Improving communication between patients and their providers is crucial to reforming the health care system to better meet patients' needs and improve patient outcomes. Strategies such as shared decision making and patient-centered medical homes, which encourage patients to play an active role in their health care and rely on strong patient-provider relationships, are founded on trust and communication. Yet recent data from the Health Reform Monitoring Survey (HRMS) suggest that providers could be having more conversations with their patients about issues surrounding their health care. Patients who have low incomes and have forgone needed care because they couldn't afford it are often at risk of having their concerns go unaddressed by providers. In this blog post, we present findings from the HRMS that demonstrate the need for progress in patient-provider communication and suggest strategies for improvement.
Patients Rate Their Health Care And Providers Highly But Gaps In Communication Exist
In the September 2016 round of the HRMS, most nonelderly adults gave high ratings for the health care they received, and most had high levels of trust in their usual providers. On a scale of 0 to 10, in which 10 indicates complete trust, the median rating for health care and for trust in one's provider was 7–8. The most common response for provider trust was 9–10 (Exhibit 1), but almost one-third of adults from minority racial/ethnic backgrounds rated their trust in their provider below the median of 7–8, compared with about one-fifth of white, non-Hispanic adults (data not shown).
Exhibit 1: Nonelderly Adults' Ratings Of Their Health Care And Their Trust In Their Usual Providers
Source: Health Reform Monitoring Survey, quarter three, 2016. Notes: Sample for rating of health care is limited to adults who received care in the past 12 months. Sample for rating of trust in provider is all nonelderly adults. We combined two versions of a question on trust (trust your provider and trust your provider with your health care) and three versions of a question on rating health care (rate your health care, rate the quality of your health care, and rate how well your health care met your health needs). Usual provider is defined as the provider seen most often for care.
Most adults felt comfortable talking with their usual providers about potentially sensitive issues, including health and health care challenges, concerns about the cost of health care, and events in their lives that caused worry or stress (Exhibit 2). Nearly all adults (90.2 percent) were comfortable talking with their provider about at least one sensitive issue, with the highest levels of comfort reported for health and health care challenges (88.1 percent) and lower levels of comfort reported for life challenges and stresses (81.1 percent) and concerns about the costs of health care (71.1 percent). However, patient-reported comfort also varied across demographic groups. White, non-Hispanic adults were more likely to say they were comfortable talking about each of these issues than adults of other racial/ethnic backgrounds (data not shown).
Exhibit 2: Share Of Nonelderly Adults Who Were Asked About Potentially Sensitive Issues By Their Usual Provider And Own Comfort With Conversations About Potentially Sensitive Issues
Source: Health Reform Monitoring Survey, quarter three, 2016. Note: Sample is limited to adults who saw their usual provider at any time in the past 12 months.
Gaps also appear in the frequency of provider-initiated conversations about sensitive issues. Overall, providers asked about these issues fairly often; about 61.2 percent of patients reported that their usual provider had asked about at least one potentially sensitive issue over the past 12 months. Providers asked most often about life challenges and stresses (53.2 percent) and health and health care challenges (41.6 percent). They were much less likely to ask about concerns with the costs of health care; only 15.9 percent of adults reported that a provider asked them about cost issues. These conversations were relatively rare even when providers addressed patients who are more likely to struggle with the costs of health care: low-income adults and adults who reported going without needed health care over the past year because they could not afford it (Exhibit 3).
Exhibit 3: Share Of Nonelderly Adults Who Were Asked About Potentially Sensitive Issues By Their Usual Provider, By Selected Characteristics
Source: Health Reform Monitoring Survey, quarter three, 2016. Note: Sample is limited to adults who saw their usual provider at any time in the past 12 months.
Cause For Concern
While consumers provide high ratings for their health care and health care providers, the relatively low frequency of provider questioning on sensitive topics and the racial/ethnic disparities in ratings, trust, and comfort discussing sensitive issues may indicate the needs of some patients are not being met and would be improved through better communication. The lack of communication about costs is notable because health care affordability is a persistent problem for many US families. It is unclear why these conversations are not occurring. Providers may not know enough about the costs of care to discuss them, and patients may not trust their providers to talk about those costs or may view providers as one of the causes of high costs. Indeed, low-income adults and adults with unmet needs for health care because they cannot afford it report lower levels of trust in their provider's ability to inform them about the costs of different treatment options, compared with other adults. Patients who can't afford their health care—or don't know the likely costs of the treatment options available to them—may forgo needed treatment and preventive care.
Improving Patient-Provider Communications
We already have some tools to improve communication between patients and providers. First, the US Preventive Service Task Force could include questions about health care costs and other sensitive issues in its recommendations for the scope of a standard primary care visit for all patients, similar to what has been done for domestic violence and depression screenings. By codifying these provider-initiated conversations in the primary care visit, we would expect to see more patient-provider dialogue and, hopefully, improved treatment adherence and health outcomes for patients. Second, discussion of sensitive issues could be built into the medical school curriculum and taught in targeted physician communication trainings. Doctors who are taught how to address cost and other nonmedical concerns are likely to carry those skills throughout their careers, leading to better relationships with patients. Finally, medical practices could allow for longer appointment times. Only 14 percent of physicians say that they have all the time they need with patients to provide the highest standards of care, and nearly half say that their time with patients is often or always limited. Increasing appointment times could allow for deeper and more candid conversations about the patient's health and all the factors that affect it. These three strategies are promising first steps toward rectifying persistent disparities in trust and communication between patients and providers.
Authors' Note
The authors' work was funded by the Robert Wood Johnson Foundation.
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