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There is much to do in primary care and little time to do it. Currently, primary care delivery is organized around visits, often 15 minutes or less, during which much is expected of clinicians. This includes establishing partnerships with patient and families; addressing acute and chronic biomedical and psychosocial problems; prevention, care coordination; and ensuring informed decision-making that respects patients’ needs and preferences. Visit-based care discriminates against socially disadvantaged patients, who often require more time due to complex health care needs and the challenge of establishing partnerships and communicating across chasms of race, ethnicity, education, language, and culture. Rushed visits exacerbate disparities in health car due to competing demands, miscommunications and activation of unconscious physician stereotypes. Addressing health care disparities requires radical transformation in the structure and financing of primary care and the roles of the health care team members and patients. One such innovation, the patient-centered medical home, organizes care around patients’ needs, not visits. Thus, face-to-face visits and physician-centered care are supplanted by team-based care that relies on multiple communication modalities, expanded health information technology, population management, culturally-sensitive outreach and follow-up, and coaching patients to assume more active roles in care. Implementation requires payment reform that allocates resources based on the true costs of providing high quality care to socially disadvantaged patients. Ensuring success will require physician leadership and training in new care models, transformation in primary care culture, and redesign of care around the needs of patients, particularly those needing care the most.
There is so much to do in primary care and so little time to do it. During 15-minute visits,1 physicians are expected to form partnerships with patients and families, address complex acute and chronic biomedical and psychosocial problems, provide preventive care, coordinate care with specialists, and ensure informed decision-making that respects patients’ needs and preferences. While this is a challenging task in straightforward visits, it is nearly impossible when caring for socially disadvantaged patients with complex biomedical and psychosocial problems and multiple barriers to care. Consider the following scenario.
Mrs S is a 52-year old female housekeeper with poorly controlled diabetes, hypertension and obesity who missed her last two visits due to job conflicts. She hasn’t reached her annual insurance deductible and pays for the visit out of pocket. She speaks limited English and the receptionist translates. Dr M explores her complaints of fatigue, daily headaches, back pain and conflict with her husband following his job loss. Dr M conducts a thorough medical history and physical exam and concludes that her poorly controlled diabetes, night shifts, work, and depression are contributing to her symptoms. He recommends mental health counseling, but Mrs S declines. Dr M recommends an antidepressant and adds 2 new medications for her diabetes and blood pressure and reviews their purposes and side effects. Mrs S politely acquiesces, knowing she cannot afford them and doubting their benefit. The receptionist interrupts Dr M to tell him he is behind and he quickly concludes the visit. Mrs S leaves the office still worried about her health and costs of care. Because the visit takes 30 minutes, her office fee does not fully cover visit costs. Dr M despairingly notes that none of Mrs S's preventive or chronic disease quality measures are at goal. He debates whether to discharge her from his practice for nonadherence to avoid being penalized under pay-for-performance.
As illustrated, constraining care to 15-minute visits for socially disadvantaged patients2 virtually ensures the perpetuation of health care disparities.2,3 Socially disadvantaged patients, often referred to as vulnerable or underserved, are defined as groups who because of shared social characteristics are at higher risk for multiple risk factors.3 They include members of racial and ethnic minority groups and persons with low literacy and low socioeconomic status, among others.4 These groups, although distinct, overlap considerably.5
In this perspective, we illustrate how the 15-minute office visit discriminates against socially disadvantaged patients (and other patients with high needs) and propose fundamental reform in primary care structure and payment to address the problem.
The average office visits in the U.S. lasts about 16 minutes,6 not enough time to effectively address multiple complex problems.7 Typically, five minutes is spent on one problem and a minute or two on the remainder.8 Providing all recommended preventive and chronic disease care takes more far more time than can be provided during an average of two adult primary care visits per year.9 To provide guideline-concordant care, a physician caring for a usual panel of patients would need to spend 35 hours on preventive health care during a typical week,10 another 50 hours on patients’ chronic care needs,11 and unknown hours for acute care –in addition to eight hours physicians currently spend on patient care outside of office visits.12 These visit constraints severely limit informed decision making7 and confirmation of patient understanding,13 and commonly result in omission of discussion of adverse medication effects and costs.14,15 For socially disadvantaged patients, who more commonly have multiple, complex, biomedical and psychosocial problems, care is worse.14,15
Caring for socially disadvantaged patients poses unique challenges requiring more time and greater team work (Table 1).16 Communicating across differences in language, culture, and health literacy takes time.17-21 Socially disadvantaged patients experience worse physical22-24 and mental25-27 health, including more impairments in vision, hearing, and cognition that slow communication.28.
Review of the key parts of the office visit illustrates the key challenges of caring for these patients during 15-minute visits.29 Initiating the visit involves establishing rapport and identifying the reasons for the visit. Achieving rapport across race, ethnicity, and educational level can be challenging.30,31 Eliciting all the reasons for the visit and negotiating an agenda may take longer due to more concerns,16,32 symptoms.28 and illnesses.33 Patients with low health literacy may not recognize key symptoms as readily.34,35 Time pressures may undermine physician empathy,36 undermining patient trust37 – particularly for marginalized patients.38
Gathering information about the illness, including key symptoms and psychosocial context, is more time-consuming because of more symptoms, more complex illnesses39 and greater psychosocial stress.40,41 Exploration of the patients’ perspective is critical to establishing partnership and understanding patients’ beliefs, but is also more time-consuming across socio-cultural distance.42
Physical examination may also take longer due to greater illness burden and disabilities that slow the process.28 Preventive care involving disrobing (e.g., Pap smears, breast and rectal exams) is less likely to happen.43,44
Discussion of diagnosis and treatment involves exchange of illness-related information, confirmation of patient understanding,45 and complex decision making and promotion of behavior change.7,16 Each of these tasks may take longer due to differences in language,21,46 health literacy,47,48 health beliefs, culture,49 and levels of trust.38,50 Participatory decision-making may seem unfamiliar to historically marginalized patients.51 In addition, primary care physicians frequently provide time-consuming mental health counseling to socially disadvantaged patients who do not have access to or are suspicious of psychiatrists or psychologists.52 Addressing barriers to specialty referral and adherence takes time.53,54
Closure of the visit – summarizing the diagnosis, treatment plan and follow-up – takes longer when communication barriers are present. Lengthening visits can help; longer visits are associated with increased empowerment among socially disadvantaged patients.55
There has been little systematic study of 15-minute visits on care for socially disadvantaged patients. However, time-pressured visits contribute to competing demands, clinical inertia, unconscious physician bias and physician-centered communication,56-58 likely contributing disparities in care.59 Shorter visits are associated with diminished quality60 and discussions of prevention and psychosocial issues suffer.61 Yet, socially disadvantaged patients receive shorter, not longer visits,1,62 and fewer visits per year.9
Clinical inertia refers to failure to implement appropriate clinical action in the context of inadequate chronic disease control.63,64 Clinical inertia is exacerbated by multiple patient demands and time pressures,65 and by physician suspicion of poor adherence.66,67 It takes less time to “wait and watch” than to implement a change in treatment plan.
Unconscious stereotypes affect care.68-70 Unconscious bias often emerges during stress and time pressure.58 Physicians, challenged to address the complex needs of patients over the course of a few minutes, more readily simplify these mental tasks by resorting to stereotypical thinking. Busy clinicians tend to attend to data that conform to preconceived notions -- e.g., non-adherence70 -- on the basis of group membership, and ignore disconfirming data. Additionally, communication with socially disadvantaged patients may result in misinterpretations even when both parties speak the same language.71 These misinterpretations are likely to result in lack of agreement about the illness, its treatment and the patient's role in care.42 Last, when decision-making is rushed, clinical judgment relies increasingly on heuristics – cognitive short-cuts – that often fail to account for individual needs.72
Patient-centered communication mitigates some of the effects of social disadvantage.73 However, patient-centered behaviors -- asking patients about their own beliefs, engaging patients in collaborative decision making, identifying adherence barriers, confirming patients’ understanding, and using interpreters -- take more time.21 Perhaps due to time pressure, clinicians engage in less, not more, patient-centered communication with socially disadvantaged patients.74
The potential consequences of 15-minute visits include disparities in patient understanding and satisfaction, low adherence, and suboptimal preventive and chronic disease care.75-81 Consequently, socially disadvantaged patients experience more adverse outcomes (e.g. preventable hospitalizations and deaths),82,83 and physicians caring for them experience higher burn-out.84,85
These disparities may be avoidable. Findings from randomized trials show that team-based, intensive interventions improve health care quality among socially disadvantaged patients and reduce health care disparities across a range of conditions.86-94 Multifaceted, nurse-led programs, and culturally-sensitive care may also be effective.95 However, most of these interventions extended beyond the scope of 15-minute physician-directed office visits.Thus, these findings, from externally funded research projects, require specific translation into clinical practice in terms of implementation of new care models supported by new systems for payment.
There are a handful of options within current health care systems (Table 2). The most obvious are to schedule patients more frequently or for longer visits. However, health plans have increasingly shifted costs onto patients through higher co-payments and reduced coverage,96 disproportionately affecting socially disadvantaged patients’ ability to see physicians more frequently.2,97 In addition, many topics are best addressed in a single visit rather than spread out over a long period.98 Visit coding is based primarily on chart documentation rather than on patients needs – e.g. language, health literacy, cultural or adherence barriers; longer visits tend to be under-coded.99
Time for paperwork, such as certification of disability or documentation of eligibility for social services, follow-up on abnormal testing, and out-of-visit medication management, is not reimbursed.12 Electronic medical records can improve documentation and increase reimbursement,100 but fewer practices serving socially disadvantaged patients have them.101,102
Group visits offer a potentially viable alternative for some patients.103 These allow for extended time for teaching, discussion and sharing of experience between patients. However, most health plans do not pay for them and some patients may feel uncomfortable talking in a group about their health or psychosocial concerns.104
Ultimately, improving care for socially disadvantaged patients requires more than just longer visits. It requires scrapping a care model predicated exclusively on physician-directed, visit-based care and replacing it with a new model; one promising example is the Patient-Centered Medical Home.
The Patient-Centered Medical Home (PCMH) arose from the need for a single clinician or practice to assume responsibility for coordinating the care for children with special health care needs.105 The purpose of the PCMH is to provide access to primary health care teams built around patients’ needs. It depends on appropriate team training and patient activation and is explicitly designed to enhance patient choice, quality, safety and efficiency. The seven core principles of the PCMH have been endorsed by the major primary care physician organizations and there is growing support for it among payers and Congress.106 The first six principles represent historic primary care ideals: a personal primary care physician, team-based care directed by a physician, whole person orientation, coordination of all facets of care, focus on quality and safety, and enhanced access to care.106 The seventh principle, payment reform, provides the means for implementing these principles.106
The PCMH represents a vision of future care for all patients,107 and many practices have already begun to adopt many of its features,108 including the Veterans Administration Health System.109 It offers particular promise for improving care for socially disadvantaged patients. The following idealized practice illustrates this.
A radically restructured primary care team might consist of one physician, one nurse practitioner (or physician assistant), a patient panel manager, and several registered nurses and medical assistants assigned a defined panel of patients. Tasks are distributed based on capability rather than traditional roles. Patient concerns requiring exploration of new symptoms and concerns are likely addressed in-person with the physician, whereas others may be accomplished through individual or group meetings with nurses and other health professionals.110 Professional language interpreters are universally available and funded. Phone visits,111,112 and secure email when feasible, are used for some routine concerns and to monitor progress. The Web can be used to allow direct patient access to their medical records including the ability to update health information113 as digital technology continues to diffuse to socially disadvantaged populations.114. Importantly, a member of the team, perhaps a nurse, is always available to supplement electronic communications, for example, when patients need to understand test results that are made available via the Web.
These innovations reflect a radical redefinition of the roles of the health care team and patient. Patients are trained to provide critical health and health care updates through various modalities. While many patients communicate electronically with the health care team from home, user-friendly computer kiosks are available in the office for patients who lack reliable web access; these could also be used for in-office demonstrations and training.115 Patients are given access to and education in interpreting their own health records including test results -- a critical step towards patient empowerment.116
Many traditional physician responsibilities are distributed among the health care team to ensure that the physician's time is used wisely – for example, for the assessment of complex problems, discussion of a new diagnosis, a family meeting or deliberation over treatment options. A medical assistant updates medical data, reviews preventive care, and helps patients identify concerns prior to the physician visit.117 Routine preventive care is provided by the nurse through standing orders, allowing the physician to address more complex or unresolved concerns in greater depth.117,118 In the vignette, a certified interpreter would translate for Mrs S and the team would quickly pick up and address her poor preventive and chronic disease care.
Following physician-patient encounters, medical assistants or nurses routinely follow up by phone or in person to elicit the patient's understanding of the diagnoses and treatment plans, correct misunderstandings, and address barriers to care.119 In the case of Mrs S, the nurse, or perhaps even a team pharmacist, would identify less expensive blood pressure medications, link the patient with self-management groups and community resources, even community-based job training for Mrs S's husband.120,121 Ideally, Mrs S would feel more empowered to improve her health.
All abnormal laboratory results, preventive and chronic care are tracked using electronic registries and medical records.122 Importantly, all members of the care team are expected and paid to meet regularly for patient panel management, e.g. to review reports, recall patients, and implement changes in treatment.123 In the case of Mrs S, the nurse would identify her nonadherence based on review of her electronic medication refill history, and the team would develop a plan for addressing it.124 By considering these complex issues outside of time-pressured 15-minute visits, as a team - particularly a culturally diverse one - there is less risk for implicit bias, and more considered deliberation of treatment options using decision-support tools and evidence-based guidelines.123
This transformation of primary care requires radical payment reform. Such reform must account for the greater health care needs of socially disadvantaged patients.125 Current fee-for-service payment, predicated on performance of a discrete procedure performed on the patient at a single point in time, is a poor fit for primary care.107,126 Payment, based exclusively on fee-for-service, is particularly problematic for patients with complex needs who require not only longer visits but also care outside of visits or care by ancillary staff. There is emerging consensus that visit-based payments represent a major obstacle to primary care redesign and quality improvement.127 It is less widely recognized that current payment models undermine a core dimension of health care quality – equity.
PCMH principles suggest four potential sources of proposed revenue:106 1) current visit-based reimbursement, potentially expanded to include non-face-to-face patient visits; 2) payment for non-visit care such as care coordination, health information technology, remote clinical monitoring, and population-based management; 3) pay-for-performance, e.g. bonuses for improved quality; 4) shared saving from potential reductions in health care costs.
Implementation of PCMH for socially disadvantaged patients requires payments that recognize the actual costs of high quality care for these patients.107,125 Currently, such care is currently under-resourced,128,129 and consequently often lower in quality.130,131
Ideally, “payments should recognize case-mix differences in the patient population being treated within the practice.”106 For example, visit-based reimbursement might be based on the time spent with the patient rather than current complex coding formulas. Monthly payments per enrolled patient should be increased according to the social disadvantage (and morbidity) of the patient population,107 based on relevant sociodemographic data of individual patients or proxy information derived from patient addresses geocoded to Census data.132 Several European countries have developed measures to account for social advantage called “deprivation indices” that are used to adjust physician payments.133-135
Pay-for-performance indices could be made more equitable by comparing practices serving socially disadvantaged patients with each other and by rewarding improvements in performance, in addition to achievement of benchmarks.136,137 However, the surest way to improve equity in pay-for-performance, and to avoid the unintended consequence of worsening disparities, is to allocate resources to practices based on patient need. Last, even limited PCMHs can reduce Medicaid costs.138 These cost saving should be shared with practices.
A new model of primary care health care should ideally free physicians to attend to the most critical areas that patients need and for which they are ideally trained, and free them from tasks that could be accomplished by other members of the team. While structural and financial changes are necessary, they are not sufficient. The health care workforce must be adequately trained to elicit and provide information effectively, and empower, activate, inform and involve patients in their care.
Physicians need training in new skills,139,140 and most importantly, new roles. Physician training may partially mitigate the time pressure. Training in specific communication skills can improve elicitation of patients’concerns141,142 and organization of the visit,143 while also reducing visit length. Physician training improves patient centered communication skills,144 empathy,145 and responsiveness to patients’ questions.146 Specific training in cultural competence may improve communication with socially disadvantaged populations.147
New communication skills are necessary to facilitate team-based care to optimize care for socially disadvantaged patients.148 These skills include team leadership and management; panel management; communication within health care teams; giving feedback to co-workers; electronic communication with colleagues and with patients; longitudinal care; collaborating with off-site care managers, patient navigators, interpreters, and families; and customizing risk information to low-literacy patients. In addition, training and guidance by an external change agent may be needed to facilitate practice change.149
It is especially important to train physicians and other team members to recognize, promote and support patient participation in care, particularly among those who are socially disadvantaged. These changes represent a culture shift from the traditional hierarchies within patient-physician relationships and within members of the health care team. These changes will not come easily and are best initiated early in training.
Socially disadvantaged patients can be empowered to take more active roles in their care.116,150 Individualized patient coaching, use of prompt lists containing commonly-asked questions, and computer programs increase patient participation during visits (e.g., question-asking)151 and potentially improve adherence,152 symptom control,153 and chronic disease outcomes.116,154 Decision aids assist informed decision-making; they should be expanded to provide information while also encouraging patients to participate in discussions with their physicians about their care. Furthermore, while increased patient participation may improve care, it may also create tension in the patient-physician relationship155 unless physicians specifically endorse patient involvement.156 Although untested, patient activation combined with physician training in organizing the visit has the potential to improve care while also limiting visit time.143 Patient training can be effectively integrated at multiple points in care by team members, using various communication modalities. Improvements in technology will facilitate tailoring of training to the culture, language, and health literacy needs of the patient.
Practice redesign requires strong physician leadership to implement new systems of care, re-allocate existing tasks, and actively support new models of patient participation in care. Such reforms represent a fundamental cultural shift in the practice of primary care and cannot succeed in the absence of strong physician commitment to reform. Changes in payment models, implementation of health information technology, and training in collaborative care models represent necessary, but not sufficient conditions for new care models. Success will ultimately depend on the willingness of physicians to champion practice redesign and quality, delegate traditional tasks to team members, and create genuine partnerships with historically disadvantaged patients.157
The disparity between patients’ needs and the time and resources to meet those needs is greatest for socially disadvantaged patients – exacerbating underlying disparities in access to, process of and outcomes of care. A couple of 15-minute visits per year is too little time to provide patient-centered, evidence-based, safe, high quality care for the average patient and particularly for socially disadvantaged patients. Elimination of health care disparities requires reform of primary care delivery system so that care extends beyond the 15-minute face-to-face visit. Work that had been the exclusive domain of the physician should include multidisciplinary teams caring for patients through multiple modalities. Such radical reform requires drastic changes in the structure of payment for primary care. In particular, health care resources must be allocated according to the health care needs of patients so that practices serving socially disadvantaged patients receive more, not fewer, resources. Only in this way, can primary care “ensure that decisions respect the patients’ wants, needs, and preferences and that patients have the education and support to make decisions and participate in care.”158 However critical, payment reform alone is not enough and transformation of primary care will not come easily. It will require physician leadership and commitment, change in practice culture, new training programs for health care professionals and patients and focused research to optimize models of care for socially disadvantaged patients.
We thank Thomas Bodenheimer, Rick Botelho, Tom Campbell, Jennifer Carroll, Clint Koenig, Gordon Moore, and Elizabeth Finigan for helpful comments regarding earlier versions of this paper.
Funding: Supported in part through NCI U01CA116924−01 and NHLBI R01 HL081066−01A2. The views expressed in this paper represent solely those of the authors and no way reflect endorsement by either funder.