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AMA Debates Role of Patient Navigators


 

FROM THE AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES INTERIM MEETING

NEW ORLEANS – Patient navigators are increasingly becoming a part of the medical landscape, especially in oncology, but their exact role needs to be better defined, delegates said at the American Medical Association’s interim meeting.

The delegates approved a report that outlines the organization’s current opinions on how navigators should be trained, how they should work with physicians and other providers, and where their responsibilities should begin and end.

The report from the AMA Council on Medical Service will essentially be a starting point for creating the organization’s policy on patient navigators.

Overall, the delegates approved a call for action for the AMA to work with the American College of Surgeons and other physician organizations "to ensure that patient navigators are free of bias, do not have any role in directing referrals, do not usurp the physician’s role in and responsibility for patient education or treatment planning, and act under the direction of the physician or physicians primarily responsible for each patient’s care."

The Council on Medical Service report found that patient navigator programs fall into four categories:

• Those focused on reducing health care disparities and increasing access to care.

• Those aimed at improving outcomes for a specific chronic condition.

• Those that try to make care more efficient and less costly.

• Those that help patients make their way through a complex health care system.

The programs are being adopted in many different clinical areas, and soon will get official government backing. In 2014, state health insurance exchanges – established as part of the Affordable Care Act – will start up. The exchanges have been directed to set up navigator programs that will give purchasers details on how to buy a health plan, as well as help with enrollment and dispute resolutions.

Training programs for patient navigators do exist, but are not widespread. The Society for Healthcare Consumer Advocacy, an offshoot of the American Hospital Association, offers a web-based certificate program. And some universities offer certificate programs or degrees in health advocacy.

The Council on Medical Service generally endorsed navigator programs, saying that they could enhance patient care. But it also recommended a set of principles to ensure that navigators stay in communication with the medical team; that they disclose training, experience, and potential conflicts; and that they refrain from making any clinical decisions or judgments.

Patient navigators can be a big help, especially when patients are overwhelmed by the system, said Dr. Mark V. Williams, chief of hospital medicine at Northwestern University, Chicago. Although hospitalists generally do not interact much with navigators, they are likely to in the future, he said. He added that he would like to see navigators integrated into primary care practices or medical homes to ensure that there is full coordination among all members of a health care team.

AMA delegates expressed concern that navigators could somehow undermine the physician’s role. And there was some worry that navigators might steer patients away from a particular physician, as well as discussion over whether navigators should act under the "direction" or the "supervision" of physicians in the clinical environment.

Dr. Chris Nunnink, a delegate representing the American Society of Clinical Oncology, said that the organization supported navigators because they helped underserved patients better access the system. But, the process needs to be "fair and transparent," said Dr. Nunnink, an oncologist at the Vermont Cancer Center, Colchester. He said he’d also had experiences where long-time patients had been steered to other systems or physicians by navigators.

That argues for better communication and the transparent process, he said.

Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society, and a delegate from the American College of Physicians, said that the cancer society is "acutely aware of the issues raised here."

The goal of the ACS navigator program, however, was to help underserved patients get access, not steer them away from particular physicians, he said. "They need our help to get through this system, otherwise they fall through the cracks, they don’t get the care in a timely fashion, and they suffer as a result," he told the delegates.

One issue that comes up for many of the underserved patients is that they come into the system without a supervising physician, said Dr. Richard B. Reiling, medical director of the Presbyterian Cancer Center, Charlotte, N.C., and a delegate from the American College of Surgeons.

Dr. Reiling argued that the AMA should alter its report language to state that patients should be under the "direction," not the "supervision," of a physician. The delegates ultimately approved that change.

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