 60 healthcare organizations. Four years ago she mostly spoke to medical groups, but more recently she has been invited to speak at several of the most reputable health systems in the U.S., as wells as ACOs, health plans, and employer groups.
The reason Dr. DiMatteo has recently become very popular is because she is one of the leading experts on enhancing the effectiveness of provider-patient encounters and improving patient adherence to treatment.
What healthcare organization wouldn’t want to improve the effectiveness and efficiency of medical office visits? With value-based payment reimbursement penalizing providers for inpatient readmissions and rewarding lower per member per month costs, we all need to get better results with the resources we have.
Though medical doctors are the most qualified professionals with regard to the technical workings of the human body, some of the breakdowns in the process of improving health are found to occur in the interactions between physicians and their patients, and how patients subsequently respond. Prescribed medical treatments are only effective when patients adhere to them.
“Medical care is delivered to human beings by human beings,” says DiMatteo. “There is a whole collection of ways to respond during an encounter that are effective and we know which specific ways are not effective.”
One example of how the wrong communication can damage treatment adherence is the ineffective use of fear to try to scare patients into following orders. Research shows that not only does fear not work, but it can cause patients to develop cognitive dissonance and downplay the seriousness of their own disease.
“The trick is to train physicians to think and respond like psychologists” says DiMatteo. “Effective communication requires knowledge and skill. You can’t ever get away from behavioral issues.”
Health system-affiliated groups have the potential to overcome these problems by providing staff with science-based training on improving communication effectiveness and adherence. One approach is the motivational interviewing method developed by William Miller and Steven Rollnick. Motivational interviewing focuses on eliciting information from patients, rather than authoritatively telling them what to do or talking at them. It can be challenging to implement this method because physicians are inherently authoritative professionals.
“Several large integrated systems, ACOs, and PCMHs have found this to be essential to control costs. Some established ACOs are doing it really well and want to do it better,” says DiMatteo. “A lot of different systems have had some training and want more. Some have only heard of it. I’ve also spoken at practices where people have never heard of this.”
Communication effectiveness can be “coded” or rated by trainers. The trainer can count the number of times the provider asked non-judgmental, open-ended questions like, “What kinds of problems do you think might prevent you from taking your medication?” Inclusive statements, statements of empathy, and asking for permission to share one’s professional opinion are all correlated with effective communication.
DiMatteo also finds that the use of care managers can effectively augment the limited time physicians may have with patients. Care managers can engage in ongoing problem solving with patients for issues not requiring physician oversight.
For example, a care manager can work with a patient on anti-coagulant therapy to develop strategies for remembering to take their drugs and watching for side effects, and provide instructions on how to correctly increase or reduce doses with the use of a pill cutter.
Improving the effectiveness of patient-provider interactions will be crucial to effectively managing the current swell of patients with chronic diseases. Though Medicare will begin paying physicians $44 per member per month in 2015 for chronic disease care coordination, these payments don’t reduce the growing demand for services or the shortage of providers. We’re all stuck playing Moneyball with the limited resources we already have.
“Thirty percent of people diagnosed with chronic diseases are depressed. In some chronic diseases it is even worse. Depression is an impediment to treatment adherence and you have to listen to diagnose depression,” says Dr. DiMatteo. “A lot of medical care organizations, whether ACOs or PCMHs, have already started and are working at it. The thing that distinguishes them is the motivation and recognition that communication increases adherence and reduces cost. They see the link to outcomes.”
—————————————- Dr. DiMatteo is Distinguished Professor of Psychology at the University of California, Riverside. She can be reached by email at robin.dimatteo@ucr.edu