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Patient-Centered Caring

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Achieving patient-centered care is difficult, but essential; since paternalism is out, the patient has a greater role to play.

The editorial, "Patient-Centered Care; What Is the Best Measuring Stick?" by Drs. Lin and Dudley (Archives of Internal Medicine), begins with an apropos quote of Sir William Osler: "The good physician treats the disease; the great physician treatsthe patient who has the disease."  It continues by establishing a fundamental point of contention in the current health care debate: our care is fractionalized and thereby uncoordinated if not actually compromised.  One reason is that patients are oftentimes not involved in decision-making; at the very least, they may be uninformed and too embarrassed to admit they are confused.  "Poor-quality decision making can lead to lower patient satisfaction with care, lower adherence* to treatment plans, and worse quality of life.8-9 Substantial  physician barriers to high-quality, patient-centered decision making include lack of time for detailed discussions during clinical encounters, lack of effective communication skills, and misalignment of financial incentives."10

Lin GA, Dudley RA. "Patient-Centered Care; What Is the Best Measuring Stick?" Arch Intern Med. 2009;169(17):1551-1553.

[8]  Greenfield S, Kaplan S, Ware JE Jr. "Expanding patient involvement in care: effects on patient outcomes." Ann Intern Med. 1985;102(4):520-528.

[9]  Joos SK, Hickam DH, Gordon GH, Baker LH. "Effects of a physician communication intervention on patient care outcomes." J Gen Intern Med.1996;11(3):147-155.

[10]  Holmes-Rovner M, Valade D, Orlowski C, Draus C, Nabozny-Valerio B, Keiser S. "Implementing shared decision-making in routine practice: barriers and opportunities. Health Expect. 2000;3(3):182-191.

* Medication Adherence is a Priority in Health Care Reform

Communication is essential at all levels and encounters of care.  Because of specific disconnects there, practitioners may not know what their patients are actually taking or doing in terms of therapies or other interventions.  In addition, there certainly is a dearth of information about the affordability constraint at the level of the doctor's office and beyond.  Consequently, while evaluating and monitoring adherence is patently essential and while it unfortunately is not common.

Some tools that can improve 'adherence' or what was once called, 'compliance' are: home based reminders, brown-bag medication review, automated refills, keeping track of medication refills, utilization review, case management, social services, open-ended enquires at the visit in the hopes of avoiding or mitigating the 'Oh by the way, Doc...' scenario or what I call the "door knob dilemma."  

Getting people to be honest about adherence matters and issues is difficult.  However, it is noteworthy that new information technology like health care apps and social media surveys, seem to encourage or enable more truthful feedback than ordinary surveys. The challenge is not only getting this information but getting it to the practitioner at the point of contact with the patient.

Attending to the principles of patient-centered care including adherence is, of course, the art of caring. Clinicians and health plans who ignore this aspect of care do so at their own peril, and it should come at no surprise that unhappiness at any level of interaction with the health care practitioner often reflects on the entire health care team.

For barriers to medication adherence, see the World Health Organization's (WHO) report: "Adherence to long-term therapies: evidence for action."   211 slides have been made available via

Merck Webcast Jan E Berger, MD, MJ .Webnar, "A Practical Approach to Help Improve Patients' Medication Adherence."  transmitted Dec 08, 2014 [© 2013]

Am J Pharmacy Benefits (AJPB at "The Power of the Pen" by Jan E. Berger, MD, MJ

Zullig LL, Bosworth H. "Engaging Patients to Optomize Medication Adherence." NEJM Catalyst Posted Mar. 29, 2017

The above-referenced Lin and Dudley article is a good, brief and important read, but I want to emphasize a side-issue they make about the "processes" in contrast to the "outcomes" of healthcare.  Indeed, Sir William Osler is attributed as saying—'Only focusing on outcomes is too coarse an objective.'  In one study, for example, the authors mention that a decision aid did not improve the "outcomes" in type II diabetics as measured by adherence or HbA1c levels; nevertheless, it did engage patients in decision-making, especially about their medications and, clearly, that is vital (and reimbursable).  From the managerial point of view, while there was a large Hawthorne effect, patients were actually helped.

Mullan RJ, Montori VM, Shah ND; et al. "The Diabetes Mellitus Medication Choice decision aid: a randomized trial." Arch Intern Med.  2009;169(17):1560-1568.

* Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients' values.... In addition, the improved quality of care and savings gained [can be enhanced] by integrating this approach into other [Affordable Care Act] ACA initiatives. For example, the documented use of patient decision aids could be used as a quality metric in patient-centered medical homes, accountable care organizations, and systems caring for patients eligible for both Medicare and Medicaid. Eligibility criteria for incentives to adopt electronic health record technology might [include this]. Moreover, information gathered by the Patient-Centered Outcomes Research Institute (PCORI) could be incorporated into certified decision aids and used to provide physicians and patients with valuable information for making health care decisions. Data about the effectiveness of shared-decision-making techniques could also be collected and disseminated by PCORI for continuous improvement of these approaches."

"Shared Decision Making to Improve Care and Reduce Costs" by Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D.   [N Engl J Med Jan. 3, 2013; 368:6-8].

What is more important--the destination or the journey?

"Payers and providers haven’t always spoken the same language when it comes to managing patients and coordinating payments. Going forward health centers will need to work closely with insurers to develop new contracts based on clinical quality and risk. Improving patient care will hinge on better information sharing between clinics and insurers. Listen to our Snapshot to learn how your organization can partner with the payers in your market to deliver better care."