Delivering Higher Value Care Means Spending More Time with Patients- HBR_HRosenberger

Attempting to place arbitrary limits on the length of appointments or setting high targets for the number of patients that he or she could see in one day may lower the cost in the front end, but they incur much higher costs later in the cycle of treatment.  The article written by Derek A Haas, Yudit Krosner, Nirvan Mukerji and Robert Kaplan discusses patient outcomes for early treatment and the cost difference between early treatment verse emergency treatment for chronic diseases. Does spending time with your patients mean higher value in care? Derek who is the CEO of Avant-garde health believes so.  This article discusses the difference in care for someone who needs dialysis for kidney failure. They illustrate the problem with someone who is in kidney failure. When kidneys begin to fail, they lose their ability to filter blood. They will need a transplant. During the time waiting for a transplant, the patient will need dialysis. Dialysis might be needed anywhere from 2 times a week to 7 times a week depending on the complexity of the kidney. They compare a patient, who has been under the care of a primary care doctor who was able to send an extra 30 min each appointment with the patient. Here Dr Nirvan Mukerji sates that during this extra time with the patient, they can have the time to discuss the importance of taking their medication, how important it is to keep their fistula or graft clean and how important it is to not miss dialysis. All of these are life saving measures that the patient needs to take. He argues that more time with the patient gives them more time to discuss expectations of what is to come. More time equals better treatment compliance. The difference would be a patient who has a twenty minute appointment where the physician does not have enough time to diagnose and speak to their patient, and they wait too long to refer their patient to a nephrologist. How a patient starts their dialysis has enormous health and cost complications. If a patient does not have time to get a fistula put in, the patient must start with a catheter inserted into a vein in the neck or chest and this process is not only more expensive, but the risk of infection is much greater as well as blood clotting and death.  In a study they learned that health complications in the year following the diagnosis of a failing kidney led to about $20,000 in extra treatment costs per patient. Surprisingly, they stated that both groups- the ones that got pretreatment and extra care, and the patients who more emergently started dialysis cost around the same amount. That is definitely something to think about, but other than cost over 2 years for diagnosis and treatment I would love to know the difference in patient outcome. Was there any difference in how long each patient lived after the diagnosis?

               Interestingly, the patients in the study who started dialysis with a fistula had the same number of appointments and care as those patients who started dialysis sub optimally with the catheter. Even including the extra cost of the two extra vascular surgery, the cost between the two sets of patients were about the same.  I do think that the author is suggesting that if we invest in more pre care for our patients with chronic illness it will overall limit the cost in the long run. I think that there are more factors that contribute to this more than patient time in the room with the physicians, however.  I would think that the more patients you see, the more costly it would be for supplies. Every time you see a new patient, you need to clean the room, get a new set of tools, new paper for the beds. More patients= more materials. Limiting the patients they see every day, will limit the number of supplies used in one room. In a recent article in the Harvard Business Review, they said that pressuring physicians to see more patients a day, is one of five counterproductive mistakes that health care facilities are making.

Physicians will be burnt out. If they continue to keep seeing patients back-to-back, they will eventually burn out. The most important part of primary care is prevention.  The article also states that 50 % of patient with chronic conditions do not take their required medications. If you are a primary care doctor, and you are burnt out, chances are they are not going to take the time to sit down and speak personally to these patients about the importance of the medication. Giving them more time with each patient, they can actually get the time to sit down and explain the complications and what could happen if they didn’t do this. They could give them examples and listen to the patient. Maybe there are other factors for the patient that they are not taking their medications. Is it too expensive? Does it upset their stomach? Maybe they really didn’t think they needed to take it? That extra one on one time might prevent one visit to the emergency room for that patient. The way I look at it, and the way the reader is trying to explain is it cost $ for one primary care visit/ follow up with their PCP. $0 co pay or like a $20 co pay for the patient. The ED visit for one patient averages around $1,389, and around $300 for a co pay on average. Costs of Emergency Department Visits in the United States, 2017 #268 (ahrq.gov) It costs less for the insurance AND the patient to go to that primary care visit vs an emergency trip to the hospital.

There are so many other examples of how primary care doctors that treat chronic illness can help prevent emergency treatment and achieve better compliance with just more time with their patients. It improves outcomes and saves money. It improves the mind set for the physicians and the patients. I think that extra 20-30 min in a patient’s room saves money, and lives.

Hiring Higher Value Care Means Spending More Time with Patients- HBR_HRosenberger

1.  Haas, D; Krosner,Y; Mukerji;N and Kaplan,R. (2014).  Delivering Higher Value Care Means Spending More Time with Patients. Harvard Business Review, p. 1-5.