Response: Re: If We Don't Ask, They Won't Tell: Screening for Urinary and Fecal Incontinence by Primary Care Providers

Abstract

amendment to our article and enthusiastically agree with the assertion that health equity is an important lens through which to gauge the effectiveness of payment models. While we assessed how these models affected health outcomes broadly, we agree that an important addition would be to specifically examine their impact on health equity.As Dr. Fiscella and Dr. Carroll note, risk-adjusted (based on social determinants of health in addition to medical determinants) global payments are one potential path toward equity, by ensuring that adequate resources are dedicated to patients with more complex needs and that there is flexibility in funds to meet social needs in addition to medical needs. In our characterization of payment models we have included whether the model includes risk adjustment.Another consideration relevant to payment models is to include measures of equity in performance metrics. We have raised concerns that models like the Merit-Based Incentive Payment System have the potential to widen existing disparities. 1 There is important work underway to develop measures that adequately assess primary care, including impact on health equity, begun at Starfield Summit III and being continued at the Larry A. Green Center for the Advancement of Primary Health Care for the Public Good.While primary care has been shown to attenuate health disparities, improved payment for primary care is necessary but not sufficient for achieving health equity. Achieving population health equity goals also requires ensuring access to health care for all, looking further upstream to payment for social services, and systematically addressing structural racism and discrimination.

Re: Impact of Medical Scribes in Primary Care on Productivity, Face-to-Face Time, and Patient Comfort

“…To the Editor: In their article reporting the impact of medical scribes, Zallman et al 1 reported greater physician productivity with scribes due to an increase in the mean number of patients seen per hour (from 1.82 to 1.98), while also reporting that visit length and visit cycle times were approximately 2 minutes longer, on average, when scribes were used. These results seems contradictory, calling into question the validity of their measures, but this issue was not addressed in the discussion.…”

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tients may deny that they suffer from these conditions, even when physicians ask about them, and that building trust with patients will facilitate more honest and open discussions about urination and defecation, which are taboo topics for many people.In a previous qualitative study, we learned that patients find it difficult to initiate discussions about incontinence with medical providers because of the associated shame and embarrassment. 1 These patients prefer that their providers ask openly about possible urinary or fecal incontinence. Providers, on the other hand, say they prefer that patients volunteer this information.

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“…In a previous qualitative study, we learned that patients find it difficult to initiate discussions about incontinence with medical providers because of the associated shame and embarrassment. 1 These patients prefer that their providers ask openly about possible urinary or fecal incontinence. Providers, on the other hand, say they prefer that patients volunteer this information.…”