Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 2. Difficulty Communicating Symptoms and Needs


Impairments can make it difficult for seniors to communicate with their providers, and these difficulties can compromise the delivery of effective care. In addition, many beneficiaries in our sample have low levels of education (Table II.4), which could impede their ability to understand written instructions. These characteristics must be addressed by organizations that want to serve high-risk seniors.

The focus-group and survey data suggest that seniors and physicians may view communication issues differently. Physicians in our focus groups saw the issue in terms of whether they had enough time to spend with patients who had complex and multiple needs. The seniors in the survey generally reported being satisfied with their ability to communicate with their providers, but those in our focus groups did report some problems.

Focus-group physicians, particularly those in the group model organizations, tended to report communication problems due to short length of office visit appointments, which are generally scheduled every 15 minutes. One internist stated:

There’s pressure to see more and more and more people, which makes it increasingly difficult to do what you need to do for the elderly. When I joined this organization, all our appointments were 20-minute appointments. We now have 10-minute appointments. And it’s not unusual to have those double-booked.

This message was underscored by another primary care physician in the same practice:

You cannot, cannot, deal with an eighty-year-old person with six or seven major medical issues and psychological issues and five to seven drugs in a 15-minute appointment.

Despite the fact that many reported several chronic illnesses and impairments, most seniors in our survey reported being pleased with their ability to communicate with providers. Overall, only 3 percent reported being unsatisfied with how physicians explained test results, medications, and other treatments. At the same time, seniors who participated in the more open-ended discussions of the focus groups reported that they had forgotten to ask questions or discuss symptoms during the office visits. Others reported that they were often timid or confused during an office visit and as a result failed to ask questions or report symptoms that they had wanted to discuss with their physician. There was a sense that communication problems resulted in their having inadequate knowledge about medications and treatment regimens. As one senior mentioned:

We were rushed and we were never allowed enough time [with the doctor]. . . . We’d find ourselves on the way home thinking, oh my God, we never had a chance to ask him this or ask him that. . . . You don’t have enough time to reflect and say what you wanted to say.

The seniors expressed particular concern about communication problems with new doctors or specialists they saw in the hospital or on a short-term basis.

You’re just not comfortable with [hospital-based doctors], because your primary care doctor knows to ask the questions they have to ask.

You get strange doctors. My wife was in the hospital, she had 14 doctors. It’s not the same care.

Both seniors and physicians expressed frustration with automated attendant telephone systems. Some seniors had difficulty following telephone instructions; others complained about having to wait a long time on the phone, being put on hold, and being given incorrect information. During one focus group discussion, a participant pointed out that he always foiled the automated attendant by pressing zero to get the operator. This strategy was eagerly embraced by the others in the group.

Finally, educating high-risk seniors and other vulnerable subgroups of Medicare beneficiaries often requires targeted strategies and one-on-one interventions (Gold and Stevens 2001). Such efforts are particularly important for the 44 percent of seniors over age 65 who score at the lowest levels of literacy (Kirsch et al. 1993).

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