The solution to combating health care costs may lie in maximizing patient involvement. Under the Centers for Medicare and Medicaid Services’ (CMS) Shared Savings Program, Accountable Care Organizations are eligible for financial incentives if they meet certain performance measures, which aim to improve outcomes, care delivery, and patient experience.
Currently, thirty-three quality measures have been defined, seven of which measure patient experience. Three of these patient experience measures include: providers ability to communicate with patients; health promotion and education; and Shared-Decision Making.
Seemingly, the interest in patient engagement has never been stronger — as evidenced by a recent study by Jessica Greene et al. in Health Affairs that increased patient engagement is associated with reduced spending.
For hospitals to be successful in a pay-for-quality environment, they need patients to be active participants in their health care discourse. How does an organization engage patients? The Agency for Healthcare Research and Quality provides some context for patient engagement: “a set of behaviors by health professionals, a set of organizational policies and procedures and a set of individual and collective mindsets and cultural philosophies that foster both the inclusion of patients and family members as active members of the healthcare team and encourage collaborative partnerships with patients and families, providers and communities.”
Moreover, according to a study of nearly 25,000 patients at Fairview Health Services in Minnesota, engaged patients are more likely to comply with their treatment and seek preventative care, and are less inclined to engage in unhealthy behaviors (which may lead to fewer emergency department visits and hospitalizations). Hospitals and providers can increase patient engagement across a number of dimensions: health literacy, Shared-Decision Making, social marketing, transparency of quality and cost data, electronic medical records, social media, and community organizing.
Patient engagement fundamentally relies on health literacy — the ability to understand and process medical information and services. Providers must become teachers, and lead the way for educating patients about their disease and motivating them to take control of their care plan.
As a measuring stick, the recent HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) national survey elicits patients’ perspectives on certain aspects of hospital care. Only 51 percent of the patients surveyed “strongly agree” they understood their care when they left the hospital. As a more specific example, a recent Cancer Care Outcomes Research and Surveillance study showed that 69 percent of patients with metastatic lung cancer and 81 percent with metastatic colorectal cancer did not realize that chemotherapy was unlikely to cure their terminal disease.
Shared-Decision Making
There is definitely a disconnect in what the patient knows and what the provider thinks the patient knows. A recent review in The Journal of the American Medical Association (JAMA) suggested that unrealistic expectations and inappropriate patient understanding of benefits and harms may be contributing to nonessential care and increased costs.
In order to bridge this disconnect, “Shared-Decision Making” (SDM) may provide some hope. SDM depends on building a strong and trusted doctor-patient relationship. During an informed decision making process, evidence-based information is truthfully shared and patients are supported to deliberate and express their preferences and views.
The Dartmouth Atlas has evaluated factors that influence variation in health care utilization: not addressing patient preferences, poor communication, and “paternalistic” medicine — all of which are major catalysts for overutilization. SDM recognizes the importance of self-determination and autonomy — empowering the patient to play an active role, rather than a passive one. These “passive patients” are less motivated to be involved in their health care decisions, less likely to get the care they desire, less likely to adhere to their treatment plan, and more likely to over utilize non-beneficial care.
SDM relies on health literacy and the ability of the provider to provide high-quality information and educate their patients. Decision aids and patient advocates are commonly used by patients to assist in the decision-making process. The ultimate goal is to provide patient-centered care, which has six core attributes: education and shared knowledge, involvement of family and friends, collaboration and team management, sensitivity to non-medical and spiritual dimensions of care, respect for patient needs and preferences, and free flow and accessibility of information.
The process can have significant results — a study by David Arterburn et al. at Group Health, published in Health Affairs, demonstrated that providing decision aids for knee and hip replacements to eligible patients substantially reduced both surgery rates and costs, with up to 38 percent fewer surgeries and savings of 12 to 21 percent over six months.
A Cochrane Review of 86 studies that evaluated the effectiveness of decision aids, showed the patients who experienced Shared-Decision Making with the use of decision aids had better understanding of their choices, better risk perception, more confidence in their decision, and better experiences — in fact, 20 percent of the patients chose less invasive treatment or conservative options.
Social Marketing
Health care institutions must find innovative ways to engage their patient community — one way is using social marketing strategies to influence patient behavior and promote preventive care. For example, Lahey Hospital and Medical Center started a lung cancer screening campaign in 2012: “Rescue Lung, Rescue Life.” The campaign encourages high-risk patients, ages 55-74 years old with a significant smoking history, to obtain low-dose lung CT scans.
To motivate and incentivize the high-risk individuals to undergo screening, and minimize the disparities of care access and affordability, Lahey started offering the CT scans for free (Medicare and most private insurances previously did not reimburse for lung cancer screening). The “Rescue Lung, Rescue Life Campaign” served as a national model for a successful lung cancer-screening program and connected patients with proper follow-up care, including smoking cessation resources.
Initiatives like these not only enhance the popularity of services at Lahey Medical Center in the competitive health care environment of Boston, they showcase an image of a health care institution going above and beyond to keep its community healthy.
In February 2015, CMS approved reimbursement for lung cancer screening with one interesting caveat: the patient must participate in a shared-decision counseling session prior to the first scan to discuss the risk and benefits of screening, which we consider a win for the patient engagement movement.
Furthermore, social marketing, specifically the use of social media, can engage patients and make them feel like a part of the hospital community. For example, Boston Children’s Hospital has more than 700,000 fans on Facebook, which not only bolsters their brand name, but also allows for rapid dissemination of health care education and resources.
Social media can provide instant feedback from the patient community, which can help promote further outreach and quality improvement efforts. Likewise, there has been a surge of hospital CEOs who now manage online blogs.
Paul Levy, the former CEO of BIDMC, used his blog to openly discuss the hospital’s safety and clinical outcomes data, and highlighted where improvements were needed to better the system and enhance the patient experience. Other institutions like Mayo Clinic have created online forums, which host a wide variety of discussion groups, blog posts, and community events, but most importantly provide an alternate non-acute platform for provider-patient interaction.
Can Data Drive Patient Engagement?
What if public reporting of physician performance scores and outcome measures, along with associated costs of treatment and work-ups, could motivate patients to make more conscious health care decisions? Enabling patients to be true “consumers” of health care, to determine the value of care they seek based on the quality and cost, will require high level of transparency and information sharing.
Certain institutions, like Massachusetts Eye and Ear, have been sharing their quality and outcomes data publicly. Payers can also play a significant role in consumer-driven health care. UnitedHealthcare, a large national insurer, has been able to provide cost and quality data for more than 240,000 physicians across various specialties to their beneficiaries.
A health-cost estimator is also available to help patient compare options and make more conscious decisions. By offering lower co-payments and premium reductions, UnitedHealthcare incentivizes its patient consumers to choose designated “high-value” care providers and financially benefit from preventive care initiatives (Rewards for Health Program).
In an ideal world, price and quality transparency would drive health care competition and lower prices if patients functioned as engaged consumers. However, access to quality data, as well as actual prices and the ability to determine out-of-pocket costs are limited in most states. Hopefully Massachusetts, being the first state to require some level of cost transparency, can serve as a national example.
Electronic Medical Records
With the evolution of electronic medical records and access to “patient portals,” there will be more opportunity for the patient to remain connected with their care plan and care provider. Beth Israel Deaconess Medical Center (BIDMC) has a web-based portal, which allows patients to see test results, communicate with their providers by email, and request appointments and prescription refills. It also lets patients check their medication lists, allergies, and test results, and gives them an opportunity to correct any inconsistencies.
The BIDMC patient portal also gives patients access to their clinical records and notes. BIDMC conducted a large study where participants were given access to their patient notes — 77 to 87 percent of them reported feeling more in control of their care and 60–78 percent said the access increased medication adherence.
The possibilities are endless with information technology — user-friendly mobile apps can help manage chronic conditions like diabetes, or document the outpatient progress of individuals as they recover from surgery through patient-reported outcomes.
A powerful strategy for promoting patient engagement is building coalitions. Patient advocacy is an intrinsic characteristic of health care providers, and there must be a national-scale community organizing approach to change the current practice culture. The examples mentioned above are isolated experiments, which require broader appeal for true benefit to be realized.
The Lown Institute, is one such organization that is working nationally to unify providers on the agenda of patient-centered care and curtailing waste. A grass roots movement of physicians, nurses, students, and community leaders is needed to influence the system and empower patients to be healthy and become better users of health care.
As we progress further into the realm of pay-for-performance, engaging patients will be vital to achieving high-value care. No matter how you define patient engagement, the end goal is the same — an informed and involved patient. The answer lies in shifting the care approach from: “this is the chief complaint … and here is the treatment,” to “this is the patient … and here is what matters to them.”
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