The Economics of Patient Engagement
For the month of April, I will be sharing things I’ve written in the process of obtaining my MS in Health Care Administration which I finished up this past fall.
For this paper, several terms not generally utilized in economics will be needed necessitating definitions of these key terms.
Shared-decision making (SDM) is a term utilized in opposition to paternalism. The latter is a form of practicing medicine in which the physician dictates what the patient is supposed to do without taking into account what the patient’s lifestyle is, the patient’s opinion, or other factors. The former is a form of practicing medicine that is gaining traction and requires the physician to work alongside the patient in order to come to a mutually agreeable decision. Informed Consent is needed in order to form this decision, meaning that the patient needs to receive education – from the healthcare team or elsewhere, but preferably the former – in order to give consent for treatment.
Quality of Life is a term that can mean many things to individuals. Overall, this is how well a patient is able to live their life. Many items can factor into the Quality of Life (or QOL) from whether a medication is an injectable or an infusion to how often blood tests are required to the efficacy of treatments to even more.
Adherence or compliance is how closely a patient may stick to their treatment regime. There are, however, a variety of things that can affect a patient’s adherence or compliance to any given regime, including but not limited to transportation, access, cost, childcare, Quality of Life, health literacy, socioeconomic status, and social support.
Patient Engagement is how involved a patient is in their medical care. This can be affected by health literacy, socioeconomic status, education, access, cost, Quality of Life, rapport with clinic/hospital staff, insurance, social support, and how involved their healthcare team is with shared decision making as opposed to paternalism. The Patient Activation Measure is a way to measure Patient Engagement via “a valid, highly reliable, unidimensional, probabilistic Guttman-like scale that reflects a developmental model of activation” (Hibbard, Stockard, Mahoney, & Tusler, 2004).
Patient Protection and Affordable Care Act
In March of 2010, the Patient Protection and Affordable Care Act (PPACA) was enacted (Healthcare.gov, n.d.). Two of the biggest draws for the consumer side were the requirement for insurance plans to cover people with “pre-existing health conditions, including pregnancy, without charging more” and making it “illegal for health insurance companies to cancel your health insurance just because you get sick” (Healthcare.gov, n.d.). Additional draws include giving younger adults more options including the ability to stay on their parents’ insurance plans up to age 26, education about the coverage a patient is receiving, and regulations placed on insurance companies surrounding increasing premium rates (Healthcare.gov, n.d.).
One of the innovations of the PPACA has been the “shifting from a reimbursement system based on the volume of services provided to one based on the value of care” (Abrams, et al., 2015). The shift from fee-for-service to pay-for-performance is a great idea in order to bring more of a focus on quality to all parts of healthcare. Sending a “clear signal to providers that they will need to adapt quickly to incentives that reward appropriate, high-quality care and good patient outcomes” has already begun to make improvements (Abrams, et al., 2015).
Among the many improvements already noted with the PPACA is “lowered annual increases in Medicare payment rates for hospitals and other facilities” (Abrams, et al., 2015). As we are reminded of constantly, the reserved funds for Medicare and Social Security are running out of money (Reuters, 2016). Paying out fewer dollars to providers can potentially help to extend the life of these programs by a few years. Even overpayments to “private plans administering Medicare benefits through the Medicare Advantage program,” which will help with this as well (Abrams, et al., 2015).
Quality has directly been targeted as well (Abrams, et al., 2015). Hospitals with high rates of “adverse medical events,” or such as Hospital Associated Infections (HAIs), have begun to be fined for subpar performance on key quality metrics (Abrams, et al., 2015). Other innovations to improve quality include the Center for Medicare and Medicaid Innovation (CMMI), the Patient-Centered Outcomes Research Institute (PCORI), the Medicare-Medicaid Coordination Office, and the National Strategy for Quality Improvement in Health Care (Abrams, et al., 2015).
With education surrounding a patient’s coverage as well as the emphasis on quality, the theory has been that the PPACA will be able to increase a patient’s engagement with their own health.
Patient Engagement
Several studies have shown that increased Patient Engagement as measured by the Patient Activation Measure lead to overall improvements in health as well as economic benefits. In addition, healthcare is moving towards Patient Engagement per request from patients and patient-led organizations.
Patients who are more activated or engaged in their own healthcare take part in more preventative measures such as check-ups than their less-engaged counterparts (Hibbard & Greene, What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs, 2013). These same patients do not delay seeking medical care and have a higher likelihood of having better overall health (Hibbard & Greene, What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs, 2013). These patients are also more likely to have better healthcare experiences when seeing the same physicians as their less-activated counterparts (Greene, Hibbard, Sacks, & Overton, When Seeing The Same Physician, Highly Activated Patients Have Better Care Experiences Than Less Activated Patients, 2013). Patients who had more provider support in education and participated in more shared decision-making processes with their healthcare team were more engaged in their own care (Greene & Hibbard, Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes, 2011).
One study in Minnesota showed that “for every additional ten points on a Patient Activation Measure score, the predicted probability of having an emergency department visit was one percentage point lower” (Hibbard & Greene, What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs, 2013). Taking this further, patients who were not as engaged as seen on the Patient Activation Measure had “significantly higher costs than more activated patients” (Hibbard & Greene, What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs, 2013). Activated patients also had fewer emergency department visits and hospital readmissions, leading to lower costs overall (Greene, Hibbard, Sacks, Overton, & Parrotta, When Patient Activation Levels Change, Health Outcomes And Costs Change, Too, 2015).
Intersectionality and Further Issues
There are some issues with Patient Engagement/Activation in that several barriers exist to many people achieving this state. While similar expectations and wishes for physicians happen across racial and ethnic groups, differences in experiences are still reported (Welnick, et al., 2011). This still occurs with other variables such as education status, socioeconomic status, gender identity, sexual orientation, age, and more (Millenson, 2016). In the pediatric world, these barriers are often necessary to work around and work with in order to provide the most exceptional care to the patients as needed. Several of these barriers can be worked around to increase engagement and education through understanding and education (Cox, et al., 2012).
Conclusion
The benefits of Patient Engagement far outnumber any negatives one might be able to find. While there are difficulties in making changes in order to put programs in place, there are few negatives to even be found. From an economic standpoint, the pay-for-performance principle instituted by the PPACA can be a vehicle for moving healthcare to focus more on Quality of Life and Patient Engagement. Costs can be expected to increase in the short-term in order to provide education to both healthcare providers and patients as well as setting up a system to measure the efficacy of these efforts. However, in the long-term, these costs can be expected to go down as Patient Engagement and Activation become the norm across the country.
References
Abrams, M. K., Nuzum, R., Zezza, M. A., Ryan, J., Kiszla, J., & Guterman, S. (2015, May 7). The Affordable Care Act’s Payment and Delivery System Reforms: A Progress Report at Five Years. (C. Hollander, Editor) Retrieved from The Commonwealth Fund: http://www.commonwealthfund.org/publications/issue-briefs/2015/may/aca-payment-and-delivery-system-reforms-at-5-years
Greene, J., & Hibbard, J. H. (2011, November 30). Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes. Journal of General Internal Medicine, 520-526.
Greene, J., Hibbard, J. H., Alvarez, C., & Overton, V. (2016, March/April). Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels. Annals of Family Medicine, 148-154.
Greene, J., Hibbard, J. H., Sacks, R., & Overton, V. (2013, July). When Seeing The Same Physician, Highly Activated Patients Have Better Care Experiences Than Less Activated Patients. Health Affairs, 1299-1305.
Greene, J., Hibbard, J. H., Sacks, R., Overton, V., & Parrotta, C. D. (2015, March). When Patient Activation Levels Change, Health Outcomes And Costs Change, Too. Health Affairs, 431-437.
Healthcare.gov. (n.d.). Health Coverage Rights and Protections: Rights & Protections. Retrieved from Healthcare.gov: https://www.healthcare.gov/health-care-law-protections/
Healthcare.gov. (n.d.). Patient Protection and Affordable Care Act. Retrieved from Healthcare.gov: https://www.healthcare.gov/glossary/patient-protection-and-affordable-care-act/
Hibbard, J. H., & Greene, J. (2013). What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs. Health Affairs, 207-214.
Hibbard, J. H., Mahoney, E. R., Stock, R., & Tusler, M. (2007, August). Do Increases in Patient Activation Result in Improved Self-Management Behaviors? HSR: Health Services Research, 42(4), 1443-1463.
Reuters. (2016, June 22). Medicare Is Going to Run Out of Money a Lot Sooner Than Expected. Retrieved from Fortune: http://fortune.com/2016/06/22/medicare-reserves-exhausted-soon/
Skolasky, R. L., Mackenzie, E. J., Riley III, L. H., & Wegener, S. T. (2009, December). Psychometric Properties of the Patient Activation Measure among Individuals Presenting for Elective Lumbar Spine Surgery. Quality of Life Research, 1357-1366.