Thursday, June 24, 2010

The primary care experience in MA

Massachusetts Health Quality Partners presents a recent survey of patient experiences with primary care. There are both positive and negative findings, compared with a survey conducted before the implementation of universal health care access in the state.

About 78,000 commercially insured patients responded to the statewide survey. There was reported overall improvement in several dimensions of the doctor-patient relationship, such as communication and knowledge of their patients, but there are aspects of doctor-patient communications that need work. A summary:

There is broad agreement that there are important dimensions of care that patients and their families should expect to receive from their primary care practice. Key findings in MHQP's latest patient experience survey highlight where there continues to be room for improvement in these aspects of care, including:

Knowledge of the patient: When asked if their primary care physician seemed to know their medical history and to know them as a person, both adults and the parents of pediatric patients reported improvements compared with 2007; but 30 percent of adult patients and 25 percent of parents say their primary care physicians do not always know important medical history information.

Informed of test results: The survey found that about 30 percent of adult and pediatric patients did not always receive follow-up reports on test results from their doctor's office, unchanged from 2007.

Coordination between primary care doctors and specialists: About 40 percent of adult patients and 35 percent of parents of pediatric patients reported that their physician did not always seem well-informed about the care they received from specialists to whom they had been referred. Pediatric results were slightly better than two years ago, while adult ratings were unchanged.


Cetus said...

Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update
June 23, 2010

Author(s): Karen Davis, Ph.D., Cathy Schoen, M.S., and Kristof Stremikis, M.P.P.

"Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries. This report—an update to three earlier editions—includes data from seven countries and incorporates patients' and physicians' survey results on care experiences and ratings on dimensions of care. Compared with six other nations—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom—the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives."

. . .

"But even when access and equity measures are not considered, the U.S. ranks behind most of the other countries on most measures. With the inclusion of primary care physician survey data in the analysis, it is apparent that the U.S. is lagging in adoption of national policies that promote primary care, quality improvement, and information technology."

Anonymous said...

I have thoughts about two aspects of this report:

1. A 30% failure rate in communicating test results to the patient is unacceptable and dangerous. In our hospital clinical lab and pathology dept, we went to great effort to communicate all test results to the clinician, including those which came in after discharge. Dr's offices need to have well defined systems for communicating these results, both negative and positive, to the patients. There are many cases where missed results have contributed to delayed diagnoses.

2. As an old fogey, I have wondered in several blogs whatever happened to the concept of the specialist as the PCP's consultant, never failing to provide both written and verbal reports of their findings back to the PCP, and discussing next steps in treatment or diagnosis. This time-honored, respectful, and patient care-centered approach seems to have flown completely out the window in today's physician culture. Perhaps our clinical colleagues can enlighten us as to why this is so.

nonlocal MD

e-Patient Dave said...


I hope we'll soon see a lawsuit to blast through the idiot laws in some states that forbid labs from delivering the news directly to patients, even if the patient asks for it. That's beyond archaic - it's dangerous.

I know two people whose cancer got much worse because the physician who order the pathology report didn't notice it or didn't get back to the patient - for a year or more. I wonder what we'd hear about that from the people who claim that the ~100,000 deaths a year in "To Err Is Human" is overstated.

On your question of what happened to your time-honored tradition, I may be wrong but after 2+ years of sniffing around healthcare my impression is that what happened is Fee For Service. You and I have both seen doctor blogs (not to mention covert hallway conversations) where docs say "Look, I can't afford to do anything that doesn't have a billing code."

Please correct or educate me, any and all - my experience is very limited.

(Oo, how nice - my Word Verification block say "cello." Must be Tom Delabanco's day.)

e-Patient Dave said...

Some of these findings point to the inexcusable inadequacy of our medical records systems.

Can you imagine a world class company in any other industry that would have failures like this in the basic area of "know thy customer"? To wit -

"30 percent of adult patients and 25 percent of parents say their primary care physicians do not always know important medical history information."

"30 percent of adult and pediatric patients did not always receive follow-up reports on test results from their doctor's office"

"40 percent of adult patients and 35 percent of parents of pediatric patients reported that their physician did not always seem well-informed about the care they received from specialists to whom they had been referred."

Again, one structural issue is that there's no billing code for care coordination.

Paul, I can't see on the survey's web page any way to segment by whether a practice has a medical records system. If I were in that business I'd be all over that question.

I'll email that question to the contact link that that page.

Keith said...

A requirement to bill a consultation is that the findings msut be communicated back to the referring physician. Of course, Medicare no longer allows consultaion codes to be billed and one result could be that consultants no longer see the necesity of doing this in the payment scheme.

What is clear is that our health care system is breaking under the tilt to high tech, newer is better, and ever more expensive treatments that give marginal gains in health, while long ingnoring the basic infrastructure of medical care; primary care, nursing care, and custodial care. One only need look at where we have shortages in our health care manpower and where we are oversupplied. The result is very expensive cutting edge care, but an inability to attend to other less razzle dazzle basic needs that result in poor health and to provide an adequate saftey net for those on the lower side of the income scale. If we just got rid of all those poor people that can't afford adequate health insurance, we would have dandy looking statistics!

Cetus said...

@e-patient Dave:

How about the mortgage industry? What's your customer's REAL annual income? Dunno. Your customer's credit history? Dunno. Customer's ability to repay this loan? Dunno.

Here's your loan, Mr./Ms. Customer. Ka-ching.

Anonymous said...

Doctor Levy

Please don't buy into the PR spin that this survey in any way reflects before and after vis a vis Romneycare. Except to the extent that the research randomly hit one of the 2% of the Mass population newly insured by Romneycare in 2007 and 2008, this information can in no way be related to Romneycare. This is just more propaganda from the people that foisted this new healthcare delivery system on the 5,000,000-plus of us here in Massachusetts that already had — and mostly always had — health insurance so that they could pat themselves on the back for insuring a couple of hundred thousand people, most of whom still haven’t taken them up on their offer of “free healthcare insurance.”

The doctor-patient relationship has already been harmed for me due to Romneycare because my insurer stopped selling to individuals (after I belonged to their plan for 20-something years) and is forcing me onto the state welfare system. As a result I will likely lose my doctor as well. Most of the rest of the 94% in Mass that had insurance before 2006 (see DHCFP info) will soon follow.

-- Dennis Byron

Anonymous said...



The PCP-specialist communication in the "good old days" to which I referred, occurred under the same fee for service system we have now. I had no billing code for calling an unexpected cancer diagnosis to the physician from my microscope, either - but I still did it, as was our policy. I can't even begin to tell you how far this coordination/collegiality aspect of medicine has deteriorated in the last 10 or more years, at least in private practice.

That said; I'm not sure, as a patient, I would want to receive the news that I had cancer from a pathology report faxed directly to me from the lab, either. Not to mention whether the patient could even understand the report; if it said "hemangioendothelioma", would you be the wiser as to whether it was benign or malignant? (Answer: it depends.....)

As Paul's Dr. Ship observed, "there is no billing code for compassion" - in the rapid, accurate and caring conveyance of a difficult diagnosis through the physician.