Millennial Preferences on Alternative
Practice Management Models
IndustryView | 2014
Recently, three unique practice management models have been increasing in popularity: shared decision-making, which is being piloted in multiple departments at UCLA; open notes, the use of which is expanding across the country and shared medical visits, being offered by a number of practices that has doubled since 2005. These models are intended to increase patients’ engagement with their medical care—but are they effective?
To find out, we at Software Advice created an online survey. We collected responses from 385 random patients within the United States—and, as it turned out, the vast majority (297) were between the ages of 18 and 35, a group also known as “millennials.”
While engagement is an issue for patients of all ages, millennials have been identified as a group that is especially difficult to please in a healthcare setting, often delaying seeking care for a medical issue because they view the process as inconvenient and irritating. Thus, this report will focus only on millennial respondents, in order to narrow in on what the second-largest and most diverse generation today wants from its medical care.
Although the term “patient engagement” has been rightfully criticized for being vague and ill-defined, a 2013 study showed that 60 percent of millennials are familiar with the term. We define it here as a patient feeling involved in their medical care and connected with the decisions being made about their health.
Of patients surveyed, a strong majority (77 percent) responded that their doctor or other healthcare professional could have done more to improve their level of engagement during their last medical visit. Only 23 percent felt that their physician sufficiently engaged them in their medical care.
When asked what their healthcare provider could do to improve their engagement, almost 25 percent of patients surveyed said their physician providing more treatment options was key to improving their engagement. Explaining the care given or treatments prescribed was another top draw, with 15 percent of respondents indicating that more details would help them to be more engaged.
Another 20 percent of patients pointed towards long wait times and brief appointments as a key factor in their involvement in their care, seeking more face time with their doctor.
One anonymous respondent said that “the visit felt very rushed, like [the doctor] was on his way out”—which indicates more than just a displeasure with brief appointments. Part of better patient engagement, therefore, may lie in improving communication with patients and making them feel their provider is fully present during the appointment.
Steve Wilkins, MPH, Author of Mind the Gap and Founder of the Adopt One! Challenge aimed at improving physician-patient communications, suggests another reason for why medical appointments feel rushed: the patient’s perception of health care workers and their own symptoms.
“Even though the doctor may not be rushed,” he asserts, “we hear it all the time -- doctors are too busy, too important, there are sicker people out there.”
Interestingly, physicians offering more treatment options and better explaining the care they provide are key components of the shared decision-making model. And more face time with doctors has been cited by participants as a benefit of shared appointments. So, could improvements in patient engagement begin with the implementation of one of the practice management models we investigated?
We asked respondents to rate their likelihood to take advantage of the three “alternative” practice management models presented, if their provider offered them. We defined these models as follows:
Over three-quarters (76 percent) of patients reported that they were “extremely” or “very likely" to use a shared decision-making model of care.
At UCLA, shared decision-making has been implemented in the urology department since 2012. Specifically targeted at men with prostate cancer, participating patients are asked to take a 15-minute survey about their preferences for care, which is forwarded to their physicians prior to the appointment.
Dr. Christopher Saigal, professor and vice chair of urology at UCLA, describes the move towards this model of care as originating from a need to improve the use of evidence in making decisions as well as overall decision quality.
“These days in medicine there’s an incredible proliferation of treatment options. But because there are so many options,” he explains, ”the benefits and the risks of these options are of different impact to patients, and there’s no one choice for everyone.”
Although the program is still relatively new, Dr. Saigal reports improvements in patient satisfaction, and states that 95 percent of comments collected from participating patients were positive.
An additional 61 percent of patients surveyed were “extremely” or “very likely" to use open notes. Shared notes have been increasingly popular since the introduction of secure online patient portals, which make it easy for physicians to transmit medical records without needing to photocopy a file.
Conversely, shared appointments were almost unanimously unpopular, with 60 percent of patients responding that they were “not at all likely” to give them a try.
Next, we wanted to discover if having a chronic disease would have an effect on patient interest in these practice management models. (Note that patients in the sample discussed are those who responded “yes” or “unsure” when asked if they had been diagnosed with a chronic disease; these findings may not be indicative of the population as a whole.)
Chronic disease patients were overwhelmingly in favor of shared decision-making and open notes—99 percent and 97 percent of these patients in our survey, respectively, were at least “moderately likely” to utilize these offerings if their doctor provided them.
Since patient involvement and self-management has been shown to be crucial to improving outcomes for patients with chronic diseases, adopting one or both of these alternative models could have an even greater positive impact in practices that focus on the treatment of chronic diseases.
Unsurprisingly, a majority (72 percent) of patients surveyed were “extremely” or “very concerned” about privacy during shared appointments. However, they were significantly less uneasy about privacy under the other alternative models. Over half were “minimally” or “not at all” concerned about privacy with open notes and shared decision-making: 55 percent and 78 percent of respondents, respectively.
Reassuring patients of privacy is key for physicians recruiting patients to shared appointments. All patients involved are required to sign a HIPAA-certified confidentiality agreement, and healthcare professionals (which may include doctors, nurses and other care team members) typically remind patients of confidentiality at the beginning of each appointment.
Dr. Edward Shahady, a family physician who practices in Jacksonville, Florida, has been conducting shared appointments for the past eleven years with groups of diabetic patients; he also teaches group facilitation skills to physicians who want to lead such appointments. In this work, he’s noticed that both doctors and patients had concerns about privacy.
Establishing a trusting environment and having a doctor trained in leading group visits, he explains, is key to successful shared appointments. For patients who are concerned about privacy, he recommends reminding them that they don’t have to share anything, and are invited to sit and listen to the group.
“The value of having other people there is that you learn from them,” he explains, going on to add that members in the group are often from within a patient’s community. This makes them more equipped to offer fellow patients advice on, for example, where to purchase healthy foods or safe spaces to exercise.
After discussing privacy concerns with patients, Dr. Shahady observed that 70 to 80 percent of them attended at least one visit. To date, studies have not yet established if shared appointments are successful at improving patient outcomes. However, Dr. Shahady evaluated 300 patients who attended shared appointments and found they were overwhelmingly satisfied: an average of 4.8 on a scale of one (lowest) to five (highest).
When asked how they thought these practice management models would impact their levels of engagement and satisfaction with their medical care, patients continued to vote in favor of shared decision-making and open notes. A combined 83 and 75 percent, respectively, reported that shared decision-making and open notes would “significantly” or “somewhat improve” their involvement. Anticipated levels of satisfaction with both models was also high, at 84 percent and 77 percent, respectively.
The use of open notes has been rapidly expanding over the past two years, with large hospital systems such as Kaiser Permanente, Geisinger and Beth Israel Deaconess recently giving their patients digital access to their medical records.
A 2012 study of patients at Beth Israel Deaconess in Boston, Geisinger Health Systems in Pennsylvania and Harborview Medical Center in Washington investigated several questions surrounding open notes, including impact on physician workload and whether open notes could improve patient care.
Dr. John Mafi, a fellow in general internal medicine at Beth Israel Deaconess, spoke positively about the results of the study and the effects on patient involvement.
“The overall message was that patients have a lot of enthusiasm about it and reported clinical benefits,” he explains. “[They had a] better understanding of the treatment plan [and] took their medication regularly, and there was little impact on the workflow of family physicians.”
Seventy-seven to 87 percent of patients reported that being able to read their doctor’s notes helped them feel more in control of their medical care. Additionally, 60 to 78 percent indicated that they were more likely to take their medication regularly after gaining access to their medical records.
Patients with chronic diseases reported that shared decision-making and open notes would have a similar impact in improving their levels of engagement and satisfaction.
Fifty-six percent of respondents were male and 44 percent were female. Sixty percent of respondents said they visit a doctor between one and three times per year, and 80 percent did not have a chronic disease.
All three practice management models—shared decision-making, shared appointments and open notes—were designed to improve patients’ involvement in their care as well as satisfaction with their treatment, their healthcare professionals and their personal health outcomes. Implementing these models is a personal decision for each physician, but is one that shouldn’t be made without an understanding of the wants and needs of the populations they treat.
Our data suggests that patients are interested in using these models to improve their engagement and deepen their understanding of their personal health. By adopting one of these practice management models, providers are better equipped to meet their patients' physical and emotional needs.
To find the data in this report, we conducted a 21-day online survey of 10 questions, and gathered 385 responses from random patients within the United States. We then filtered the data to only include those respondents between 18 and 35 years old, giving us 297 total responses. The questions were worded to ensure that each respondent fully understood their meaning and the topic at hand.
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