Friday, August 11, 2023

Why medicine needs greater context

As physicians, we are trained to diagnose and treat illness. But all too often we know that the surface-level symptoms we address mask health risks that run much deeper. When an asthmatic child from an inner-city neighborhood makes repeat visits to the emergency department, the excellent care he receives works to stabilize him so that he can safely return home. But how long will it be until he returns?

Unfortunately, until healthcare advances, it will only be a matter of time – which is why this traditional model of care is no longer enough. To provide genuinely comprehensive care, physicians must look beyond the immediate to understand the true context of health. In the case of the young boy, his pediatrician would wonder why an otherwise healthy child requires regular emergency attention. He’d partner with local resources to look outside his diagnosis, and beyond his immediate symptoms, to check whether localized air pollution might be exacerbating his condition.

By knowing their populations, caregivers can ensure they can customize plans to help close gaps in care, limit the effects of SDOH, drive health equity, and advance preventive care that reduces costs. Only then will medicine be able to truly impact well-being, population health outcomes, and spend.

Providers looking to expand their approach to care can begin with these three steps:


1. Ask questions to improve outcomes at scale


Even if it seems simple, start with the basic questions: Are you eating enough? Will you have a ride to your follow-up appointment? Does this care plan make sense to you? By asking questions, you’ll unearth clues to the range of factors contributing to your patients’ overall health. By learning whether your patient can purchase enough fresh fruits and vegetables, you’ll learn a lot about how to improve their overall health. In so doing, you’ll reduce their long-term risk of chronic disease, such as diabetes, heart disease, or dementia. By providing clear instructions – and protocols – that make sense to your patients, you’ll increase their likelihood of compliance. For all these brighter outcomes, context – informed by the right questions – is key.


2. Right-size care by knowing needs


By understanding your patients’ whole health, not only will you be able to drive improvements in outcomes, but you’ll also be able to reduce healthcare spend. By providing preventive care, you’ll naturally help reduce the need for expensive hospitalizations and emergency room visits. When healthcare challenges inevitably arise, working to ensure individuals have access to routine care or care management can ensure the most appropriate level of care to meet their needs. In the long-term, and at scale, managing symptoms and keeping chronic conditions at bay will mean fewer intensive, emergency, costly resources. On a whole, any approach that addresses the gamut of invisible health drivers can also reduce the overall burden of disease, contributing to lower need, utilization, and cost over time. “


3. Think locally for life-changing care


Comprehensive care takes a “village.” By treating symptoms and identifying risks beneath the surface, physicians can act as a first line of defense for an individual’s long-term health. But, it takes targeted interventions and proactive collaborations to truly address SDOH and close these gaps in care.For example, physicians can partner with community organizations to help ensure their patients have access to vital resources, such as healthy foods or safe, stable housing. Caregivers can partner with schools and community organizations to provide patients with access to education, language translation services, and healthcare literacy classes. When providers and community-based organizations are in lockstep, individuals in need are truly supported.


Technology makes whole person health possible at scale


Years ago, physicians and other providers were limited in their ability to proactively address SDOH. Without an integrated technology platform to document clinical history, identify SDOH risks, connect with community resources, and “close the loop” on non-clinical referral requests, comprehensive care was difficult to sustain.

By uniting all relevant information for a “whole picture” of health, technology today makes comprehensive, preventive care possible on a whole new level. With these powerful tools, physicians are empowered to begin moving beyond the traditional model of care and toward a brighter, more equitable, and healthier system for all.


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Thursday, August 10, 2023

How patient-centered communication can address maternal health inequities

The United States is one of the most dangerous among wealthy nations for women to give birth.

Disturbingly, it’s even more dangerous for women of color. Black women are about three times more likely to die from pregnancy-related complications than white women, while maternal mortality rates among American Indian and Alaska Native (AIAN) women are two times higher. The COVID-19 pandemic only exacerbated these issues.

Maternal mortality rates underscore this country’s deep-rooted health inequities. Although this problem is endemic, it’s not intractable. In fact, more than 80% of pregnancy-related deaths in the U.S. are preventable.

The healthcare system must work to address all of the factors that contribute to maternal health disparities, including barriers to care, systemic inequities, and the way health plans communicate with consumers. By breaking down these barriers and improving communication, we can ensure that all women have access to high-quality maternal care.


How poor health communication adds to maternal risk


There are myriad factors that contribute to the disproportionate rates of maternal deaths among Black women and women of color. They include structural racism and biases within the healthcare system, limited access to quality providers and facilities in marginalized communities, and socioeconomic barriers (such as lack of insurance coverage and financial constraints). And these are only a few of the challenges.

Inadequate communication exacerbates many of these problems. For example, marginalized communities often have lower rates of health literacy and higher levels of distrust of health providers, which can make it difficult to navigate our complex healthcare system.

Or consider someone with limited transportation options. They may be more likely to delay or miss prenatal check-ins or obtain necessary interventions, treatments, and prescriptions that providers recommend. It does little good for a health plan to send follow-up reminders or other messages that don’t take into consideration this barrier. Instead, messages should prompt follow-up conversations that urge people to arrange other transportation options, if necessary.

Likewise, if educational materials and content don’t provide clear, accessible, and culturally relevant information, health plans will struggle to connect, engage, and build trust with vulnerable populations. That includes addressing language barriers and offering materials in different languages, along with interpreters and translation services that are readily available. Without these supports, marginalized communities may be more susceptible to misinformation and less likely to understand all of the facets of prenatal and postpartum care, whether it’s the stages of pregnancy, warning signs of potential complications, birthing options, or more.


Building a better communication strategy


The stark disparities in maternal health outcomes for marginalized populations highlight the importance of intervention. Targeted health communications and engagement in particular are tools that can help to overcome the socioeconomic barriers associated with prenatal and postpartum care, reduce health risks, and empower pregnant individuals to actively participate in their healthcare decisions.

Consider taking the following steps to build a patient-centered communications strategy that will address the needs of marginalized populations and improve maternal healthcare outcomes for all patients throughout your health system:


1. Promote cultural competence throughout the organization


Cultural competence that respects and understands the diverse backgrounds and experiences of all communities should be the standard for all health plans today. To start, health equity should be prioritized as a strategic goal and a central component of your mission. Leaders need to acknowledge existing disparities and build a clear plan to address them.

It’s encouraging that many health plans have created roles specifically to focus on health equity issues, but these initiatives must also be backed by tangible action and dedicated resources organization-wide. Developing cultural competence and addressing implicit biases through routine training and ongoing education for all employees should be part of your larger DEI goals. These efforts are the first step toward building the right internal culture throughout your organization and ensuring all touchpoints — whether digital or in-person — will be informed by cultural competence.


2. Actively collaborate with impacted communities.


The best way to ensure your digital experience resonates with marginalized communities is to collaborate directly with impacted community members. Key community stakeholders can help identify specific needs, cultural preferences, and barriers to care that your organization may overlook or fail to understand.

For example, one client at mPulse — a healthcare engagement and communications provider where I lead behavioral science — is a medical system that serves low-income populations and individuals struggling to access care. This medical system worked directly with pregnant mothers to develop a prenatal texting care program. Members of the group came up with key phrases and terms to avoid, such as messages in an overly authoritative voice that could trigger psychological resistance to information. By actively involving community members in the planning and implementation of healthcare programs, as our client did, you can build rapport and develop tailored approaches that connect with the populations you aim to serve.


3. Incorporate behavioral science principles.


Behavioral science has become a crucial component of health engagement programs. Incorporating behavioral science into maternal healthcare communications can directly impact health outcomes during your members’ pregnancies.

For example, mPulse worked with mothers and maternal care experts to develop a prenatal engagement campaign that incorporates the behavioral science principles of “social proof” and “storytelling,” with videos of mothers from various communities sharing their stories and experiences. By highlighting the experiences and stories of pregnant individuals within the community, health plans can foster greater trust, dispelling many common concerns from mothers and increasing the likelihood that they would engage and respond to outreach materials.


4. Prioritize data-driven decisions.


Health plans collect an abundance of data about their members — so it’s important to use that information. Data enables you to better understand the barriers and needs of marginalized populations so you can tailor interventions and outreach efforts to address barriers more effectively and build more personalized, relevant experiences that resonate with consumers. For example, knowing that someone recently joined Medicaid can inform which educational materials and content you send them, like how they can navigate insurance throughout their pregnancy.

Data analytics can also help in deploying behavioral science methods. For instance, cognitive overload often causes members to become overwhelmed and tune out vital information. Analyzing viewership and engagement with online videos can inform the length and substance of those videos. If you find a majority of members stop watching content about the risks of aspirin during pregnancy, you may start to develop shorter, quick-hit videos optimized for Facebook, TikTok, or other social media platforms.


5. Use multiple communication channels.


In today’s digital landscape, consumers interact with health plans through a variety of touchpoints, whether online, on their phones, at telehealth visits, at the clinic, or in a provider’s office. You should leverage a variety of communication channels to reach marginalized populations no matter how they interact with your organization.

Beyond traditional channels like phone and email, you can broaden reach and engagement through community events, social media, and partnerships with trusted community leaders and influencers. Multiple avenues for engagement are particularly important when addressing underlying social determinants like homelessness or unstable housing—these members may not have access to a single, consistent communication channel.

Improving maternal healthcare among marginalized populations demands a multifaceted approach centered on cultural competence and active engagement with communities. And today’s advanced digital tools offer new opportunities to put these tenets into practice within your health plans.

By embracing these approaches and adopting a patient-centered mindset, health plans can begin to bridge the gaps in maternal healthcare disparities and achieve better outcomes for all. Together, we can work toward a future where every pregnant individual receives the care and support they need to experience a healthy pregnancy and childbirth.


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Wednesday, August 9, 2023

Enhancing doctor communication

As doctors, we have the responsibility to educate our patients. Unfortunately, we have no didactic training regarding communication with our patients. This blog will focus on suggestions for improving communication and rapport with our patients.

Two scenarios of ineffective communication:


1. A defensive doctor


Patients ask for additional information or credible websites to learn more about their medical problems. The doctor responds, "If you don't trust me, you should go elsewhere."


2. An inattentive doctor


The doctor operates on a patient and leaves the surgical area without speaking with the patient's family. The family asked the secretary in the surgical reception area to talk to the doctor and heard that the doctor was in his office and couldn't take a call from the family.

These two doctors have lost rapport with their patients\families. Both scenarios are examples of dismal communication skills. These examples may lead to losing confidence and trust in the physician, which may impact outcomes and place the doctor at increased risk of litigation.

Studies have shown that doctors overestimate their ability to communicate with their patients. Studies on doctor-patient communication have demonstrated patient discontent even when many doctors consider the communication adequate or excellent.1

Nearly 75% of the orthopedic surgeons surveyed believed they communicated satisfactorily with their patients. However, only 21% of the patients reported satisfactory communication with their doctors. Patient surveys have consistently shown that patients want better communication with their doctors.2

A doctor's communication and interpersonal skills include history taking, making an accurate diagnosis, recommending appropriate treatment, and establishing a caring relationship with patients. These are the core clinical skills in medicine to achieve the best outcome and patient satisfaction.

Patient-centered medicine has not always been standard practice. For example, in the 1950s to 1970s, most doctors considered it inhumane and detrimental to terminal patients to disclose bad news because of cancer's bleak treatment prospects.3 Today, the health consumer movement has led to the shared decision model putting the patient at the center of doctor-patient communication.


Benefits of enhanced communication


Not too long ago, physicians were judged by their "bedside manner." Good doctor-patient communication can help enhance patients' emotions, facilitate understanding of medical information, and better identify patients' needs, perceptions, and expectations. Patients reporting good communication with their doctor are more likely to be satisfied with their care, especially to share pertinent information for accurate diagnosis of their problems and comply with the doctor's advice.4 When patients understand the nature of the treatment and the need for follow-up, this is strongly associated with their recovery. Others have observed a decrease in the length of hospital stay and, therefore, the cost of individual medical visits and fewer referrals.5

A patient-centered encounter makes a better patient likely to have a favorable outcome and doctor satisfaction. Satisfied patients are less likely to lodge complaints or initiate malpractice suits.

Satisfied patients benefit doctors with greater job satisfaction, enhanced online reputation on medical review sites, less work-related stress, and reduced risk of burnout.


Suggestions to enhance patient communication


Breaking the ice. Please don't start the dialog with a new patient by launching into their medical problem. Instead, ask an open-ended question about what they do, where they live, have traveled, their hobbies, or their families. This allows you to focus on the whole patient rather than an organ system.

Communicate by listening. When physicians monitored patients, the average time before the physicians interrupted the patient was sixteen seconds. This abbreviated time hardly qualifies as good listening.

When patients share their symptoms, they must demonstrate curiosity and concern. Ask clarifying questions. Ask how the symptom or problem is impacting lives. Avoid questions that are answered with yes or no.

Focused or active listening means looking eyeball-to-eyeball with the patient and not the computer. If you multitask and use your cell phone, you can't convince a patient you are listening. Also, inform your staff that you are only to be interrupted if there is an emergency, such as a call from the emergency room, the operating room, or the intensive care unit.

Check your "doctor speak" at the door. This an excellent study with eye-opening results on common phrases we use as healthcare providers and how often patients do not understand them. Only 9% of patients understood what was meant when asked if they had been febrile. Only 2% understood what was meant by "I am concerned the patient has an occult infection." Only 21% understood that "your x-ray findings were quite impressive" was bad news.

Other terms physicians use to explain things most patients need help understanding include bilateral, systemic, and evidenced based. As you explain things to patients, check back to review that they comprehend your explanation.

Patients appreciate honesty and sincerity. Many symptoms in medicine end up without a diagnosis. When the diagnosis is uncertain, it is important to be honest with the patient and share why you think it is okay to initiate definitive treatment once more information is available. This also benefits patients' trust when unsure about the diagnosis because it indicates that you don't have an answer for everything.

Another effective way to connect with your patients is to ask what they think is causing their symptoms. The answer to this question may give insight into patients' fears. You can discuss their worries, even if it isn't something you are considering. Knowing what they are fearful of, you can reassure them when appropriate.

Finally, communication includes answering the patient's questions before concluding the encounter. Answering questions can be facilitated by giving patients a 3 x 5 card to write down what questions they would like answered on their visit. (Sample from my practice is shown below) This avoids the uncomfortable situation where your hand is on the doorknob, and the patient has just one more question.


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Tuesday, August 8, 2023

Financial success for specialty medical groups depends on a strong back-end approach

Specialty groups like physical therapy organizations are feeling the pinch of higher expenses due to inflation and increased labor costs—and it’s a challenge that will limit growth in provider profits, McKinsey projects.

It’s one reason why the approach medical groups take to post-service financial engagement is critical to their short-term and long-term health.

Some specialty groups already face unique challenges when it comes to patient financial engagement due to the number of claims they process on behalf of patients. For instance, when a single patient receives care multiple times a week—common among patients with chronic and complex conditions—each visit constitutes one claim. Imagine what happens when a patient receives multiple billing statements, each with a different balance. Suddenly, navigating the cost of care becomes confusing, increasing the risk that patients will either delay payment or simply choose not to pay it at all.

Leading groups look for ways to eliminate confusion not just on the front end, when transparency and communication around options for payment are key, but also on the back end, when the quality and even cadence of outreach and the range of patient payment options available makes a significant difference in financial performance.


Making the right moves for financial health


At Central Nebraska Rehab Services, a 16+ location physical, occupational, and speech therapy group, taking a proactive approach to patient payment engagement incorporates digital-first communication and tightly coordinated messaging among staff. It’s a strategy that has enabled Central Nebraska Rehab to collect over half of electronic payments within the first 14 days of bill notification. It has also decreased inbound calls, giving staff more time to focus on denial prevention and management.

There are four lessons learned that specialty groups could incorporate to strengthen revenue while protecting the patient experience.
  1. Adopt a text-to-pay approach to improve cash flow with better patient engagement and convenience. When insurance pays its portion for care, a billing system will show a patient balance right away. However, it may take three weeks or more for a patient statement to be mailed via traditional paper statements. Add to that the time it takes the patient to pay the amount due and it’s easy to see how cash flow can be strangled by traditional paper-based processes. It’s one reason why text-to-pay is a powerful tool for specialty groups—at Central Nebraska Rehab we utilize PatientPay. A text is sent as soon as the patient balance is generated, and the corresponding payment could be executed within a couple minutes, not four to eight weeks later. A digital-first solution like this means specialty groups see immediate cash in their bank, rather than being dependent on slow payments that are mailed. For any size group today, faster cash flow is critical to financial health.
  2. Pro tip: Make sure the secure link sends patients directly to their bill with all of the details included, such as insurance and office payments made to date. The convenience of digital payment becomes lost if a patient must remember their patient portal username and password to access their account, where they not only must determine where to pay their bill, but also don’t have the key details needed to fully understand it.
  3. Educate staff—from front-office staff to therapists—on the move to digital offerings, including text-to-pay and email. At Central Nebraska Rehab, for example, therapists hold a position of trust with patients due to the amount of time they spend together on care—sometimes a few days a week. It’s natural, then, that patients might ask their therapist questions about new digital payment offerings, from text-to-pay to the ability to enroll in a payment plan online from the privacy of home. By combining staff education with marketing of digital offerings, such as information in billing statements a month before go-live, office signage and website messaging, specialty groups can anticipate patients’ questions and help them feel more comfortable from the start.
  4. Pro tip: In multi-specialty clinics, make sure the branding of each group, including the logo, is clearly presented in all communications and on patient bills to avoid confusion.
  5. Make sure patients see new balances first. When patients with chronic or complex conditions see their provider multiple times a week, such as for therapy, their balance continually changes. This can make it difficult—and frustrating—to stay on top of what they owe. By ensuring the order of out-of-pocket amounts due starts with the most recent date of service, patients can gain a clearer view of which claims have been processed, how much they owe, and which appointments and services have been paid for to date. This decreases the potential for confusion while giving patients greater confidence that they can manage their account.
  6. Pro tip: Offer the patient the ability to pay the full amount now or at a later date and to enroll in a payment plan. This reduces inbound calls by presenting all the options up front. At Central Nebraska Rehab, the combination of digital payment offerings and support helps the organization collect 40% of electronic payments within the first eight days of bill notification, before a paper statement drops, reducing mail time and costs.
  7. Offer self-service options for account management—including the ability to self-enroll in payment plans. When patients feel in control of their payment experience, they are more likely to manage the cost of their care in a timely way. At Central Nebraska Rehab, patients can self-enroll in a payment plan directly through the text-to-pay solution. From there, text reminders let them know three days in advance of when monthly payments are processed. These types of reminders help keep payment plan failures to a minimum.Self-service options such as this decrease administrative work for staff. They also contribute to a boost in online payments. Today, over 80% of card payments made by Central Nebraska Rehab patients are completed without involving office staff.
  8. Self-service payment plans have been a big win for Central Nebraska Rehab and its patients. Before incorporating this option, patients might make a single low payment every month or so, which not only took longer to pay off their balance, but increased administrative burden/cost. Now, patients set up larger payment amounts on their own, and they gain the ability to manage their account at any time of day.
  9. Pro tip: Offer flexibility in payment plan terms, such as a tiered system based on the balance due, and find a solution that understands the billing. For instance, Central Nebraska Rehab leverages a “lifetime” bill, where the patient really only has one active bill at a time. Its patient billing and payment system automatically recognizes the bill and assures that current and past services are combined.

A prescription for better financial health


The financial pressures some specialty groups experienced last year aren’t likely to ease up this year, given rising expenses and workforce shortages, McKinsey projects. By taking a proactive approach to post-service patient financial engagement, specialty groups can empower patients to manage their cost of care in ways that meet their needs while protecting their organization’s bottom line.
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