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The Biggest Barrier that Prevents Physicians from Providing Optimal Chronic Care


A Quest Diagnostics study sheds light on Medicare patients with multiple chronic conditions and the top three care gaps.



The traditional medical care model may be insufficient to meet the needs of Medicare patients with multiple chronic conditions, according to a new study.

About 71% of all healthcare costs are due to chronic conditions, according to the CDC. Another big cost issue is medication nonadherence. Other research finds that patients with chronic conditions account for 83.1% of all prescriptions in the United States, and nonadherence is associated with approximately $100 to $300 billion of U.S. healthcare costs annually.

“That suggests that solutions to monitor for emerging health conditions, keep patients with chronic conditions out of the hospital, and address medication nonadherence could make a major dent in costs. The fact that those solutions are reimbursable is another major benefit,” according to Jeffrey Dlott, MD, medical director for chronic care management, Quest Diagnostics.

The Quest Diagnostics’ study, “Hidden Hazards: Closing the Care Gap Between Physicians and Patients with Multiple Chronic Conditions,” which was commissioned through Regina Corso Consulting, an independent research firm, shows that time constraints and a feeling of helplessness to address patients’ comprehensive needs concern physicians, while patients’ professed satisfaction with their care may mask social and behavioral risks and needs. The findings are based on an independent survey commissioned by Quest of primary care physicians (PCPs) and adults aged 65 years and older who have multiple chronic conditions and are Medicare beneficiaries.

Specifically, the survey results found physicians are too time-constrained to probe for complex care needs. Nearly all physicians (95%) said they entered primary care to care for the “whole patient.” Yet, 85% say they are too pressed for time to address complex clinical issues and 66% say they don’t have time to address social and behavioral issues, such as loneliness or financial concerns that could affect their patients’ health. Only 9% of physicians are very satisfied that their Medicare patients with multiple chronic conditions are getting all the attention they need to care for all medical issues.

The study also suggests patients may not recognize or share all health-related concerns. While physicians worry about care gaps, more than nine in 10 patients (92%) surveyed are satisfied they are getting all the attention they need to deal with their multiple medical issues from their PCP, the findings suggest patients may not recognize or communicate all health-related issues that may impact their care and health. Two in five patients say they do not tell their doctor about loneliness, isolation, transportation barriers and other factors that influence health. Many admit they “struggle to stay on top of my health issues and need more support.”

“There are two main reasons we wanted to explore this important issue,” says Dlott. “First, three in four Americans over the age of 65 have two or more chronic health conditions. This is significant part of the population. We wanted to better understand where there are gaps in care between PCPs and their Medicare patients with multiple chronic conditions, and what those gaps meant for patient health. We hope managed care organizations, which are already making great strides toward closing gaps in care, can use these insights to inform their provider strategies.”

But Dlott says the researchers also wanted to explore to what extent chronic care management (CCM) services could help bridge this gap. In January 2015, CMS began reimbursing for CCM services for Medicare beneficiaries with two or more chronic conditions to support patients in between physician visits. CCM services are non-face-to-face services, such as electronic and phone consultation, and often focus on medication management, coordinating visits with hospitals and other providers, personalized guidance on setting health goals, and 24-hour access to care providers.

But participation in CCM programs by PCPs has been slow, according to Dlott, although CMS estimates 70% of Medicare beneficiaries-roughly 35 million people-would be eligible. “It’s clear that broader adoption of CCM services would help to address many of the issues that came to light through our survey,” Dlott says. “We hope managed care organizations, which are already making great strides toward closing gaps in care, can use these insights to inform their provider and reimbursement strategies.”

The study found perception of complexity by PCPs is a clear deterrent to CCM use, so solutions that simplify the process (by providing counsel on coding, for example) stand a better chance of adoption, according to Dlott.

“Our analysis also suggests points of discussion providers in managed care networks can raise with patients to encourage their use of CCM,” says Dlott. “First, providers may wish to explain to patients that social and behavioral factors, including medication adherence, play critical roles in health, and extra monitoring may help identify potential problems. Second, they can reassure patients that CCM has only modest copays under Medicare, as they may otherwise assume a steep financial burden for participating. And perhaps most importantly, providers may wish to explain that CCM may help them identify issues before they become a major medical concern.”

Other unique findings

In terms of Medicare patients with chronic conditions, the survey found they have multiple concerns and fears, which the surveyed call “hidden hazards.” Forty-three percent worry about getting new conditions, and 27% worry about falling outside and 22% about falling at home.

In some of our most concerning findings is that 15% of patients say they have no one to talk to. Nearly one in five patients (19%) say they struggle to stay on top of their medical issues and need more help. The same percentage admit that “much of the time I feel like a burden because of my different conditions and am hesitant to ask anyone for help.” So, for many older and sicker patients, healthcare is a solitary journey.

And in terms of physicians, the study found that they worry lack of time impedes care quality for their patients with multiple chronic conditions. Ninety-five percent reported that they became a PCP to look at the whole patient, not just the different conditions they have. But 93% wish they had some sort of help available to make sure my patients with multiple chronic conditions were doing all the things they are supposed to be doing; 92% are concerned that their patients struggle to stay on top of their issues; 89% say their office tries to follow up with patients with multiple chronic conditions, but there is only so much they can do; and 88% worry that patients with multiple chronic conditions are not practicing medication adherence, such as taking medications as prescribed.

Top 3 care gaps for patients with chronic conditions

  • Patients don’t always recognize or share all health-related issues. “We found patients may not always connect the quality of care they receive from their primary doctor-and social and behavioral factors that occur outside the physician setting-to their overall health,” says Dlott.

Two in five patients with multiple chronic conditions (44%) tell their doctor about their medical conditions, but not other issues they are facing that could affect their health, such as loneliness, financial issues and/or transportation issues. Some patients feel overwhelmed by their medical needs, feel like a “burden” on loved ones, and feel no one understands their concerns.

“That’s significant given other research that finds 80% of health outcomes are related to factors outside the traditional realm of healthcare delivery, including social, economic, and behavioral,” says Dlott.

  2.  Medication nonadherence is a major concern. Eighty-eight percent of PCPs say they are concerned patients with multiple chronic conditions are not taking medications as prescribed. Patient survey responses suggest this concern is valid: Nearly one-quarter (23%) of patients say there have been times when they forgot to take some of their medications or took the wrong ones. Yet, less than one in 10 (8%) patients reported medication adherence as a concern. That disconnect between their actions and their understanding of the importance of those actions is one of the reasons nonadherence costs are so high.

  3.  Patients are concerned about limited interaction with their physicians. “While patients overwhelmingly say they feel their PCP gives them enough attention, when probed further, many wish they could spend more time with their doctor,” says Dlott.

More than four in 10 patients (42%) believe that seeing their physician only one or twice a year to manage their multiple conditions “is just not enough.” And their doctors agree: Most PCPs surveyed believe that they should visit with their patients with multiple chronic conditions as often as six to eight times a year, and one in four say it should be monthly, weekly, or as often as needed.

“That’s where CCM services come in. CCM may help illuminate potential health risks before they occur, so individuals can retain their health and independence longer while reducing caregiver needs. With improved monitoring, individuals with multiple chronic conditions may expect a better quality of life,” says Dlott.

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