From the Patient
From
the Patient’ss Perspective: their Perspective: their
Continuously Changing Relationship with Primary Care Physicians
Primary Care Physicians
Lisa D. Marceau
sa . a ceau
John B. McKinlay
ACADEMY HEALTH ANNUAL RESEARCH MEETING
JUNE 28, 2010
Changes in Primary Care and the Physician
Changes in Primary Care and the Physician Transformational changes to the organization and financing of primary health care have resulted in changes affecting the work of primary care doctors…
• Most PCPs are now salaried employees of large organizations; Most PCPs are now salaried employees of large organizations;
• Increasing specialization is marginalizing PCPs (reduced to “gate‐keeper” status); status);
• Private health insurers dictate what PCPs are permitted to do; • Clinical guidelines have become a practice imperative. Changes in Primary Care and the Patient
Changes in Primary Care and the Patient
…with substantial impact on the patient’s role in the Doctor‐Patient relationship • Patients
Patients go online for health information (self‐diagnose, develop go online for health information (self diagnose de elop
expectations); • Direct‐to consumer advertising activates patients; Direct to consumer advertising activates patients;
• Negative publicity (errors, private investments and insurance company malfeasance erodes patient trust);
malfeasance erodes patient trust); • Malpractice threats are now commonplace (defensive medicine); • Changes in employment and unemployment impacts health insurance; • Health care increasingly viewed as ‘commodity’ ; • Popular media no longer portrays physicians as culture heroes.
TV Portrayals of Doctors have Changed:
Markus Welby has become Gregory House
Markus Welby, MD (1969)
Gregory House, MD (2007)
Source: www.museum.tv (The Museum of Broadcast Communications); http://www.43things.com/gallery/view/311807
The Doctor Patient Relationship of the Past
The Doctor‐Patient Relationship of the Past
Internet Use Generates Specific Suggestions and Internet
Use Generates Specific Suggestions and
Requests for Physicians
“If you’re not engaging patients, you’re doing it wrong.”
Recent quote from Health 2.0 Conference, San Francisco
• Eight in ten internet users have looked online for health information. • M
Many e‐patients say the internet had significant impact on how they care for ti t
th i t
t h d i ifi t i
t
h th
f
self or others.
• 51% of adults used the internet to look up health information in last year.
51% of adults used the internet to look up health information in last year
• 8‐18 is a wired generation…
Pew Internet, 2010
The Next Generation will be More Savvy
The Next Generation will be More Savvy
Kaiser Family Foundation, Generation M2, Jan 2010 ; Pew Internet, Social media and young adults 2010
Help seeking in the Digital Age
Help‐seeking in the Digital Age
The Rapid Increase in Direct‐to‐Consumer (DTC) Advertising in the US, 1993 – 2005
4500
4000
3500
US millions
3000
2500
2000
1500
1000
500
0
1993
1994
1995
1996
1997
1998
1999
Years
Source: IMS Health and Competitive Media Reporting, (www.imshealth.com) 2006 2001
2002
2003
2004
2005
6 Stages in the Emergence of Retail Clinics
Retail Clinics
Retail Clinics are Filling a Gap
Retail Clinics are Filling a Gap
• 35.8% of the urban US population lives within 10‐
minute drive of a retail clinic.
• Of the 119 million visits to hospital ERs per year, 55% are for non‐emergencies.
• CA hospital survey found 46% of ER patients thought they could have resolved issue with visit to primary care, but were unable to obtain timely access.
• Estimates are 1,100 to 1,200 retail clinics currently. The number is likely to grow to 3,200 by 2014. Attention Shoppers:
Wal Martification of Health Care Services
Wal-Martification
Source: New York Times (M. Freudenheim 5/14/2006); Patient Satisfaction Pressures
Patient Satisfaction Pressures
Measurement of patient satisfaction is playing an increasingly important role in accountability for health care providers. • Satisfaction scores are often tied to financial incentives and payment b
bonuses with capitation contracts. ih
i i
• Practices use the surveys to retain patient populations and attract more market share
market share.
• Recognition that lawsuits are significantly related to total numbers of p
patient complaints, suggesting that lawsuits are less likely with higher p
gg
g
y
g
patient satisfaction ratings.
Much emphasis is placed on patient satisfaction Much
emphasis is placed on patient satisfaction
without considering for quality of care
This results in conflicting goals for primary care:
• To increase quality outcomes
• Enhance safety
• Lower the cost of care
Doctor Patient
Provider
Provider‐Client Encounter
Client Relationship
Encounter
Current Status of the Doctor‐Patient Relationship
Current Status of the
Implications for Policy
Implications for Policy
• Much of the health care debate still focuses on preservation of the D‐P relationship. • Yet, the extent to which the “relationship” has changed and whether it even exists given structural changes to the health care system, has received little i
i
l h
h h lh
h
i d li l
attention.
Future policy must consider the current and future playing field in order to policy must consider the current and future playing field in order to
• Future
improve quality of care and reduce health care disparities. NERI
Health Services and isparities Research
Health Services and Disparities Research
neriscience.com