Care Redesign

Care Redesign Survey: In the Push for Convenient Care, Protect the Patient-Doctor Relationship

Insights Report · July 14, 2016

Analysis of the second NEJM Catalyst Insights Council survey on the Care Redesign theme. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.

METHODOLOGY AND RESPONDENTS

  • In May and June 2016, an online survey was sent to the NEJM Catalyst Insights Council, which includes U.S. health care executives, clinician leaders, and clinicians at organizations directly involved in health care delivery. A total of 498 completed surveys are included in the analysis. The margin of error for a base of 498 is +/- 4.4% at the 95% confidence interval.

  • The majority of respondents were clinicians (49%), with executives (22%) and clinician leaders (29%) nearly evenly split. Most respondents described their organizations as hospitals (38%) or health systems (14%). These hospitals were predominantly midsized (34% had 200–499 beds) or larger (47% had 500 or more beds).

  • Only 10% of respondents indicated that their major affiliation was with a physician organization. Those physician organizations tended to be big — 43% had 100 or more physicians.

  • Nearly three-quarters of the organizations (72%) were nonprofit, with the remainder of respondents coming from for-profit organizations. Every region of the country was well represented.

On a recent trip to Australia, I paid close attention to sentiments about the country’s adoption of disruptors such as telehealth and retail clinics. Australia has paced about a decade ahead of the United States in these fields, but as I learned there, being ahead doesn’t always mean better care.

I got the distinct impression that despite the prevalence of convenient health care — there are clinics in shopping malls — patients and physicians alike are dissatisfied with care relationships.

The problem, from what I gathered, is that Australia has moved so far down the path of convenience, they have lost the essence of health care: the relationship between the healer and the patient.

In this second edition of our quarterly survey of the NEJM Catalyst Insights Council for the Care Redesign initiative, we posed questions to health care executives, clinical leaders, and clinicians to assess the penetration and impact of disruptors such as telehealth, retail clinics, and health apps (such as those found on mobile devices) on the U.S. health care system. Has convenience started to erode patient-doctor relationships and, therefore, the true quality of care?

Not surprisingly, nearly three quarters of respondents said market disruptors improve convenience for patients. However, 8 in 10 believe these disruptors will lead to a fragmented patient-doctor relationship. And more than two-thirds of respondents don’t believe that these disruptors will lower the cost of care — which is a clear focus of value-based care. Notably, clinicians (23%) are far more skeptical about this potential outcome than executives (39%).

Negative Outcomes of Market Disruption to Care Delivery Models

Care Redesign Insights Report. Click To Enlarge.

What these results indicate to me is that, if the U.S. health care system starts favoring convenience, or transactional care, over relationship-based care, then patients will sour to traditional health care altogether and seek alternative, and potentially more expensive, less effective treatments.

The good news, according to the survey, is that there is still opportunity for executives, clinical leaders, and clinicians to strike the right balance between convenience and relationship-based care. Though a third of respondents said disruptors are hurting primary care, 42% of respondents said they have no opinion yet about the impact of these disruptors — i.e., it’s too early to tell.

Retail Clinics — Helping or Hurting Primary Care?

Care Redesign Insights Report. Click To Enlarge.

Widespread Adoption of Market Disruptors

At least half of respondents indicated that the disruptors listed in the survey, which also included wireless home health devices and automated/online decision support for patients, are already taking place in their local marketplace or will do so in the next one to two years. The Northeast was particularly bullish on the onset of market disruptors.

Take, for instance, retail clinics. Respondents reported overwhelmingly high presence of urgent care centers, walk-in clinics, and the like across all geographic regions.

Timeline for Care Delivery Disruptors to Impact Local Market

Care Redesign Insights Report. Click To Enlarge.

Health apps, such as those that monitor activity levels for chronic disease, also are experiencing significant adoption.

Without a direct link to electronic medical records, however, these apps put a wall between health behaviors and health care. They might suggest improvements to diet that don’t take into consideration a patient’s pre-existing conditions or genetic factors. For instance, a health app avatar might not know that a patient is taking the steroid prednisone, which would impact his ability to lose weight.

Telehealth (which includes the range of technologies and services for remote consultation and self-care) was considered the biggest disruptor by survey respondents, with 44% penetration today. Another quarter of respondents said telehealth would reach their local market within 2 years, and 18% more said within 2–3 years. Thus 87% of people say that telehealth has arrived or will soon.

Biggest Disruptors to Care Delivery

Care Redesign Insights Report. Click To Enlarge.

Executive, clinical leader, and clinician respondents to the NEJM Catalyst survey all agree that disruptors will force traditional care delivery organizations to improve patient experience and customer service. In other words, these disruptors are set to change the way traditional practices deliver care.

Impact of Disruptors to Traditional Care Delivery Organizations

Care Redesign Insights Report. Click To Enlarge.

How Traditional Care Organizations Should Respond

Primary care practices should embrace the factors that make retail clinics attractive to patients: great access, flexible timing, and easy navigation. Retail clinics have figured out how to break down the barriers to care.

Traditional care delivery organizations should become more flexible and open with the flow of good information, rather than enabling an environment of fragmented care, inaccurate medical information, and less coordinated care — which are all negative outcomes for U.S. health care that the survey respondents fear.

Some traditional providers and academic institutions already have responded to the retail clinic threat by starting up their own branded urgent care clinics, including Beth Israel Deaconess Medical Center and my own organization, Providence St. Joseph Health.

Now is the time when the industry also has to look at opportunities such as linking mobile apps to a patient’s medical record and their physician for insightful care pathways.

Nearly half of respondents to the NEJM Catalyst survey believe that a positive outcome of telehealth, retail clinics, and other disruptors will be improved self-care. That consequence could benefit primary care and ultimately move the needle on value-based care and healthy outcomes overall.

Positive Outcomes of Market Disruption to Care Delivery Models

Care Redesign Insights Report. Click To Enlarge.

The classic 1993 JAMA article “Actual causes of death in the United States” (McGinnis and Foege) reported that about half of all deaths come from behaviors. So if patients can take care of themselves by better eating, sleeping, exercising, and stress management, then they’ll need less medical intervention. That’s a win for everyone. And if health care providers can improve coordination of care for patients with chronic conditions — which 44% of respondents believe will be the outcome of these market disruptors — then we have a better chance at ensuring the best possible health outcomes for the patients and families we care for.

 

Namita Mohta, MD, Clinical Editor for NEJM Catalyst, contributed to this Insights Report. Check NEJM Catalyst for monthly Insights Reports not only on Care Redesign, but also on the New Marketplace and Patient Engagement.

VERBATIM COMMENTS FROM SURVEY RESPONDENTS

Are retail clinics helping or hurting primary care?

“Primary care clinics are not meeting the needs of patients and thus retail clinics attract business. Eventually health care systems will absorb or co-brand with retail clinics as we advance towards ACO models.”
— Clinical Leader of a large teaching hospital in the Midwest

“Let me honest about this. The retail clinics are a cash and carry business.”
— Executive for a small nonprofit physician organization in the Northeast

“May be decreasing volume slightly, but I suspect a significant number of patients would either defer care or go to ER.”
— Clinician at a midsized for-profit clinic in the South

“Decreased continuity and substandard care. It’s a logical reaction though to the disruptions caused by the constant churning and disruption for-profit health plans intentionally introduce into health care delivery.”
— Physician Executive for a small nonprofit clinic in the West

“This is not a black and white issue, all depends on the skill level of the provider. A well-trained NP at CVS may be better for a patient than an overworked, underpaid, burnt-out MD, however we have all seen numerous patients coming in as train wrecks with simple problems because they have only been treated at an urgent care. Additionally, when only extremely complex patients are seeing their provider in the office, this makes the day of the physician extremely arduous, and I think would increase wait times for patients, as well as decrease the physician’s professional satisfaction. Everyone needs a minute to breathe in the day.”
— Clinician at a small for-profit clinic in the Midwest

“We need changes in the delivery system and not another competitor. I do not see how Walgreens, CVS, or a for-profit urgent care physician group are interested in true transformation or a truly new delivery system.”
— Chief Medical Officer of a nonprofit clinic in the West

“It is mixed — they duplicate services that may be repeated by misdiagnosing patients, but they also relieve some volume, and in light of current scarcity of primary care docs that is a positive.”
— Executive for a large nonprofit health system in the South

“Provide patients with another choice making it more likely that the patient will access timely care. The challenge will be to ensure that the medical record is seamless across all delivery sites.”
— Clinical Leader of a government organization in the Northeast

“Inconsistent care. Increased medication interaction errors. High utilization of unnecessary antibiotics. Lack of quality incentives to guide care with a greater concern of meeting the patient’s perceived expectations instead of molding expectations toward better health through quality care delivery. That requires a trusting relationship.”
— Physician at a large nonprofit health system in the South

“There is no reason that patients have to be forced into waiting for a unique appointment time, in a doctor’s office — which is typically unappealing, poorly designed, and requires waits in excess of the appointment time.”
— Vice President of Medical Affairs for a large nonprofit insurer in the South

“The providers in these settings aren’t as well trained. The care fragments the PCP-patient relationship. The providers in these settings have no mandate to adhere to quality (HEDIS) guidelines, which has a negative impact on PCP metrics and a downstream negative impact on the ability of the PCP to capture incentive dollars, which is especially important in markets where FFS payments have not increased.”
— Clinician at a midsized physician organization in the Midwest

“Patients want and need convenience; you do not need to see your primary care provider about everything but primary care providers do need to be notified that care took place.”
— Vice President of a large teaching hospital in the Midwest

Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Michael Bennick Yale New Haven Hospital Medical Director of the Patient Experience - Yale Living History Project

The Living History Project: Open-Ended Patient Interviews Create a Therapeutic Bridge

A program at Yale has students conduct open-ended interviews with patients about their lives, their hopes, their values, and what they most want their medical team to know — creating the opportunity for human connection and a better care experience.

Fisher02_pullquote hypertension guidelines

Hypertension Guidelines: Achieving 90% Success

Focused and innovative health systems are managing to control blood pressure for 9 in 10 patients, which is well above the national average of 50% to 60%.

Health Care Organizations Are Moderately Effective in Using Data

Survey Snapshot: Using Data for Change

NEJM Catalyst Insights Council members discuss how data and analytics are being used at their organizations, both now and with the future in mind.

Percentage of U.S. Adult Hemodialysis Patients Achieving Dialysis Adequacy, 2013-2016. Data will be released in early 2019.

Innovation in Dialysis: Continuous Improvement and Implementation

The U.S. dialysis sector has been criticized for its lack of innovation, but this criticism disregards the kidney community’s success in creating — and continuously improving on — dialysis as a safe, globally scaled, quality-oriented outpatient therapy.

Cleveland Clinic Time-to-Treatment Cancer Programming Overall Scorecard 2015-2017 Sample

Reducing Time-to-Treatment for Newly Diagnosed Cancer Patients

How Cleveland Clinic initiated a multidisciplinary program to reduce time-to-treatment and accomplish a 33% reduction.

Treatment Authorization Increases and Rapid Boost in New Mexico Medicaid Members Treated for Chronic HCV

A Collaborative Model to Expand Medicaid Treatment Coverage for Chronic Hepatitis C Virus

How managing the benefit coverage expansion for the treatment of HCV in New Mexico was successfully achieved after less than 2 years.

Data Analytics Improves Clinical Care

Care Redesign Survey: How Data and Analytics Improve Clinical Care

Data and analytics are a key means for clinicians, clinical leaders, and executives to transform health care delivery. Yet health care organizations have work to do in getting measures right and much to learn about effective use of data, according to our most recent Insights Council survey.

Nobody Wants a Waiting Room sketch

Nobody Wants a Waiting Room

A study in system change.

Orszag02_pullquote - In Defense of the Hospital Readmissions Reduction Program HRRP

In Defense of the Federal Hospital Readmissions Reduction Program

In the current debate about HRRP, the evidence tilts toward no effect or a beneficial one on mortality, says the former Director of the U.S. Office of Management and Budget.

odel for Complex Gynecologic Care Team at the Women's Health Institute

An Innovative Approach to Treating Complex Gynecologic Conditions

How the Women’s Health Institute at The University of Texas at Austin designed their clinic to provide comprehensive, team-based, and patient-centered care for women.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Hypertension Guidelines: Achieving 90% Success

Focused and innovative health systems are managing to control blood pressure for 9 in 10…

Primary Care

182 Articles

“Breaking Bread” to Combat Burnout

Can a simple dinner create community among health care providers?

Sustainable Financing for Complex Care Management…

Care management should be payer-agnostic at its core.

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now