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March 31, 2005

Senate plenary explores better doctor-patient relationships

The days of Marcus Welby, M.D., TV’s medical icon of the 1960s and ’70s, are gone forever.

“Back in the ‘old days,’ we as patients could go in to see our physician and talk about our activities, chat about what our grandchildren were doing, cover other areas of our family life,” said the keynote speaker at last week’s Senate spring plenary session.

In that bygone era, the patient mostly was a passive participant, unquestioning of the doctor’s instructions, and hopeful — as opposed to expectant — of a successful outcome, said Margaret Smith Washington, president of Washington Associates, a Pittsburgh-based consulting firm that provides training and workshops in communication to physicians, health care providers and patient groups across the country.

Today, with no time for chit-chat, a more-informed patient population, heightened patient expectations due to advances in technology and ubiquitous advertising, higher costs and other factors, there is a widespread crisis in communication between physician and patient across-the-board in today’s health care system, Washington said. “That crisis is caused by physicians who don’t listen and patients who don’t hear,” she said. “There’s plenty of blame to go around on both sides.”

Washington’s talk was part of the March 23 plenary session’s theme, “Consumer Satisfaction With UPMC,” which included a panel discussion by Washington and three physicians of consumer-oriented scenarios. Those scenarios, which were solicited from Pitt faculty and staff who are UPMC Health Plan subscribers, were compiled by plenary session moderator Nathan Hershey, Pitt professor of health law.

The event also included introductory remarks by Pitt Chancellor Mark Nordenberg.

Washington, who has consulted for groups around the country, said she hears the same concerns everywhere from both patients and physicians.

“Patients wish that physicians would look at them when they talk; would not ruffle papers; would not take phone calls that are not emergencies; would not prescribe medications without giving some thought to how difficult it will be for a patient to pay; would not prescribe medications that are not on the formulary for their insurance plan,” said Washington.

Patients also are annoyed by long waits without explanation, by discourteous treatment and by resistance of physicians to accept their input.

The physicians, she said, find patients too vague about their symptoms and say patients have unrealistic expectations about their health care outcomes. The doctors also are reluctant to partner with poorly informed patients in health care decisions.

“One of the things I would recommend is that every patient does become a partner,” Washington said. “Whether the physician wants you to be a partner or not, you must take that role, you must insist that you have an equal say in how your treatment plan is developed.”

However, that requires the patient to learn about his or her condition, to better describe and to be totally honest about symptoms and pain, and to be prepared to ask questions, she said. “It’s very sad when I talk to a college graduate who tells me: ‘I didn’t want to ask a question, because I didn’t want to look stupid.’ There is no such thing as looking stupid; but there is such a thing as being misinformed, and therefore having bad outcomes because you chose not to ask a question.”

On the other hand, physicians need to know that when a patient has made the effort to learn about his or her condition, that patient should not be rebuffed.

As an example, Washington cited a doctor in one of her focus groups who complained about a patient who had researched a medical condition on the Internet and then suggested the physician was not applying the best treatment.

She said the physician told the patient: “Then call the Internet at 2 o’clock in the morning if you need a pill. If you’re going to second-guess me, I don’t need this.”

A better answer, Washington told the physician, would be to thank the patient for doing the research, promise to read the findings and agree to discuss the treatment at their next meeting.

The physician told Washington he didn’t have the time for that. “I’ve got to get them in and get them out. I don’t have time for a lot of conversation.”

That kind of communication breakdown continues to be a problem that physicians need to acknowledge. “As long as a physician says, ‘There’s nothing wrong with me, it’s the patient,’ the problem will continue,” Washington said.

“If you tell me, as a patient, to go have a test done on Monday, I don’t want to have to wait for two weeks to find out the results,” she said. “This speaks to the basic relationship between the physician and the patient. If you, as a physician, respond: ‘If there was something wrong, we would have called you’ — that’s not good enough. That might have worked 10 years ago, but we’re dealing with informed people who want to know and need to know.”

She added that if doctors expect patients to follow their instructions, they have to be reviewed thoroughly beforehand to make sure the patient understands what to do.

On the flip side, patients who withhold problems put their lives at risk, she said. “Many patients believe ‘I don’t have to tell the doctor. When they draw my blood they will know.’ That’s a very dangerous game to play. By the time the doctor knows, it might be too late.”

In the same vein, she said, many patients are reluctant to divulge their conditions fully for fear of a physician’s judgmental reaction.

“For instance, a standard question always is: Do you drink? You might say ‘no,’ when in actuality you’re knocking back three or four drinks a night after dinner. That doesn’t mean you have a serious drinking problem, but it does mean the physician should have that information,” Washington said.

“But if in response to the question you say ‘yes,’ and the physician raises his or her eyebrows or looks very judgmental, that encourages you not to be as forthcoming with information the next time around, and that could be detrimental to the outcome of your health.”

Patients also need to be forthcoming about what they can do and are willing to do. “According to the doctor, you need such and such care. If the doctor tells you to do something you can’t do, you need to say, right then, ‘I can’t do this. I can’t afford the medication, or I can’t afford the time to complete all the therapy sessions,’” Washington said.

“We have to create an environment where patients prefer to ask questions, where patients prefer to listen carefully to instructions,” she concluded. “Physicians must accept a new partner, and recognize that patients will question rather than challenge them,” Washington said.

Both patients and physicians are aware that there are time constraints. “If that’s the reality of our system, then we must learn to maximize that time. As patients, we must insist that we get clear answers, so that when that time is over, we are prepared to follow instructions. If we’re not, it’s a waste of time.

“I would encourage all of us to make a commitment to be better patients, and for physicians to make the commitment to treat me as a person, as a partner, and not a commodity.”

Moderator Hershey led the discussion of health care scenarios that consolidated concerns by UPMC Health Plan subscribers. “Now we’re dealing with real-life questions, where the rubber meets the road,” he said.

Those scenarios included: handling of patient appointments and physician availability; coordination of care among the PCP and specialists; referrals and co-pays; pharmaceutical issues; patient contact time, and cost issues.

Scenario No. 1

Regarding patient appointments following a physician’s exit from a practice, Hershey said, there were two concerns: one, the subscriber may not be notified at all by the practice of the change; or two, if the subscriber is notified, the subscriber is not told who the new doctor will be and is not allowed any choice in the matter.

“Is the [subscriber] entitled to prior notice of this change?” Hershey asked. “Particularly in the case of an OB/GYN, is it not appropriate to notify the patient that the physician is leaving, and that the patient should select another physician?”

Loren Roth, senior vice president, quality care and chief medical officer, UPMC, replied, “I can tell you what is supposed to happen. We have templates that are shared with all the faculty and community positions that should explain that the physician has left, on the physician’s letterhead, and including the names of the physicians who could be chosen.”

Initially, the patient would be re-assigned automatically to another doctor in the group, and the subscriber is entitled to know this. After the first appointment, should the patient wish to choose a physician other than the one assigned, they are welcome to do so, and if they wish to go to a physician outside the practice they can do that as well, by consulting the UPMC Health Plan.

“The most important thing is that the patient have some doctor, some name to refer to, at all times,” to avoid interruption of service, Roth said.

Michael Culyba, vice president for medical affairs at UPMC Health Plan, added: “Every member of the health plan has a requirement to go through a primary care physician. If a PCP decides to leave for whatever reason, or if a practice is no longer part of Health Plan, we have a requirement to alert the patient within 30 days, and we recommend [participating] physicians who are in the general geographic locale as the patient.

“In addition, our comprehensive directory, that is updated, of participating physicians is available on the health plan’s web page, if you want to choose or change your physician,” Culyba said.

Washington cautioned that perception did not always match reality.

“This is not specific to UPMC, but it is a quite common complaint for patients to believe there is an absence of choice. Patients felt they had no right to choose, they were assigned.” She added that many patients do not consider geographic proximity as the best measure for choosing a physician.

Scenario No. 2

Hershey said that breakdowns in the coordination of care among the PCP and referred specialists were causing patient frustration. “What role does UPMC see the PCP playing as coordinator of care? Is there a mechanism whereby specialists can be brought together with the PCP to analyze their information collectively?” Hershey asked the panelists.

Roth acknowledged that coordination of care is a sticky issue. “At UPMC we believe that the PCP should be the coordinator of care, not just the first contact but one called upon to coordinate at all the points of service.”

Specialists should be sharing what they find with the PCP and the patient, but the possibility exists that the patient will get results from a specialist that are incomplete or do not pinpoint the patient’s problem, leading to frustration, especially if multiple specialists are involved.

“Even under the best circumstances, our system is more fragmented than people would like, with an overwhelming amount of information and a limited amount of time to see physicians,” Roth said. “I do believe in the future the presence of an electronic record, which gives a comprehensive account about and reveals the totality of the patient’s condition, in a shared record and a shared database will help this particular problem.”

Panelist Nicholas Bircher, associate professor of anesthesiology and critical care medicine, said: “My view as a hospital-based sub-sub specialist is not the same as a PCP’s. However, I view it as my obligation when I need information from another physician, to get hold of them directly, or make use of the electronic medical records to the maximum extent possible.”

He cautioned, though, that electronic records can be a minefield of data that is time-consuming to navigate.

“Secondly, with respect to patients speaking up, they speak up to me as ‘the court of last resort,’ because they’ve tried to get to their PCP, and they’ve tried various other things, and finally they come to a person they know as a friend. This is a serious problem and it needs to be addressed, by making the PCP more available or have fewer patients, to somehow make themselves more responsive to patients who have been to doctor after doctor after doctor, and still have not been given the answer to the underlying problem.”

Culyba said, “Ideally, the PCP would be the one to facilitate that sharing process. While we lack the opportunity to have ideal communication, we at the health plan try to promote processes and programs that would help facilitate that type of communication, for example, a shared database of more common chronic disease information.”

“What we need are more people,” Roth said. “Not necessarily physicians, but health care providers who can monitor the care among specialists and the PCP. Unfortunately, under our system, those care managers are not paid for.”

Washington said, “This is another reason for expectations being articulated early in the relationship. Patients need to hear from their PCPs: ‘I’m going to make a series of referrals. I’m going to keep you in the loop. If you haven’t heard from me in a week, call me.’ Otherwise, without that communication, by the third or fourth referral, patients are reluctant to go. They don’t know why they’re going to a specialist. They don’t hear that.”

Scenario No. 3

Hershey said that patient referrals are handled inconsistently. Sometimes, a patient is asked to make an appointment first, then call the PCP’s office to obtain a referral. But the PCP’s office does not notify the subscriber or send the subscriber a copy of the referral, which can get lost in she shuffle, penalizing the patient at the specialist’s office with a larger co-pay.

“Is this co-payment/referral problem best resolved by contact with the health plan or the physician’s office?” Hershey asked.

“Secondly, who actually benefits from the additional $15 co-pay and what purpose does the referral requirement actually serve?”

Culyba said, “One thing the health plan strongly believes is that all patients should have a PCP. All of our subscribers have an insurance product where that is a requirement. The basis for that is that it is essential to quality care.”

The co-pay concept originated precisely to give an economic incentive to patients to have their care coordinated by the PCP, he maintained.

“We do ask specialists to say on the claims form whether the patient was referred by the PCP, and that makes a difference in how the payment structure goes, when the claims form is submitted.”

But the specialist receives the same amount regardless of the referral. For a $100 charge, the health plan pays $85 if the patient is referred, but only $70 for a non-referred visit. The patient pays $15 for not having a referral.

Ideally, a referral mix-up should be resolved at the PCP’s office, not with the health plan. “If that’s impossible, the approach should be through the health plan’s membership services. We will make sure a claim is appropriately adjudicated.”

Roth added that a resolution often depends on how active the patient is in making sure a referral has been passed on to the specialist. “But I also believe, when a patient says he got a referral, it would be appropriate for the physician to accept a lower fee. That doesn’t really resolve the problem, though.”

Washington said, “I believe this is part of the patient’s responsibility as an informed consumer to make sure that referral is there when they get there. And if it’s not, someone needs to get on the phone and check that. But the patient should not just dump on some clerical staff who may not be the source of [the mix-up].”

Bircher chimed in, “As a patient I pro-rate aggravation very highly. If it’s going to take me six hours to straighten out a $30 charge, I’ll ignore it. As a physician, however, if the mistake is from another office, I take great umbrage if I’m going to be penalized financially by another office’s personnel over whom I have no control. I get mad.”

Scenario No. 4

A common patient complaint is that contact time with the physician is rushed, robbing the patient of time to ask questions. This is particularly frustrating when the physician acts as if he or she is way behind schedule and attempting to catch up, Hershey said. “Should this problem be reported to UPMC or to the health plan, or both? If the duration of each visit is set in advance by some process, who decides the time allotted to each patient?”

Washington responded, “I have heard over and over: ‘My doctor is too busy.’ But you are entitled to the physician’s time. I don’t accept the claim that the physician is too busy for time with a patient. It can be negotiated about when the best time is, but patients should not be afraid to demand that time.”

Culyba said that UPMC Health Plan does not set any time structure for patient visits, which instead is left up to the individual physicians and practices. “What we do do is have a complaint process. If communication breaks down, the health plan can intervene. We can contact the doctor and investigate.”

He added that the health plan is a strong advocate of the physician/patient relationship. “That means more than the physician just making a diagnosis and then determining treatment. It’s really a relationship in how they communicate, the dialogue, not just about their illness or wellness but how they are receiving care. If there is open communication with physician and office staff, a lot of those things don’t happen.”

Scenario No. 5

A low-salaried patient has been referred for physical therapy but the total cost of co-payments for all the sessions is too high. So the patient decides to attend only some of the sessions to economize, Hershey said. “Is it possible to eliminate some of the co-payment responsibilities for low-salaried [patients]?” Hershey asked.

There are movements afoot to change health insurance to a tiered system based on a patient’s ability to pay, Culyba said. “But the whole concept of medical insurance is to distribute the risk equally among all members, so premiums are the same for those who are healthy as those who have an illness, and we all are sharing the cost of health care. Those co-payments for individual services reduce the premiums.”

Roth said the situation of rising costs will get worse before it gets better. “Patients need ‘a skin in the game.’ You have to pay something to get service, so there won’t be over-utilization of service. That’s the market belief. But employers are shifting the burden of costs progressively toward the patient. That is the growing, nationally sanctioned view as to how to control utilization and health care costs.

“At UPMC, first of all, we do not want patients to forego treatment. You can’t just raise fees so high that people are missing care. Our fiscal people are looking at care proportional to ability to pay,” Roth said.

Culyba said that the health plan’s sliding co-payment scale for drugs has been successful in changing people’s habits. “We have a three-tiered network for use of pharmaceutical agents,” generic, preferred brand and non-preferred brand.

“The co-pays are different, and there is a significant difference for the non-preferred brand. We’ve seen dramatic shifts in choosing drugs based on the co-pays.”

—Peter Hart

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