Could more joint decision-making between patient and physician improve chronic care in the U.S.?

Accounting for nearly a fifth of its GDP annually, the United States spends more on healthcare than any other country. But that doesn’t mean every patient is getting optimal care, says a professor in Binghamton University’s School of Management.

“This country spends so much on healthcare, but we don’t get a lot for our money,” says Saligrama Agnihothri, professor of operations and business analytics. “The healthcare system in the U.S. is very good at providing options for high-level, advanced care, but very inefficient when it comes to the provision of basic and chronic care.”

According to Agnihothri, chronic healthcare (the treatment of long-lasting, incurable conditions such as diabetes, asthma, dementia, etc.) accounts for a majority of drug prescriptions, hospital admissions and doctor visits. Chronic conditions also account for the majority of deaths in the United States.

With chronic conditions accounting for the majority of resources in the nation’s healthcare system, inefficiencies work against both patients and the physicians responsible for helping them.

Agnihothri, with the help of his son, Raghav, created a new framework for managers of healthcare organizations to use when making decisions about delivery-system design, infrastructure and the incentives that motivate physicians, support staff and patients to act. Building upon and addressing gaps in the existing literature, their framework was published in a special issue of the journal Management Decision, which featured research papers focused on evidence-based management for performance improvement.

“Chronic care is very important. Conditions can often be taken care of with early detection and changes to diet and exercise habits,” Agnihothri says. “Early detection can be tough though, and most people don’t know they are developing a condition until it’s too late.”

Agnihothri says the key to making chronic care more efficient is to make meaningful interaction between the physician and patient the most important goal.

“When you have a heart attack or are in a major accident, physicians and doctors will take care of you. You don’t have a role in the treatment. But in chronic care, where treatment lies mostly in behavioral changes, you play a very active role in the treatment. Chronic care should be driven by joint decision-making between physician and patient,” he says.

But with a physician’s time being spread very thin between seeing numerous patients daily (and then filling out all the paperwork for those patients), patients typically only have an average of 15 minutes with their provider during an appointment. Agnihothri says this is not nearly enough time to have a meaningful discussion about behavioral adjustments, especially when a number of other topics need to be covered during a checkup.

The framework explores a number of evidence-based incentive systems that may influence patients, physicians and healthcare managers to buy into a system that prioritizes more personalized care.

“You need to change the entire system. In order for changes to happen, all of the stakeholders need to have the same objectives, and that is difficult to do. That is the problem in a nutshell,” he says.

Agnihothri says there are three changes to the system that could vastly improve chronic healthcare in the United States:

1. Rely more on technology: “There is no reason why some patients need to go to their healthcare provider as often as they do with the technology and apps available. We have the infrastructure, such as telemedicine, to get quite a bit of supportive care for chronic conditions without leaving our homes.”
   
2. Aim for a more holistic approach: “If you have multiple conditions, you’re probably seeing multiple physicians, and they probably aren’t all talking to each other. Your care for one condition could be contradicting care for another. With increased communication, we should aim to care for the whole person, not just individual conditions.”
   
3. Increase customization of care: “The recommended dosage for an average person may not work for every person. There is enough data available where we should be able to look at an individual patient’s needs and consider their input to adjust medication accordingly.”
   

Agnihothri acknowledges that any changes to the current healthcare system are incredibly difficult to make — especially with healthcare being such a hot-button political issue — but he says he sees encouragement in the students that he teaches.

“I’m optimistic about the future of healthcare. There are a lot of young entrepreneurs out there who have great ideas on how to change things,” he says. “I often tell my students that I hope they can be the catalyst for change in this system that means so much to all of us.”

Agnihothri’s paper, Application of evidence-based management to chronic disease healthcare: a framework, can be found here.