Physicians say time and money constraints, other barriers hinder care for dementia
Built-in limitations of the health-care system in the United States, such as time and reimbursement constraints, inhibit the ability of primary care doctors to best meet the needs of dementia patients and their families, according to a new study by researchers at UC Davis Health System.
In a study now available in the online edition of the Journal of the Society of General Internal Medicine, the researchers found that physicians often feel challenged in caring for dementia patients, especially those who are more behaviorally complex. Constraints that are intrinsic to the contemporary practice of medicine may lead to the delayed detection of behavioral problems, a reactive as opposed to proactive management of dementia, and an increased reliance on treatment with drugs instead of psychosocial approaches.
However, short of major organizational changes, the researchers believe there are steps that individual primary care physicians can take to help dementia patients and their families.
Based on interviews with 40 primary care physicians in Northern California, the study assessed a variety of practice constraints, including low reimbursements, lack of teamwork and rushed office visits. The principal investigator is Ladson Hinton, associate professor in the UC Davis Department of Psychiatry and Behavioral Sciences.
"Our study highlights layer after layer of issues that are contributing to a growing public health crisis where patients with dementia and Alzheimer's are concerned," said Hinton. "The present system is just not set up to meet their needs. These structural constraints are clearly very important, but we found that physicians often omit simple interventions that may help families find help for behavioral issues, such as a referral to the local Alzheimer's Association or the National Institute on Aging's Alzheimer's Disease Education and Referral Center, at (800) 438-4380."
The interviews identified these four major constraints to providing good care to people with dementia and their families: Lack of sufficient time, low reimbursement, difficult access and communication with specialists and social service agencies and Lack of an interdisciplinary team approach.
— Ladson Hinton, UC Davis associate professor and study principal investigator
The physicians interviewed said it was difficult to care for persons with dementia during the standard 15 minutes typically allotted for appointments. This lack of time and the subsequent failure to systematically assess behavioral problems may delay their detection and management until a time of crisis, according to the study.
Insufficient time, overwhelming workloads and unfamiliarity with dementia-related problems inhibited some physicians' desire to see patients with dementia.
"We are all trying to keep our heads above water," said one doctor. "These people (patients with dementia) do take a lot of time and energy. Sometimes … you just don't want these people in your practice because a 15-minute visit turns into much more than that."
The time constraints were noted across different types of practice settings. In large group practices, clinicians are pressured to practice in a "time-efficient" manner and have little control over scheduling. In smaller group and solo practices, clinicians had more flexibility but still felt compelled to see patients quickly because of economic pressures.
One of the interviewed physicians said that the lack of time and other barriers to good care leads to "reactive care" that may contribute to family burnout and, ultimately, to the patient's institutionalization. In addition, the study states, "Clinicians may rely more on medications if they are less familiar with psychosocial approaches or perceive these as potentially more time-consuming."
An over-reliance on drugs has important public-health implications, the study says, because recent research calls into question "the efficacy and safety of psychotropic medications for older adults with dementia, making non-pharmacological approaches more attractive from a risk-benefit perspective."
Low reimbursements, access issues
Interviewees also noted that the reimbursement process for physicians inaccurately reflects the time required to care for patients with dementia. They cited limitations of "relative value units," or RVUs, a nationally standardized scale that is used by Medicare and many health insurance companies, and is intended to reflect the time, technical skill and mental effort required of a provider to perform a service.
"When you deal with a patient who has dementia … as well as hypertension and diabetes, it's a lot more complicated than the intact 50-year-old hyperintensive diabetic, but the reimbursement is the same," said one physician.
Because of their relative unfamiliarity with dementia, primary care physicians often seek consultations with specialists such as neurologists and psychiatrists, but just as often find it difficult to do so "because of limited availability and cumbersome referral processes," the study states. Access to specialists is complicated further by certain insurance plans in which mental health benefits are "carved out" to a mental health care manager. Under this system, patients are required to set up their own appointments.
"I have not had very many patients who have been successful in getting into the system, and they have to be very persistent," said one physician. "It is really a harsh system the way it is set up."
Better education of and support for families to be more proactive in making requests for appropriate treatments is one of the study authors' suggestions for improving care for patients with dementia. Improvement in care also might be achieved via physician education on the management of behavioral problems and availability of community services and agencies. In larger practices, dementia care teams could be established to help manage more complicated cases. Improved medical coding that more accurately reflects time spent with patients and families also could help, the study states.
"More ambitious" reforms include increasing reimbursement for treating patients with "substantial behavioral complexity," and establishing incentives for delivering more comprehensive, albeit costly, care upfront to delay costlier, subsequent outcomes, such as institutionalization.
Without improvements, "dementia in primary care settings is likely to continue to fall short of standards of good care," the researchers state. "As a result, persons with dementia, particularly those with difficult behavioral issues, will be unnecessarily exposed to psychopharmacological drugs and increased risk of institutionalization."
Among the study's limitations noted by the authors was its reliance on physician perspectives rather than those of other stakeholders, such as families. Also, the surveyed physicians were in a single geographic region and not representative of physicians nationwide.
However, the study stated "that despite this geographic limitation, physicians were practicing in a variety of treatment settings, making it more likely that the findings will generalize across settings."
At UC Davis, Hinton's co-authors were Yvette Flores, professor of Chicana/o Studies; and Richard Kravitz, a professor in the Department of Internal Medicine and the Center for Health Services Research in Primary Care. Other co-authors were UC San Diego psychiatry professor Carol Franz; UCLA School of Medicine researcher Geetha Reddy; and UC San Francisco medical anthropology professor Judith Barker.
The study was funded with support from the National Institute on Aging and the UC Davis Alzheimer's Disease Center, which conducts research and coordinates care for patients who have been diagnosed with Alzheimer's disease and other forms of dementia.