What to do when patients don't buy our healthcare agenda

1/18/2014 03:32:00 PM
You can build it, but you can't make them come.
In health services research, we often hear about proposals to improve quality of care and reduce health costs. These generally start with the presumption that patients should have a long-term relationship with a particular provider and will call that particular provider whenever they are having a health problem, rather than visit an emergency room. This arrangement should, in principle, result both in better care--because the providers can keep track of all of their patient's health issues and focus on treating the condition, not merely the apparent symptoms--as well as lower costs by keeping them out of emergency rooms, which generally cost more to treat the same symptoms. Unfortunately, not all patients are on board with that idealized system.

In Cincinnati what we've found is actually that many patients actively avoid this type of system. Often, patients with chronic conditions that require active management frequently bounce around between hospitals, relying mostly on ER visits, which is particularly problematic because of the poor communication and information-sharing between these hospitals.

Despite the higher costs of ER visits and the theoretically lower quality care caused by frequent bouncing from one provider to the next, there are several understandable reasons a patient might do this. One reason is that because they have chronic conditions, they visit hospitals frequent enough to learn how each hospital handles different complications and develop preferences between them. A patient may, therefore, prefer how one hospital handles one type of complication, while also preferring a different hospital for different complications. The differences can range from mere differences in the amount of paper work, to the friendliness of the staff, to actual differences in the health outcomes at the different institutions. It's also not hard to figure out why these patients are crowding up emergency rooms: when they wake up in pain in the middle of the night, they don't want their regular doctor to tell them to come in during regular clinic hours next Tuesday--they want something done about it right now. The fact that their pain happens to be part of a chronic condition doesn't make waiting till Tuesday any more tolerable.

Those are all perfectly rational reasons to deviate from the "ideal" model of healthcare delivery, and while they do cause some inefficiencies, we could potentially overcome those inefficiencies through better information sharing between health providers, and building better alternatives to emergency room care. But there is another, more human reason patients with chronic conditions bounce between providers: they don't want their doctors to know how often they are having problems. By going to a different hospital--which they know does not share information very well--patients mislead their regular doctors into thinking that they are going to the hospital less often, and that their condition is better than it really is. The psychology at work is hard not to sympathize with--patients want their doctor's recommendations to work, and don't know how to face their doctor when it doesn't. Yet this is obviously problematic because it is very important for doctors to know when a condition is worsening, or when a course of treatment is failing to get better.

We can extend health insurance coverage. We can build urgent-care clinics. We can improve information-sharing between providers. We can manipulate payment formulas. But what can we do when patients just aren't on board with our healthcare improvement agenda?