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Patient-Centered Physician Selection: A Necessary First Step for Accountable Care
Brian W. Powers, BA, and Sachin H. Jain, MD, MBA

Patient-Centered Physician Selection: A Necessary First Step for Accountable Care

Brian W. Powers, BA, and Sachin H. Jain, MD, MBA
There is a notable gap in our system-wide efforts to promote accountable, patient-centered care: physician selection. The past decade has borne witness to significant advances in reorienting the processes and experiences of care around patient preferences and values, but the same level of focus has not been directed to helping patients identify the best physician for their needs.

Instead, our prevailing approaches to matching patients with physicians remain largely agnostic to variations in patient preferences, tethered to the traditions of peer recommendation and reputation-based referral. Even recent efforts to bring more transparency and consumer choice to healthcare decisions focus primarily on costs and outcomes,1 and neglect other domains of the patient experience.

This eschews a growing understanding of the divergent priorities many patients have when selecting a physician. Some patients place a premium on clinical reputation and technological advancement, while others are concerned more with measures of quality and value. These preferences are layered on top of additional dimensions as varied as communication style and cultural appropriateness.

Appreciating and acting on this heterogeneity is essential to improving patient ability to interact with the system and identify clinicians that best fit their needs and preferences. Strengthening the attention to patient preferences in this critical first step of a patient’s healthcare experience is critical if patients are going to become engaged partners in their care and form strong therapeutic alliances with their physicians. As accountable care, value-based purchasing, and other new models of care delivery and financing intensify our focus on patient-centered care and longitudinal relationships with physicians, it is necessary to improve the healthcare system’s capacity to match patients with physicians who fit their specific needs, preferences, and values.

In this perspective, we draw on the insights from research into patient preferences to propose a framework for understanding and organizing the information necessary to successfully match patients and physicians. Specifically, we outline 5 factors that should be considered when matching patients with physicians, and provide examples of the information and attributes that are important to consider within each factor.

1. Communication and decision making. Communication and decision making anchor the patient-physician relationship, and patient preferences in these areas vary considerably. Physician communication style and the tone of patient interactions, inclusiveness of the patient in decision-making, and attitudes and approaches to uses of clinical evidence are all important variables to consider when selecting a physician. Clinical measures of individual physician performance or survey data from other patients can be important supports to patient choices in this area.

2. Therapeutic approach. For many elective, “preference-sensitive” conditions, the aggressiveness and intensity of treatment vary among physicians.2 These are precisely the procedures for which patients spend the most time trying to identify the right physician, and it is important that patients understand with clarity the therapeutic options favored by their physician-of-choice. Similarly, a physician’s willingness to provide complementary or alternative therapies, along with his or her use of new technologies or investigational drugs and procedures, are important factors of consideration in this area.
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3. Social and cultural appropriateness. Patients should be matched with physicians who can deliver care that is consistent with their social, cultural, or religious preferences. For example, patients from historically disadvantaged or marginalized groups are often more comfortable working with physicians with a special aptitude for or interest in working with those groups.3 Other factors many patients will find important to consider are nationality, ethnicity, or fluency in their preferred language.

4. Cost and value. Economic considerations have a profound effect on healthcare-seeking and -utilization activities.4 As out-of-pocket deductibles rise and patients increasingly bear the costs of care, appropriate financial data, such as expected or estimated out-of-pocket costs, will be key variables to consider in choosing a physician.

5. Practice environment. The attributes of the system within which a physician practices have a profound impact on a patient’s experience with his or her physician. Patients are sensitive to system characteristics such as wait times, the use of patient portals, physician use of electronic health records (EHRs), and the care delivery model in which the physician operates (eg, medical home). Many patients—especially patients with complex illnesses—are especially cognizant of the extent to which clinical interactions across an extended delivery system are coordinated.

This framework is intentionally comprehensive and, in many cases, attributes of clinicians and patients will have relevance across the 5 categories. Patient preference will govern the relative importance of each dimension and its attributes; aligning a patient with the right physician requires information across all of these dimensions. Table 1 outlines preferences of 3 sample
patients to demonstrate the profound heterogeneity that must be considered and managed if patients are to be able to select physicians aligned with their unique needs, preferences, and values.

True patient-centeredness will only emerge when we acknowledge this reality and build the tools, systems, and strategies to understand and manage this heterogeneity. Fortunately, there has been a dramatic influx in the availability of the data needed to populate the various components of this framework. Patient groups and societies sometimes offer direction on choice of provider and therapy. Commercial and government websites such as Physician Compare offer information on patient experience and attributes such as communication style and cultural  appropriateness. Commercial insurers are releasing tools that allow patients patients to receive tailored, real-time estimates of out-of-pocket expenses for different providers. Multi-stakeholder organizations such as the National Committee for Quality Assurance and the Healthcare Information and Management Systems Society have information on system-level factors such as EHR adoption and disease management capabilities. Importantly, certifications from groups like the Joint Commission and data made public by private payers and Medicare can yield information on condition-specific outcomes.

With growing quality, the infrastructure and information exist to move toward a more patient-centered approach to physician selection. But the information is siloed, housed in myriad sources that are hard for patients to navigate and even harder for them to integrate. Helping patients find the right physician requires integrating existing data sources and providing patients with the information they need to select the right physician for their needs. The responsibility for making available these integrated resources will fall on accountable care organizations, physician groups, employers, governments, and patient groups, all of whom share an interest in enabling patients to make sound decisions and begin their healthcare experience by identifying the best physician for their needs.

“A New And Emerging Concept” in Care

In an interview with Evidence-Based Oncology, Sachin H. Jain, MD, MBA, lecturer in healthcare policy at Harvard Medical School, and chief medical information and innovation officer at Merck, said, “Characterizing the physicians and their approaches to practice is quite important.” The thought is that the physician and the patient must fit well together, for which efforts must be
made in the clinic and by the institution. Citing the example of Memorial Sloan Kettering Cancer Center, Jain said, “The website has information available with regards to an individual physician’s
practice, the type of patients they see, etc. These are both subjective and objective attributes, but are valuable to patients in physician selection.” Jain went on to add that “patient-centered physician selection” is a new and emerging concept that will need a lot more work to be fully implemented.

Although he sees value in using patient liaisons or care navigators in the process, Jain thinks the liaisons are being utilized as “patches between the physician and the patient, since the  physicians are always time-crunched. What I’d like to see is a seamless system.” On the role of a patient’s family members in the process of physician selection, Jain said that the family “can be very involved in identifying patient preferences.” Citing his own family as an example, he noted, “My sense of care is very different from that of my parents. The patient’s
family, though, can facilitate communication and help the patient’s views or goals reach the clinician or the doctor.”

The article also alludes to physician awareness of the patient’s cultural background. According to Jain, acknowledging that differences exist would be a step in the right direction. “We, as physicians, are not necessarily reflective of everyone, and that needs to be realized. Opportunities exist to enrich our understanding of our patients’ individual preferences and needs through
conversation. The primary goal, therefore,” he concludes, “is communication.”
References

1. Huckman RS, Kelley M. Public reporting, consumerism, and patient empowerment. N Engl J Med. 2013;369:1875-1877.

2. Institute of Medicine. Patients Charting the Course: Citizen Engagement in the Learning Health System. Washington, DC: National Academies Press; 2010.

3. Chen FM, Fryer GE Jr, Phillips RL Jr, Wilson E, Pathman DE. Patients’ beliefs about racism, preferences for physician race, and satisfaction with care. Ann Fam Med. 2005;3(2):138-143.

4. Manning WG, Newhouse JP, Duan N, Keeler EB, Leibowitz A, Marquis MS. Health insurance and the demand for medical care: evidence from a randomized experiment. Am Econ Rev. 1987;77(3):251-277.
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