Patient Engagement & Physician Engagement: Not Just Buzzwords

Posted March 24, 2017

Many times treatment adherence is talked about solely in terms of the patient.

We sat down with Dr. Avinesh Bhar, MD, a pulmonary, critical care and sleep Physician practicing at Mercer University, to talk about both “sides” of comprehensive chronic care management.

The Entire Adherence Equation

For patients with chronic conditions, barriers to medication adherence come down to three common factors: cost, complexity, and comprehension of the treatment.

“As physicians, the true financial cost of treatment is skillfully hidden from the healthcare equation,” explains Dr. Bhar, who explains that in the past, consideration of cost of care was viewed as unsavory.

Contrast that to today, where it is no secret that it’s being re-examined so that our nation can alter the trajectory of health care cost.

What may surprise many to know is that today’s physician has as obligation—or rather responsibility—to consider financial harm in her decision making process when creating and tailoring a treatment plan.

Add this to the complexity of multiple medication scheduling and route of administration, and you can see why medication management is not an easy problem to solve and is quite complex.

On top of this, most patients with chronic conditions are elderly, also posing another set of “barriers” to adherence.

“Take one half tablet, three times daily, at bedtime, thirty minutes before breakfast— if these were driving directions, we would all be lost,” says Dr. Bhar. “There needs to be medication stewardship similar to antibiotic stewardship, as it certainly seems easier to start rather than discontinue a medication. Many medications are continued despite a lack of indication or effectiveness,” he says, alluding to another difficulty with multifaceted medication/treatment plans. Technology combined with behavioral support—such as MedaCheck—can help make a difference with medication management. But it is clear that part of the responsibility is also on physicians and care teams.

Comprehension & a Patient’s Ability to Self-Manage Her Health

Dr. Bhar points out that physicians have the ability to distill the list of medications to the most needed, and the most effective, for each patient. “Comprehension is an issue frequently swept under the carpet due to constraints on physician-patient time,” adds Dr. Bhar.

He explains that even with the luxury of time, the complexity of care in chronic conditions sets up a path—in many cases—for poor treatment adherence. Case in point: “A patient last week told me she had reflux just because she was discharged from the hospital on a proton pump inhibitor!”

Then what should be the objective of the care team and physician?

It comes down to improving health literacy and working to achieve patient comprehension.

“[This] will allow patients to actively participate in their own healthcare, facilitate discussions about cost and complexity, thus ‘greasing the wheels’ of chronic care management.”

If medication can become even more personalized, such patient-provider communication will clearly support adherence efforts. Personalized medicine can also mean plans can be altered based on an individual’s financial ability, her preference, and comprehension (and genetic predisposition), among other factors. “We still have a long ways to go tailor each treatment plan in that way to get to this ‘holy grail’ of comprehensive chronic care management,” says Dr. Bhar.

A part of this “holy grail” kind of a concept also involves greater engagement with all players across the medical neighborhood.

“Much of the focus has naturally been on patient engagement, however, the role of physicians as more than clinical cogs in the wheel of health care is increasingly recognized.”

For Dr. Bhar, the idea of physician engagement is a broad one, and it some ways, it can be useful to examine the idea of physician disengagement.

“There is a growing need to re-engage physicians as the status quo in health care is not sustainable. The onus is on both management and physicians to streamline operational and clinical goals. When these two goals come together, healthcare will make more sense and become less of a byzantine labyrinth for both patients and physicians.”

So what is a physician to do as they travel along the yellow brick road— one littered with skeletons of HMOs, and efforts such as Meaningful Use 1.0 and 2.0 leaving much to be desired?

Physicians in the trenches of patient care have to start considering the cost of actions: the “cost” on and for patients, their families, and patient’s communities.

“We have to justify each action taken, weather it be ordering a MRI, antibiotics, or pulmonary function test. We can ask ourselves, ‘will this change my management?’, ‘Is there a better way?’, ‘What does the evidence show?’ and ‘What would I want done if I was the patient?’” argues Dr. Bhar.

“The introduction, survival and success of ACOs and PCMHs—and other acronyms thrown at physicians—may be a matter of debate, but focusing patient care should not.”

Dr. Avinesh Bhar, MD, is an internal medicine, pulmonary, critical care & sleep Physician practicing in Macon, Georgia, at Mercer University. Find him on Twitter at @AviBhar.