Blog | Thursday, February 23, 2012

This doctor's 'complex' patients aren't who you think they are


The government, academics and policy wonks are always in the process of "redesigning" health care. Patients with increased health care needs are considered "complex" and these patients consume the major health resources (translate: "money").

In fact, 65% of total health care expenditures are directed toward the 25% of patients with multiple chronic conditions. Eighty percent of Medicare spending is on patients with four or more chronic diseases. For the first time a study has been done and published in Annals of Internal Medicine that actually asks primary care physicians (PCPs) what defines patient complexity. Who better than the treating doctor to answer this question?

The researchers asked 40 primary care physicians to rate the complexity of 120 of their own patients and to document the characteristics associated with complexity. Over one-fourth of patients were described by the doctors as "complex." The doctors were not told what defined "complexity," but instead were asked to describe it in their view. Once a patient was described as "complex," the doctor was given five domains to choose from, developed from previously published concepts. The five domains were:
--medical decision making (cognitive effort needed to make appropriate diagnoses and therapeutic decisions),
--coordination of care (overseeing care involving others and for making sure that the medical system is working for the patient),
--patient's personal characteristics (challenging patients),
--patient's mental health issues (includes substance abuse), and
--patient's socioeconomic circumstances (home and work issues, inability to afford medication).

Some characteristics of PCP-defined complex patients stood out. They were more likely to be over age 60 and women. They were more likely to have government insurance (Medicare/Medicaid) than commercial insurance. They were more likely to be undereducated and had many office visits. They took more than twice as many prescribed medications.

I find it fascinating that most of the PCP identified complex patients were not considered high risk by the Medicare model and other known models. The algorithms that guide payment and other policy decisions didn't hold up. The patients identified as complex by PCPs affect their workday and time, yet the known models would not have called them complex. More than co-morbidity and other case-mix definitions, factors like inadequate insurance, alcohol related problems, prescriptions for anxiety and other mental health issues were all associated with increased complexity per the physicians. These patients generated more visits, more high cost procedures and more need for mental health services.

The fact that doctors are finally being asked about their work is promising. It is predicted that 32 million uninsured Americans will come into the primary care system with the passage of the Patient Protection and Affordable Care Act. This, at a time when fewer medical school graduates are entering primary care and many PCPs are leaving clinical practice due to work related stress and decreased job satisfaction.

These results actually provide insight that should be considered in designing a health care system that works for patients and care-givers. It should influence payment mechanisms, office support and allow the extra time it takes to care for complex patients. These changes would go a long way to increasing the work satisfaction for PCPs. The fact that this was the first study that actually defined complexity from the PCP perspective is amazing. Let's hope it is the start of something that will ultimately improve the health care system for patients and PCPs.

This post originally appeared at Everything Health. Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.