A key component of health care reform involves changing the way providers are paid, moving from a fee-for-service medical model to one based on holistic outcomes.
Health care in America is expected to become more complex as the aging American population is burdened with a composite array of medical, mental, social and financial issues.
Metrics to define and measure patient complexity are necessary to guide how care is organized, how physicians and health care systems are paid, and how resources are allocated.
Researchers report that some primary care physicians (PCPs) are a step ahead in satisfying the new model as the PCPs define patient complexity using a broader range of factors — including mental health, social factors and financial issues.
The PCP approach appears to provide a more accurate indication of case complexity replacing traditional methods that merely look at comorbidities (the presence of one or more disorders) and cost.
“Simply counting the number of comorbid conditions does not really capture whether a patient is complex,” said Richard W. Grant, M.D., M.P.H., the paper’s lead author.
“All primary care physicians can point to patients of theirs with very complicated medical histories who are relatively straightforward to manage, whereas other patients can be a real challenge despite relatively few medical diagnoses. Our results emphasize the importance of social and behavioral contexts that can create important barriers to delivering high-quality primary care.”
The study enrolled 40 primary care physicians from 12 private practices and community health centers.
Participating physicians used a web-based tool to review a list of 120 of their own patients and indicated those who, in their view, were complex.
For those complex patients, they were asked to indicate which of five domains — medical decision-making, coordinating care, mental health or substance abuse problems, health-related behaviors, and social or economic circumstances — were involved in that determination.
The authors found that primary care physicians designated about one-quarter of their patients as complex – with older, more experienced physicians and those working in community health centers reporting higher proportions of complex patients.
Compared to non-complex patients, complex patients were older, more often women, and had more clinic visits to many different providers.
Complex patients were also prescribed more medicines — including prescriptions for antipsychotic medicines — were more likely to miss appointments, and were more likely to live in neighborhoods with lower income and educational levels.
The authors then found that the results of physician assessment differed substantially from those of other common methods for assessing complexity.
“Managing complex patients requires greater clinician effort, increased health care resources, and substantial family and community support,” said Grant.
“In order to redesign our health care systems to more effectively care for complex patients, we need a better handle on exactly who they are. By asking primary care physicians about their experiences with their own patients in a systematic and quantitative way, we were able to bring out the importance of social and behavioral factors, in addition to specific medical problems.
“This work may help guide efforts to redesign health care systems so that we can deliver high quality, cost-effective care tailored to individual patient needs.”
The article is found in the journal Annals of Internal Medicine.
Source: Massachusetts General Hospital