Study says physicians need better tools for chronic care management

Chronic Care ManagementThe vast majority of primary care physicians don’t have the time or tools to adequately address the needs of their patients with multiple chronic conditions, leaving some patients to struggle with health-related social and behavioral issues on their own, according to new research from Quest Diagnostics.

The findings are based on an independent survey commissioned by Quest of primary care physicians (PCPs) and adult patients 65 years and older who have multiple chronic conditions and are Medicare beneficiaries. Care for chronic conditions, such as hypertension, cancer, arthritis and diabetes, accounts for an estimated 71% of all healthcare costs. Three in 4 Americans over the age of 65 have 2 or more chronic health conditions.

The analysis suggests that the traditional medical model – an annual office visit with a primary care physician – is insufficient to care for patients with complex health issues, and PCPs know it. It also suggests many patients do not associate social, behavioral and other factors with healthcare, and therefore fail to discuss these issues with their primary physician.

The report, “Hidden Hazards: Closing the Care Gap Between Physicians and Patients with Multiple Chronic Conditions,” is available for download.

“Two in 3 Medicare patients have multiple chronic conditions that require ongoing medical attention and substantial resources from the healthcare system,” said Jeffrey Dlott, MD, Medical Director for Chronic Care Management, part of the Extended Care offerings of Quest Diagnostics. “Our survey findings show that PCPs desperately want to deliver high quality care, but they feel they are failing their patients with the most complex care needs. Patients approve of their primary doctors’ care, but are not sharing a litany of social and behavioral issues that, if not resolved in time, could escalate into serious health matters. For some patients, healthcare feels like a solitary journey.”

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Among the key findings:

Physicians are too time-constrained to probe for complex care needs:  Nearly all physicians (95%) said they entered primary care to care for the “whole patient.” Yet, 85% say they are too pressed for time to address complex clinical issues, and 66% say they don’t have time to address social and behavioral issues such as loneliness or financial concerns that could affect their patients’ health. Only 9% of physicians are very satisfied that their Medicare patients with multiple chronic conditions are getting all the attention they need to care for all medical issues.

Patients may not recognize or share all health-related concerns: While physicians worry about care gaps, more than 9 in 10 patients (92%) surveyed are satisfied they are getting all the attention they need to deal with their multiple medical issues from their PCP.

Yet, the survey findings suggest patients may not recognize or communicate all health-related issues that may impact their care and health. The number one worry cited was “getting another medical condition” (43%), and the second was “being a burden on my loved ones” (32%). Yet, 2 in 5 patients say they do not tell their doctor about loneliness, isolation, transportation barriers and other factors that influence health. Many admit they “struggle to stay on top of my health issues and need more support.”

The findings are significant as approximately 80% of health outcomes are related to factors outside the traditional realm of healthcare delivery, including social, economic, and behavioral.ii

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Physicians view medication nonadherence as a major concern: Eighty-eight percent of PCPs say they are concerned patients with multiple chronic conditions are not taking medications as prescribed. Patient survey responses suggest this concern is valid: Nearly one-quarter (23%) of patients say there have been times when they forgot to take some of their medications or took the wrong ones. Yet, less than 1 in 10 (8%) patients reported medication adherence as a concern.

Other research finds that patients with chronic conditions account for 83.1% of all prescriptions in the United States,iii and nonadherence is associated with approximately $100-$300 billion of U.S. healthcare costs annually.iv

PCPs and patients see value in chronic care management (CCM), but hurdles limit adoption: Most PCPs (87%) see value in CCM services to help monitor their CCM patients and 90% say CCM medication monitoring would provide “peace of mind.” Yet, only half (51%) surveyed know that CMS may reimburse for CCM for Medicare beneficiaries with multiple chronic conditions, and only 1 in 4 (23%) have implemented CCM, citing complexity of coding (43%) and burdensome paperwork (37%) as key barriers. Nearly half of patients (45%) say they would be likely to access CCM servicesv; that number jumps to 58% when informed that it is a covered benefit through Medicare.

Patients in Medicare are eligible for an Annual Wellness Exam. In January 2015, the Centers for Medicare & Medicaid Services (CMS) began reimbursing for CCM services for Medicare beneficiaries with 2 or more chronic conditions to support patients in between physician visits. CCM services are non-face-to-face services, such as electronic and phone consultation, and often focus on medication management, coordinating visits with hospitals and other providers, personalized guidance on setting health goals, and 24-hour access to care providers.

Participation in CCM programs by PCPs has been slow, although CMS estimates 70% of Medicare beneficiaries—roughly 35 million people—would be eligible.

“Physicians are open to adopting CCM, but it has to be easier to implement and a trusted extension to one’s practice,” said Katherine A. Evans, DNP, FNP-C, GNP-BC, ACHPN, FAANP, immediate past president, Gerontological Advanced Practice Nurses Association (GAPNA).  “The Quest research also shows that older patients are worried about receiving new medical diagnoses and being a burden on caregivers. Physicians may explain to patients that CCM can help illuminate emerging health issues before they turn serious, so they can lead independent lives longer. With improved monitoring, these patients may expect a better quality of life.”

Quest commissioned the study to uncover insights into gaps in care for older patients with chronic conditions, and opportunities to better manage these populations with Chronic Care Management and related services. In recent months, Quest Diagnostics has begun to offer “Extended Care” services, such as Chronic Care Management and, through its recent acquisition of MedXM, at-home risk assessment. These services help providers and health plans close gaps in care and better manage populations outside the traditional physician setting. For more information, please visit, or click here to download the full study.

With Chronic Care Management being a Quest product, we have a successful process in place to provide our RNs timely access to Quanum EHR so that they may contact the patient within 24 hours of the order being placed (weekends and holidays excluded). For more information on the Quanum EHR, contact us at 1.888.491.7900.

The survey was conducted by Regina Corso Consulting on behalf of Quest Diagnostics, February 2-18, 2018. A total of 801 study respondents, comprised of primary care physicians who care for Medicare patients with multiple chronic conditions, and adults 65 and older with patients with multiple chronic conditions were surveyed. Forty-seven percent of the PCPs claim to participate in an accountable care organization. Respondents completed online surveys regarding perceptions and experiences with chronic care and chronic care management services. Strengths of the research include the specificity of respondents’ medical state and nationally representative data, while limitations include self-reported data and a lack of direct comparability between study populations.

i Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple Chronic Conditions Chartbook. AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality. April 2014.
ii Health 3.0. Addressing non-clinical care factors in health outcomes. Available at
iii Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple Chronic Conditions Chartbook. AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality. April 2014.
iv Iuga AO, McGuire MJ. Adherence and health care costs. Risk Management and Healthcare Policy 2014;7:35–44
Viswanathan M, Golin CE, Jones CD, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med 2012;157:785–95.
v Described as a service “their doctor could provide where a nurse or nurse care coordinator would call and talk with them about their conditions, make sure they were taking medications as prescribed and answer questions they might have and then update their doctor.”

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