Consumer Reports surveyed 1,000 Americans about their experiences with physicians and to rate 16 preselected patient complaints on a scale of 1 to 10, with 10 being the highest magnitude. They are listed below. Suggested approaches to addressing this issues, when possible, have also been provided.
The following 16 complaints were ranked as follows:
- Unclear explanation of problem (score of 8.1)
- Test results not communicate quickly enough ( 7.9)
- Billing disputes hard to resolve (score of 7.8)
- Hard to get an appointment quickly when sick (score of 7.8)
- Rushed during office visit (score of 7.8)
- Discharged too quickly from hospital (score of 7.7)
- Issues discussed within earshot of other patients (score of 7.6)
- Side effects of medication not fully explained (score of 7.6)
- Long wait times (score of 7.6)
- Hard to reach provider by phone or email (score of 7.0)
- Doctor recommends test to quickly (score of 6.7)
- Inconvenient office hours (score of 6.5)
- Doctor will not renew prescription with a visit (score of 6.2)
- Doctor takes notes on device and does not look at the patient (score of 6.2)
- Having to fill out to many forms in waiting room (score of 6.1)
- Doctor discourages alternative therapies (score of 5.7)
Discussion: Complaints #1, #5, #8, #9, #10, and #14 are closely related and tied to challenges related to levels of reimbursement and documentation requirements in primary care and many specialties. In order to make ends meet, the amount of face-to-face tie with patients has been shortened. Add to that the need to enter data into electronic health records (EHRs). This requirement is relatively new and providers are struggling with EHR systems that in most cases were designed to support billing requirements more than physician workflow. It is very difficult to be both a clinician and a data entry clerk at the same time, in particular when data entry involves navigating software that is difficult to use and even more difficult to customize.
Reimbursement tied to outcomes rather than billing levels has the potential to help this situation, but providers will still be driven to provide quality care on the highest number of patients possible. Thus, the emphasis on providing quality of care over traditional forms of reimbursement may not address the provider-patient interaction issue. Some providers have been able to improve their efficiency by customizing their EHR in a manner that supports their workflow. However, the level of sophistication needed to customize EHRs is generally well beyond the abilities of most providers, who paid for EHR training but were overwhelmed by learning the basics. If nothing else, investing time and energy into making current EHRs perform optimally through customization and advanced user training is emerging as a logical next step in healthcare’s transition to information technology. (Practice optimization, including workflow analysis and EHR customization is a service provided by Stearns Healthcare Consulting).
The #2 rated compliant is readily solved by technology. In particular patient portals have the ability to address getting lab results to patients as quickly as possible. This is another aspect of practice optimization and meeting Meaningful Use requirements that can be readily addressed.
The #3 rated compliant is tied largely to complex insurance requirements. Some have estimated that 1 or every three dollars spent on healthcare (approximately 1 trillion dollars) is wasted on administrative overhead. This impacts practices and patients, who must navigate complex rules and requirements put forth by 100’s of payers. Alternatives to the U.S. healthcare system have their drawbacks (e.g., single insurer systems) but they tend to have high levels of reimbursement transparency. Until true healthcare administrative simplicity requirement are adopted, this complaint will likely remain as a leading complaint by patients and provider organizations.
The #4 compliant, tied to getting quick access to providers when needed, is obviously a more significant issue when practices are very busy and/or understaffed. A growing primary care physician shortage is likely to amplify this issue significantly. Providers can address this by opening up walk-in hours in their clinics, but the patient may not see their usual provider. Some practices have also added mid-levels (e.g., Nurse Practitioners) to help triage patients with acute issues. An emerging trend that may help address this is telemedicine, where the patient can undergo an evaluation online by a provider who may be a any locations of time zone (e.g., Australia).
The #6 compliant, being discharged to quickly from the hospital, is a function of pressures on hospitals to shorten stays by insurance carriers. Better management of patients following discharge, including some relatively new forms of reimbursement for physicians tied to post-discharge management, may help to reduce this complaint. Telehealth visits post-discharge, home visits, and remote monitoring using devices designed for the home may help with the transition process.
The # 7 compliant, discussions held within earshot of other patients, is not surprising given the way most clinics are set-up. Increasing clinics are being designed to allow for private communications with patients, as also can evolve into a compliance issue with HIPAA and related privacy requirements.
The #11 compliant, that the doctor recommends tests to quickly, is a byproduct of the time providers are allowed to spend with patients. It may also be the result of defensive medicine or in some cases financial incentives for the provider may at least appear to influence their decisions, at least from the perspective of the patient. The extremely high level of reimbursement for procedures vs. cognitive effort has been of concern for decades, but it is tied to the culture of healthcare in the U.S. As a matter of fact, many specialists would not be able to cover their overhead expenses without performing procedures. The vast majority of physicians only perform procedures when they are truly necessary. However, the “bias” to perform procedures from a reimbursement perspective and in some cases to protect the providers from potential litigation has been an unfortunate byproduct of U.S. healthcare for many years. Technology has the potential to validate the medical necessity of a given test, and to suggest alternative tests that may yield more clinical important results. The use of these systems is far from ubiquitous, but over time they may play an important role in healthcare and order justification.
Complaint #12, inconvenient office hours, could also be addressed by an increase in the use of midlevel providers and telehealth, however in some settings shortages of primary care and/or specialists may make this issue difficult to resolve.
Compliant #13, doctor will not renew prescription without a visit, may be readily addressed through improved communication as to why an actual visit is needed. The majority of patients would likely find a visit acceptable if they understand a visit is required if they are being monitored for efficacy (e.g., blood pressure control, CHF findings, etc.) of the current regiment, the potential need to modify the regimen, and other medical considerations. Sharing the reasons why a face-to-face visit is needed during each visit and sending it to the patient via their portal, email, as a text message, etc., has the potential to address this complaint. E-visits may also offer an alternative, as the patient can be “seen” via email and in some cases this interaction is reimbursed by payers.
Complaint #15, having to fill out to many forms in waiting room, is an artifact of the paper era of medicine. Over time insurance information, past medical information, medication lists, and other relevant information will populate electronically, removing the need for the patients to reenter this information when they see a new provider. Patient portals and kiosks also allow patients to enter information about their current symptoms that can then flow into the EHR. Portals have the advantage of allowing the patient to enter this information form their own home or work location, even via their mobile devices.
Complaint #16, the doctor discourages alternative therapies. Unfortunately many of alternative therapies, include some which seem to be safe and highly effective, have not be validated via the scientific method. Given the number of claims that are made regarding healthcare therapies on the Internet and via other forms of media and word of mouth, physicians are having to serve as gatekeepers. Many of the remedies are harmless or at worst a waste of the patient’s funds. However, some may actually cause harm. Providers may seem dismissive of questions about alternative therapies given the amount of time it takes to enter into a discussion with a patient about the potential risks or lack of efficacy of a given approach. This is an area that requires a significant amount of “finesse” as a healthcare provider, as patients need to feel that their questions are given serious and adequate attention. For very frequent requests about the same alternative therapy, the provider may be advised to create or reference a qualifies source that discusses the alternative therapy in detail. This often helps the patient make an informed decision and shows that the provider has addressed the issue in some detail.
The information contained in this article, unless otherwise attributed, represents the opinions of its author, Michael Stearns, MD