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Physicians lack time and tools to discover hidden risks in patients with chronic conditions

The vast majority of primary care physicians don’t have the time or tools to adequately address the needs of their patients with multiple chronic conditions, leaving some patients to struggle with health-related social and behavioral issues on their own, according to new research from Quest Diagnostics.

The findings are based on an independent survey commissioned by Quest of primary care physicians (PCPs) and adult patients 65 years and older who have multiple chronic conditions and are Medicare beneficiaries. Care for chronic conditions, such as hypertension, cancer, arthritis and diabetes, accounts for an estimated 71 percent of all healthcare costs. Three in four Americans over the age of 65 have two or more chronic health conditions.

The analysis suggests that the traditional medical model—an annual office visit with a primary care physician—is insufficient to care for patients with complex health issues, and PCPs know it. It also suggests many patients do not associate social, behavioral, and other factors with healthcare, and therefore fail to discuss these issues with their primary physician.

“Two in three Medicare patients have multiple chronic conditions that require ongoing medical attention and substantial resources from the healthcare system,” said Jeffrey Dlott, MD, Medical Director for Chronic Care Management, part of the Extended Care offerings of Quest Diagnostics. “Our survey findings show that PCPs desperately want to deliver high quality care, but they feel they are failing their patients with the most complex care needs. Patients approve of their primary doctors’ care, but are not sharing a litany of social and behavioral issues that, if not resolved in time, could escalate into serious health matters. For some patients, healthcare feels like a solitary journey.”

Among the key findings:

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 percent say they are too pressed for time to address complex clinical issues and 66 percent 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 percent 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.

  • Almost nine in ten PCPs (86%) say they have felt unable to address the needs of their chronic care patients adequately.
  • Two in five patients with multiple chronic conditions (44%) don’t tell their doctor about issues they are facing that could affect their health, such as loneliness, financial issues and/or transportation issues.
  • Only one in four physicians (23%) have implemented Chronic Care Management (CCM), Medicare-reimbursed services which help to bridge the care gap for patients with chronic care needs.

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.

Yet, the survey findings suggest patients may not recognize or communicate all health-related issues that may impact their care and health. The number one worry cited was “getting another medical condition” (43%) and the second was “being a burden on my loved ones” (32%). Yet, 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.”

The findings are significant as approximately 80 percent of health outcomes are related to factors outside the traditional realm of healthcare delivery, including social, economic, and behavioral.

Physicians view medication nonadherence as 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.

Other research finds that patients with chronic conditions account for 83.1 percent of all prescriptions in the United States, and nonadherence is associated with approximately $100-$300 billion of U.S. healthcare costs annually.

PCPs and patients see value in chronic care management (CCM), but hurdles limit adoption: Most PCPs (87%) see value in CCM services to help monitor their CCM patients and 90% say CCM medication monitoring would provide “peace of mind.” Yet, only half (51%) surveyed know that CMS may reimburse for CCM for Medicare beneficiaries with multiple chronic conditions, and only one in four (23%) have implemented CCM, citing complexity of coding (43%) and burdensome paperwork (37%) as key barriers. Nearly half of patients (45%) say they would be likely to access CCM services; that number jumps to 58% when informed that it is a covered benefit through Medicare.

  • Nearly all physicians (95%) surveyed say they entered primary care to care for the "whole patient," yet 66 percent say they don’t have time to address social and behavioral issues that could affect health.
  • Fears related to medication nonadherence, falling at home, and being a burden on caregivers cited as concerns by physicians and patients—but often not discussed during the physician visit.
  • Eighty-four percent of physicians say Chronic Care Management services could be an extension of their practice to help provide quality care, but only 23 percent have implemented it, citing coding administrative complexity, like billing codes and paperwork as barriers.

Patients in Medicare are eligible for an Annual Wellness Exam. In January 2015, the Centers for Medicare & Medicaid Services (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.

Participation in CCM programs by PCPs has been slow, although CMS estimates 70 percent of Medicare beneficiaries—roughly 35 million people—would be eligible.

“Physicians are open to adopting CCM, but it has to be easier to implement and a trusted extension to one’s practice,” said Katherine A. Evans, DNP, FNP-C, GNP-BC, ACHPN, FAANP, immediate past president, Gerontological Advanced Practice Nurses Association (GAPNA). “The Quest research also shows that older patients are worried about receiving new medical diagnoses and being a burden on caregivers. Physicians may explain to patients that CCM can help illuminate emerging health issues before they turn serious, so they can lead independent lives longer. With improved monitoring, these patients may expect a better quality of life.”

The report, “Hidden Hazards: Closing the Care Gap Between Physicians and Patients with Multiple Chronic Conditions,” is available for download at (on the right hand navigation).

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