Discussion on Cost of Care and Social Determinants of Health with Dr. Coin

May 7, 2019

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Dr. Wendy Coin of Family Health Centers 

First, please tell us a little bit about you and your practice

I graduated UNC Chapel Hill Medical School then  from the MAHEC Family Medicine Residency in 1993, worked in Franklin, Angel Hospital  Emergency Department for a year, then came to the Family Health Centers (FHCs) in 1995 and have been here ever since. FHCs are privately owned by the physicians and there are 3 offices now that function seamlessly as one unified practice largely thanks to our EHR integration in 2005, which was a progressive step at the time.  I served as our Medical Director for quite a few years but now am joyfully back to only patient care.

How do you approach addressing patients’ concerns about the cost of care during their visit?

I recognize that many patients have financial concerns when entering a Doctor’s office. I try to clear the air and ask patients to set those concerns aside momentarily so that we can first talk directly about their symptoms. After I assess their symptoms and what care the patient might need, then I can address their concerns regarding finances (or any other personal concerns) so that we can develop a logical plan. For example, I might elect to delay a non-urgent lab test to accommodate the patient’s financial situation. Most patients are financially concerned and experience difficulty paying for specialty medical care now, not just Medicaid/Medicare patients. I’ve started encouraging them to redirect their concerns to their representatives and legislators. We also try to contract with as many insurance companies as we can so that patients don’t have to transfer doctors for financial reasons. Good healthcare comes through having consistent primary care.

What inspired you to start asking patients about their financial concerns and other social determinants of health and when did you start asking patients these questions?

I want to be happy with how I’m spending my day and it brings me joy to get to know people better and understand their concerns. I still see a lot of patients, but I’m in a fairly good balance. I might have a somewhat lower income than other physicians  because I don’t see 30 patients a day, but it brings me more happiness in my job. I recognize that’s not possible for all physicians, but I have the opportunity to limit my schedule to 18-23 per day now.. The majority of our patients are chronically and severely ill. If we had the opportunity to spend a full hour with each of those patients, we could probably do a better job keeping them out of the hospitals. I do the best I can to see my patients regularly and spend as much time with them as I can. If physicians has the opportunity to spend much more time with the chronically ill patients, , we could save so much on healthcare costs, but that’s not the reality of our system right now. I do the best I can within the current system we have.

How do you think addressing these factors influences patient outcomes?

Most patients that come in are tired and unhappy and wanting to feel better which can lead to the over-prescription of pain medications, sleeping pills and antidepressants. However, by asking them more questions about their life outside of their symptoms, you might discover they can’t afford the house they’re living in, they’re working three jobs, they don’t get time to be active or outside, etc. It’s no surprise they’re tired and unhappy. I think that we can influence better patient outcomes by spending more time with them. I think that’s where the real improvement in healthcare could come from.

Do you have a specific example of when a financial or other social determinant of health was particularly relevant/impactful for a patient’s outcome?

I could give at least one example a day. One of my most complex patients was scheduled to see me today and I spent 15 minutes reviewing his chart this morning so that when he came in I would know where we needed to start. I noticed that Since my last appointment , he had not seen any of his specialists as planned,  and the only new information was a note from a Humana FNP home visit which concluded that he “needed to schedule an appointment to see his primary physician.” At the last appointment with me, my Clinical Pharmacist and I personally called Humana Case Management and Humana’s mail order pharmacy in an attempt to address his need for aggressive assistance in affording and understanding both his medications and visits with specialists. We were with the patient and on the phone for 1 hour. In 6 months, nothing had really happened to improve his health. A lot of effort was put in and it resulted in a failure. He didn’t show up for his appointment and a lot of these issues are out of my control. I don’t know if his phone was not working or if he just could not afford his copay today. Good support systems are not in place to help people with complex medical problems.

Medicine is a service industry, but I also think it’s innately unpredictable what services a person may need before arrival at the appointment with a doctor. I am sure this frustrates people. Health care should NOT cost money. The philosophy that people overuse health care when there is not financial disincentive is just not true. We get so many calls before a visit asking “what will the visit cost?”.  I think doctors and patients need to have the freedom to spend the time together needed to get the care they need. Really frustrating for everyone.

Do you think all providers should feel responsible to address financial and other social determinants of health? Why or why not?

I think so. It is part of FHC’s intake questionnaire now, but it is challenging to start truly addressing those things. The one luxury of being a long-term doctor with the same patients is that you develop relationships and a better understanding of your patients. With time in practice also comes mastery of your skill which makes things easier. Understanding your EHR is also key. If a physician has not mastered their EHR or if the EHR is malfunctioning, they are distracted. Medical care has gotten so complex that you have to build up external support systems to help. For example, we now have a clinical pharmacist who can immediately help us which has been great. They can help me with things regarding new or unfamiliar medications.

What advice would you give to a Physician wanting to begin offering a similar level of comprehensive care?

One incentive to engage your patients on their issues outside of the exam room is that it brings a lot of joy back into your practice. I would also encourage Physicians to focus on pre-visit chart preparation. It takes me about an hour in the morning to review everyone’s info if I’m seeing my typical load of 18-23 patients per day. If you’re prepared for your day and not entering your appointments “cold”, you’ll have more time to dive in deeper with each patient.

Dr. Coin encourages her fellow Physician colleagues to advocate for a universal, comprehensive Single-Payer National Health Program. Click here to learn more.

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