Stakeholder Perspectives

 

Editor’s note: This is part 3 of a series exploring what value means to the stakeholders in healthcare. Part 1, “Expanding the Value Conversation,” appeared in the May/June 2021 issue, and part 2, “Understanding Value in Cancer Care,” appeared in the July/August 2021 issue.

 

Introduction

Caring for patients and improving their health is the core mission of our healthcare system. What gives providers meaning and satisfaction in their work? Understanding this is essential to address the physician and nurse shortage that is expected to worsen due to the burden of treating post-COVID-19 health problems, clinician burnout, and aging provider demographics. Retaining current staff and attracting capable and caring individuals to join them are priorities.

 

"Why do intelligent young people want to work in medicine? The desire to help people, cure the sick, and improve overall health and well-being is a major attraction."

 

 For over a decade, the supply of working physicians in some key specialties has been trending downward. Reimbursement is more lucrative for medical procedures than for cognitive services. That inclines medical students toward surgery and other procedural specialties and away from primary care¹ and specialties like endocrinology and rheumatology, where the work is mostly cognitive. With the growing number of Americans with diabetes, the endocrinologist shortage is particularly worrisome.² The shortage is worst in rural areas.³ This reimbursement imbalance is can be corrected by action at the federal regulatory level, but it will take several years before the impact is seen in young physicians entering the understaffed specialties.

 Why do intelligent young people want to work in medicine? The desire to help people, cure the sick, and improve overall health and well-being are major attractions. Physicians are well paid, but other careers are equally, if not more, remunerative and require less training. Providing value to each patient in daily practice is a strong motivator. Workdays for the physicians, nurses, and others that provide hands-on patient care are long, intense, and exhausting. Every patient visit is an opportunity to help, but also to harm if a mistake is made, an important clue overlooked, or a wrong conclusion drawn. At the end of each day, it is important to walk away thinking, “I made a difference in someone’s life today. I gave them something of value.” To understand what that looks like, I asked the people doing the work, physicians with decades’ experience caring for patients. They have seen much change in that time, and their perceptions are sharp and insightful.

 

Aligning Treatment Goals

The physicians I spoke with deal mostly with chronically ill patients. To help them, the provider must establish a long-term working relationship with each one. As the doctor-patient relationship develops, the physician listens to the patient and tries to discern and clarify that individual’s goals for treatment. In some cases, the patient arriving for a first consultation doesn’t know their diagnosis or the possibilities for treatment. Physicians diagnose, monitor progress, and refine their own goals for each patient. Often the doctor’s and the patient’s goals don’t align well, and the physician tries to find common ground, meet the patient’s expressed (and sometimes implied) needs, and achieve whatever other objectives the physician deems important.

Patient satisfaction is essential. As one patient with cancer put it, “You got me what I wanted.” Every doctor wants to hear that—for personal satisfaction and because medicine is a business. Patients are consumers. When a patient comes in for a consult, if you don’t convince them, “They’ll just go down the street and make another appointment, so now the health plan gets another charge, and the [first] visit has no value,” as Leo Bustad, MD, a cardiologist in Anchorage, Alaska, explains. “The hardest thing I do is nothing and you don’t get paid for doing nothing. It takes a while to decide that nothing is the most appropriate course of action, and you have to then convince the patient and family that you know what you’re talking about, which takes time.”

Gary Craig, MD,  a rheumatologist from Spokane, Washington, has practiced in the same community for many years and established long-term relationships with many patients, some of whom have continued to see him even after moving to other states. “I think value in healthcare depends on your perspective,” he says. “From a patient’s perspective, at least in my specialty, improving their pain control and physical functioning is probably the number one priority. The physician’s biggest thing in rheumatology is actually preventing damage, to start people on a biologic drug that prevents damage, reduces their pain, improves their functional capacity, reduces their long-term loss from the workplace, and reduces their long-term mortality.” Craig continues, “The problem is that patients fear the toxicity of these powerful new drugs. It takes a long office visit discussion, often 2 visits, to convince them to try the recommended drug.”

 “In rheumatology,” he says, “It’s really easy to improve short-term pain outcomes. You put them on steroids, which are probably the single most destructive class of medications in rheumatology. All of our drugs have side effects in percentiles, but steroids are the only class of drugs I know of that have side effects in 100% of people. So, the short-term aim of the patient can be accomplished with drugs that are not widely appreciated to have dramatic toxicity but do, and patients’ perception of drug toxicity is much higher with more aggressive disease-modifying drugs that are actually much safer than long-term use of steroids.” Eventually Dr Craig is able to convince most of his patients to try a safer drug, but it takes time to change their minds, and payers resist paying for that.

Psoriasis is an autoimmune disease that can cause permanent joint damage similar to rheumatoid arthritis, although the more noticeable skin lesions cause some people to dismiss it as a skin disease. Many psoriasis patients are relatively young and live busy lives. Appearance, functionality, and convenience of administration all matter. Managing them involves helping them finding that balance, as Kristina Callis Duffin, MD, MS, Professor of Dermatology at the University of Utah, explains. “What I try to do in my world is figure out what the patient’s values are, what matters most to them, and then to fit the right treatment that’s safe for them. I dig into people’s values a lot.” She explains that in the past, treatment involved phototherapy in a hospital setting. “That was very time-intensive and costly. Phototherapy is now available at home, where if the patient does well, there’s low risk. Not too much time, and if it’s effective for them, it can be a good value.”

 

"The time constraints of today’s medical office environment require dependence on mid-level practitioners, such as nurses, physician assistants, behavioral health specialists, and pharmacists."

 

With a plethora of emerging biologics for psoriasis, patients have the same worries that Dr Craig hears from his arthritis patient. Some of Dr Duffin’s patients wonder how long a product has been approved. When they ask that question, “and you say it’s been on the market for 4 or 5 years, and they say, that’s not very long compared to Stelara that’s been around for 11 years, you have to dig into that. More often I can persuade people to use the more highly efficacious drugs, because at the end of the day, I really just want to be clear.” She helps patients balance effectiveness, safety, cost, speed of response, time required for treatment, and frequency of administration. For those who travel frequently, Stelara may be the best option because it’s given once every 3 months. “It’s great to have all these choices and it allows us to tailor them to the patient really nicely.”

 

 Communicating With Patients

A common concern of providers is having adequate time to communicate with each patient and gain their trust. “I would like to be able to do what I think is best for the patient that’s sitting across the room from me,” says Dr Bustad. “They need to feel that you have their best interests at heart, that you are devoting an adequate amount of attention and time, that you know
what you’re doing. If you can do those 3 things, they will leave thinking they got value. Time is the one factor that will, in patients’ minds, diminish the perception of value. If they are rushed through their appointment, if they don’t feel that they were listened to or that they were heard, or there just wasn’t time to tell their story, their perception of value would be greatly diminished.”

Explanations take time, as Dr Craig says, “We struggle to balance information presentation to patients in a way that provides a realistic view of the short-term and long-term benefits, but also warns them appropriately of what the long-term risks are—how to mitigate those long-term risks by properly reporting early side effects such as infections. When you have an active autoimmune disease, your immune system is attacking you and doesn’t attack other things very well. But the risk of dying from a fatal infection on our current drug therapies, despite their immunosuppressive effects, is lower because having rheumatoid arthritis is more immunosuppressive than our therapies are, and it’s really hard to explain that balance to patients.”

Monitoring the patient’s medication list and assessing adherence are important in any medical practice. Doing it right takes time, as Dr Bustad explains. “If somebody is taking 8 different drugs, I need to find out what they’re taking, not what they’re supposed to be taking or what’s prescribed, but what they’re actually taking, how much, and how often. If you have a 20-minute appointment, that might take 10 minutes. Oftentimes the initial reaction is no, nothing’s changed, but when you go down the list medicine by medicine: ‘How often do you forget to take that medicine? Did you take that medicine today? Your blood pressure is up a little bit.’ In my experience, the electronic medical record med list is not reliable.”

 

Hands-On Care Takes Time

The time constraints of today’s medical office environment require dependence on mid-level practitioners, such as nurses, physician assistants, behavioral health specialists, and pharmacists. Diabetic patients benefit from working with a dietician that can take the time to understand their cultural and personal preferences, schedule constraints, and budget to help them plan healthy meals that facilitate blood glucose control, provide proper nutrition, and do not cause problems with other medical conditions the patient may have. Organization into teams or “pods” with improved internal electronic communication may increase efficiency.⁴

Cardiologists often see patients with heart failure that need ongoing IV treatment or close monitoring in a congestive heart failure clinic with a specialized nurse. The patients interact mostly with these nurse practitioners, who have time to provide the hands-on care they need. Nurses are very cost-effective in this setting. They provide the subjective relational care for these patients that face increasing limitations on physical activity. Intensive management is needed to maintain the delicate balance that preserves independence for as long as possible. When that balance is disrupted, the patient will spend several days in the hospital at considerable cost.

Dr Bustad described how patients with atrial fibrillation are referred to an electrophysiologist “who would then hopefully spend considerable time talking about atrial fibrillation, outlining diagnosis and treatment. After that initial discussion, the electrophysiologist would hand off to his nurse, who does all the patient interaction necessary to arrange the diagnostic phase of the evaluation, and then as they progress down the road to more invasive things. The doctor writes the orders in 5 minutes, and the nurses carry them out for the time it takes. If the nurse, does a good job, the patient perceives value.”

 

Extending Life and Improving Its Quality

In recent years, some specialties have achieved major improvements in extending life expectancy. Dr Craig reports that, “Over the 20 years from 1971 to 1991, the average age at death of rheumatology patients increased from 58. It’s now 79, the same age as the general population. The most common causes of death for these patients were cardiovascular disease and infection. Cardiovascular disease in well-treated rheumatology patients is now the same level as the general population, so the modern therapy of rheumatoid arthritis has improved survival by 20-odd years and has improved patient quality of life very dramatically.” Perhaps the greatest success story is the effective treatment of HIV. In 1996, patients expected to die in a few weeks were rescued and returned to life. 

 

"Providing emergency care on site at the residential facilities makes sense because it leverages the staff’s familiarity with the problems residents are likely to have and how to handle them."

 

Pediatric practice has its own rewards and challenges, says Neil Kaneshiro, MD, a pediatrician in Woodinville, Washington. “For me, value means that patients’ health outcomes are better, and they are at a higher functional status than they were before intervention. And it was done in a reasonable fashion that wasn’t overly costly in terms of money, time, or effort. I see a fair number of medically complex kids because I have a relationship with Seattle Children’s, so they know I’m capable of managing some more difficult cases, kids that are intubated.”

“Parents value access to care, in a way that works with their schedules and ability to make those appointments, either in person or virtual and expect to solve whatever problems they are bringing to the table,” Dr Kaneshiro explains. “For the patients, I think they value being able to function normally. That is the big thing. So, for a 5 year old it’s, maybe, go to kindergarten together, play with friends to the best of their ability. If we can do things that will optimize them, that’s where they stand. They’re going to have this condition for the rest of their lives, so what we’re trying to do is maximize their ability to participate in life to the fullest extent that they can.”

Special patient groups often need customized interpretations of value. For 2 ½ years, Stephen Kolesk, MD has overseen and provided on-campus primary care for children and youth at Woods Services, a Pennsylvania nonprofit organization that provides residential programs for over 500 young people and adults with a variety of learning disabilities, including autism and traumatic brain injury. He describes this practice as “a very, very unique space.” Woods has a “value-based arrangement with a small insurance company here in Pennsylvania.” The insurer understood that, “We were able to see folks with our primary care physicians rather than sending them to the emergency room.”  Of the 500+ residents, only about 120 have insurance. “We saved close to half a million dollars, and they got quality care—good or better care and continuity of care. We are able to achieve success with that.”

Providing emergency care on site at the residential facilities makes sense because it leverages the staff’s familiarity with the problems that residents are likely to have and how to handle them. “When folks with developmental disability and behavioral issues show up in the emergency room, it is a foreign place with people that don’t know how to take care of them,” Dr Kolesk explains. “They frequently become agitated and that creates a whole maelstrom of different things that happen to them that shouldn’t.”

His role is the culmination of decades of practice focused on prevention. “If you take care of patients the way preventive care is supposed to be, that you as a family physician see them on a regular basis, counsel them with their needs, and deal with those issues, you can prevent them from going into high-cost hospitals for their acute needs. For patients with diabetes, if you can affect their ability to take their meds and watch their diet, you could avoid the high-cost diabetic complications that occur. In this population, it’s usually about behavior and seizures. That’s the biggest thing we deal with—make sure that the person gets the medicine right, correctly assign the right medicine. Certain medicines might interact with their seizure medicines and affect their seizures.” If patients transfer to a group home setting, someone still needs to make sure they take their medications.

 

Closing Thoughts

Providers see value through 2 lenses—their own and their patients’. Being a healthcare professional in the daily grind of today’s high-tech, high-speed environment is not easy, and COVID-19 has made it even harder. We must help these dedicated providers continue to find value and satisfaction in what they do if we are to succeed in recruiting the next generation of smart and caring young adults to work in healthcare. The future health of our nation depends on it.

 

References

1. Petterson SM, Liaw WR, Phillips RL, et al. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med 2012;10(6):503–509.

2. Sadhu AR, Healy AM, Patil SP, et al. The time is now: diabetes fellowships in the United States. Curr Diab Rep. 2017;17(11):108.

3. Kulka Amrita, McWeeny D. Rural Physician Shortages and Policy Intervention. Published December 12, 2019. https://ssrn.com/abstract=3481777. 

4. Green LV, Savin S, Yina Lu Y. Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication. Health Affairs 2013;32(1): 11–19.