The potentials for improved chronic disease management under the PCDMP
The PCDMP offers physicians the opportunity to improve their chronic care practices by incorporating valuable tasks that often tended to be neglected previously. This opportunity led to initiating changes in their approach.
Systematic management of chronic diseases
The PCDMP requires comprehensive assessment for patients every year, enabling physicians to acquire comprehensive information about their patients’ health conditions, life styles, depressive symptoms, and other relevant factors. The study participants reported that these tasks prompted them to pay closer attention to changes in their patients and to share this information with them during consultation. This personalized feedback process effectively enhanced the patients' self-management activities.
In reality, I normally don’t ask about sleep habits and often can't specifically ask about things like weight or exercise habits. But as I input data for each item, now there are things I have to ask about. So by checking those things, it has become much easier to inform patients about areas where they are doing poorly. (E7)
Another important change mentioned was that study participants started performing desirable but previously overlooked tasks for best practice in chronic disease management, such as conducting foot examinations and recommending regular eye examinations for patients with diabetes.
We have to conduct several tests, like diabetic complication tests, which we didn’t do before. We now perform foot exams. For eye exams, we encourage patients to visit eye clinics once a year. (E5)
The provision of vouchers for free laboratory tests was found to be helpful in performing regular laboratory tests and facilitating systematic monitoring of disease progression. According to the study participants, primary care physicians are occasionally hesitant to order necessary lab tests due to concerns about negative reactions from fee-sensitive patients. Therefore, the voucher had the positive effects of not only providing direct benefits to patients but also reducing the psychological burden on physicians.
I believe patients are sometimes hesitant to pay for lab tests because they're used to getting prescriptions at other clinics without undergoing tests. Though I tend to avoid prescribing unnecessary tests, it was still difficult. Nonetheless, the provision of free lab tests through the PCDMP has proven to be beneficial. (E1)
Increased concern on patient education and counselling during consultation
The PCDMP's mandatory requirement to allocate dedicated time for education and counseling during consultations increased physicians’ concern on effective patient education methods and materials. The provision of both online and offline educational materials in the program has been beneficial in reducing the burden on physicians and garnering positive reactions from patients, although there were difficulties in utilizing appropriate materials within the constrained timeframe. Most of the study participants favored direct explanations over the more time-consuming online education, showing a preference for selectively using only the relevant content from the PCDMP's online resources.
It employs a somewhat coercive approach, but at the same time, it also allows us to continuously discuss contents that must necessarily be included in education. So, it appears to have dual effects. (E4)
Additionally, the increased concern on patient education presented an opportunity for physicians to recognize their insufficient skills in counseling and behavior modification, prompting a need for retraining programs.
I acquired some counseling skills when I was a student, but it was not enough. My understanding of how to assist patients in self-directed lifestyle modifications is limited. Unfortunately, there are few opportunities to further develop these skills. (E5)
Improved therapeutic relationships with patients
Participation in the PCDMP encouraged study participants to dedicate more time and attention to patients than they would have been otherwise, ensuring adherence to guidelines for comprehensive assessment, education, and monitoring. Continuing such care practices had a positive impact on patients and contributed to fostering trust among patients. The participants also highlighted that physicians’ increased attention to their patients helped to promote better therapeutic relationships with patients, which in turn improved patients’ medication adherence and engagement in chronic disease management.
Frequent interactions with patients foster closer relationships and lead to more in-depth conversations. This is a certainty. The more I engage with them, the more I learn about each patient, acquiring valuable information. (E8)
Sure, it's good. Because I listen to their stories, that's better for them. Therefore, they come more regularly for their prescriptions, and when I tell them they're doing well, it appears to create a positive cycle. (E7)
Assuming greater responsibility for managing chronic diseases
The provision of previously unavailable remuneration for patient education and counseling in this program was positively evaluated by the participants. They acknowledged that this was a significant change since they no longer had to rely solely on professional ethics without compensation for better chronic disease management.
We are not a charity. If reasonable reimbursement is guaranteed for those services, that benefits patients and also makes us work harder as there are now rewards. (E3)
Realizing that patients pay additional costs for education and counseling services also prompted the participants to assume greater responsibility and to provide better chronic care. Moreover, participating in a government-led pilot program earned the clinic additional credibility, fostering a sense of responsibility in meeting their patients’ expectations.
Patients tend to trust information banners provided by the government, so displaying them in my clinic makes patients think that this clinic is working with the government on something. It's about publicizing that my clinic is involved in public-interest activities. (E8)
A positive “spill-over” effect of participating in the PCDMP was also observed: non-enrolled patients visiting for reasons other than hypertension or diabetes were now more likely to be offered blood pressure measurements or blood glucose screening tests, contributing to the early detection of hypertension and diabetes in previously undiagnosed patients.
Patients visiting for skin conditions or pain often present with chronic diseases. Consequently, I approach patient care holistically, always considering the possibility of an underlying chronic condition. I try to test blood pressure for all patients and specifically check blood sugar levels in those exhibiting slow recovery. (E4)
Challenges in chronic disease management under the PCDMP and beyond
During the implementation of the PCDMP, the study participants encountered various challenges that impeded more effective chronic disease management in primary care settings. These challenges stemmed either directly from the PCDMP or from related contextual factors.
The gap between guidelines and their implementation in real-world settings
While the PCDMP stipulates a set of comprehensive services tailored for patients with hypertension and diabetes, there was a tendency for study participants to choose specific services within their capabilities. Typically, they conducted comprehensive assessments, devised simple care plans, and held education sessions that lasted less than 10 minutes. Although the PCDMP mandates the formulation of personalized care plans through patient discussions following comprehensive assessments, participants often provided simple advice for weight control, dietary management and regular exercise, in parallel with their standard care practices. This approach was influenced by time constraints and a lack of consensus on implementing individualized plans for each patient.
I don't think there is a significant difference in care plans… it's about managing diet and then exercising, and the numbers that we set as our goals. (E5)
The compulsory minimum time allocation for patient education sessions, particularly the 30 minutes for the first session, significantly increased participant dissatisfaction in the PCDMP, leading to the adoption of shortcuts to meet these time requirements. Participants criticized this mandate as being unrealistic and a major obstacle to program participation. Moreover, participants' approaches to patient education, particularly the focus on simple, repetitive messaging to address knowledge gaps, led to discrepancies between the program's intended plan and actual implementation.
Who can comfortably educate a patient for more than 10 minutes here when there are 5 or 10 patients waiting outside? You can't. Instead, it’s better to provide educational materials, ensuring they remember this. (E2)
In the PCDMP, patient monitoring was often neglected due to the complex requirements for medical claims. This, coupled with patients' low participation in submitting data, resulted in poor performance in patient monitoring by physicians.
In this program, I usually do patient registration, comprehensive assessment and patient education. While I'm aware of incentives for additional tasks like remote counseling and texting, these require patients to submit data and necessitate extra work on my part for data entry. (E4)
Time-consuming administrative work
Participants reported a significant rise in administrative duties, especially during the patient enrollment phase. The procedures of selecting, persuading, and registering patients added to their already heavy workload, negatively affecting their enthusiasm for the program. To ease this burden, they often enrolled patients with whom they had a strong rapport and who were expected to comply readily, or Medical Aid beneficiaries exempt from copayments. However, the completion of these administrative tasks during patient consultation further increased their burden, affecting their concentration on patient care.
I tend to recommend this program to long-term patients with whom I have established a good relationship, as they are more likely to commit to participating. Additionally, I approach Medical Aid patients for the program, since they are exempt from paying for PCDMP services, thus easing any financial concerns they might have. (E6)
If I don’t input the data during consultation time, I have to take more time to do it. (E5)
Patient's out-of-pocket expenses for the PCDMP services
In the PCDMP, patients under the National Health Insurance must pay a ten percent copayment for services, resulting in higher fees than otherwise. This discouraged physicians from participating in the program and led those already in the program to seek ways to minimize additional costs for patients. The participants noted that many patients are not accustomed to paying for educational or counseling services in primary care, and patients’ dissatisfaction with increased expenses could negatively affect clinic reputations. As a result, most of the participants chose not to impose copayments for the additional PCDMP services on patients, which reduces their willingness to participate and hinders active implementation.
Patients are still not ready to pay for intellectual knowledge provided in clinics, although they are willing to pay for the costs of treatments and tests…. I think few patients are willing to pay for this type of (intellectual knowledge) services. This has been a problem so far and continues to be the biggest obstacle. (E7)
Insufficient incentives for fostering a team-based approach
The PCDMP's recommendation for a team-based approach, involving hiring a care coordinator such as registered nurses or licensed nutritionists, has been met with reluctance. Most participants believed that the financial incentives offered by the PCDMP were insufficient for hiring additional staff, resulting in the participating physicians in the PCDMP shouldering all administrative tasks.
For larger clinics with more than two physicians, hiring a care coordinator might be feasible, but for smaller clinics with solo practitioners, this can be a significant burden. As a solo practitioner myself, I find it impossible to employ a care coordinator. (E6)
Beyond the aspect of hiring a care coordinator, physicians' perceptions of the PCDMP's financial incentives varied based on their level of engagement and individual situations. Most study participants viewed the PCDMP’s reimbursements as insufficient compared to standard consultation fees. However, one physician, actively involved in the program with over 400 enrolled patients, held a more favorable opinion of the program's financial compensation.
Honestly, from a doctor's perspective, seeing a patient with a common cold or prescribing basic medications typically takes just 1–2 minutes. Within a span of 10 minutes, I can attend to 4–5 patients. But, if I spend 10 minutes delivering basic education to a patient, the fee earned is similar to that for a follow-up consultation. (E3)
Contextual factors influencing chronic disease management
The study participants emphasized the importance of considering various contextual elements that influence the implementation of the PCDMP. These elements included physical and social environments, organizational factors, physician individual factors, and patient-related factors in current primary care settings. The participants mentioned challenges such as limited clinic space hindering group education and care coordinator employment. Organizational and community factors, such as a shortage of trained staff, inadequate support systems, and limited community resources, also affected participation. Initially, physicians often had to rely on peers or pharmaceutical representatives for support. The lack of official channels for physicians to share opinions and experiences contributed to a sense of being left alone, impeding their active involvement in the program.
I submitted the claim in the following month, but reimbursement was rejected on the ground the claim wasn't complete for review. There was nowhere to ask about it. (E7).
Physicians' individual factors, such as digital literacy and attitudes toward government-led projects, significantly influenced their participation. Apprehension about future policy changes and the possibility of more stringent regulations reduced their willingness for active participation. On the patient side, challenges included unfamiliarity with paying for education and counseling, rushed appointments, and reluctance to participate in educational activities. These factors collectively contributed to barriers in the effective implementation and active physician participation in the PCDMP.
“People of my age feel uncomfortable inputting data on a computer in front of patients, which makes it difficult to participate in the program. (E2)”
No matter how much I talk about the importance of dietary control and emphasize it, patients think that simply taking medication is enough. They believe that taking medication is enough to resolve their issues. (E3)