Health care’s Holy Grail: Patient engagement

Consultant Leonard Kish likened the effect of patient engagement to that of a blockbuster drug. He cited a 2009 Kaiser study showing that coordinated cardiac care reduced the risk of dying of a cardiac-related cause by 88 percent within the first three months after a heart attack and overall mortality by 76 percent during the same time period.

“Can you imagine what the headlines would be if a new cardiac drug showed this kind of effectiveness?” he wrote.

Kish pointed out that patient and family engagement, which is part of Meaningful Use’s (MU) Stage 2, may be the hardest MU goal to achieve.

Defining patient engagement is elusive. The National eHealth Collaborative surveyed health-care organization leaders about it. Nearly all said it was important. But they could not agree on what it meant.

The most common description was offering patients resources to help them learn about their condition. Other descriptions involved face-to-face communication between physician and patient.

Patient activation and patient engagement are not synonymous. Patient activation encompasses the knowledge, skills and willingness to manage one’s own health and care. Patient engagement seeks to increase activation and promote healthy behavior.

One study found that patients with the lowest activation scores cost the health-care system 8 percent more in 2010 and 21 percent more in 2011 than patients who had the highest activation levels.

Being a compliant patient would seem to be a relatively easy task. However, a Kaiser Permanente researcher created a chart for a theoretical 67-year-old patient with diabetes, hypertension and high cholesterol and calculated what it would take to heed all medical recommendations. The final tally was more than 3,000 separate behaviors.

Better health outcomes and more years of healthy life require patient engagement. An activated patient consistently does what needs to be done to gain the greatest benefit from available health resources.

How many do this? Patients can be divided into thirds. One-third are engaged. Another third are tentative and inconsistent. The final third are disengaged. People with more education, income and self-confidence are more likely to be in the first group.

People who do not take charge of their health will fare poorly and be a drag on the performance of their health-care providers under accountable care.

Hospitals will be penalized if they do not provide a high level of patient-centered care. That means they must provide a comfortable, emotionally supportive environment. However, it also means patients will be encouraged to be involved in their own care. They will be asked to participate in decisions about their care and follow treatment plans so they are not readmitted needlessly.

Organized systems of care emerging from health reform, such as accountable care organizations (ACOs) and patient-centered medical homes (PCMHs), will be paid based on the health of their patients. That is a shared responsibility. Access to physicians increasingly will become difficult as the number of insured patients increases. Providers may end up “firing” patients if they are not compliant.

High-deductible health plans will be a central feature of the health-insurance exchanges established by the new law. An increasing number of companies will offer them – in some cases exclusively – as a means of controlling costs. These plans assume that engaged consumers will make wiser personal-health choices to minimize their out-of-pocket costs.

Engaged patients are not deterred by the complexity and fragmentation of the health-care system. They practice good health habits. They manage over-the-counter medications, minor wounds and injuries on their own. They collaborate with their providers and participate in making treatment decisions. They successfully navigate the health-care system, paying attention to provider quality and performance. They seek out reliable information on their own.

Ultimately, personal health requires self-care. Consider that physicians spend about two hours annually with their diabetic patients. Otherwise, those patients log an average of 8,758 hours a year managing the condition on their own.

Research consistently shows that engaged consumers have better health, make better choices and avoid medical errors. Engagement leads to better compliance with treatment, lower health-care costs and better-quality care. Patients do not have the power to change the health-care system. However, they do have the power to change their own care.

The disengaged are overwhelmed. They are less likely to have a usual source of care. They forget 40 to 80 percent of what the physician tells them in the exam room. Six out of 10 with employer-based insurance blame their disengagement on not knowing where to go for information. One in 4 Medicare beneficiaries are disengaged, and would “rather have someone else tell me what I need to do.” One in 3 of those who are uninsured are simply “not interested.”

Researcher Judith Hibbard has developed a way to measure this, called the Patient Activation Measure. The measure includes four stages to becoming a fully competent health-care consumer. She believes activation is constantly changing and subject to a range of flash points that encourage or discourage engagement. She suggests that providers start with the easiest behaviors to instill confidence and break those behaviors down into smaller steps.

The payoff is worth it. Hibbard found that highly activated patients have better care experiences and greater satisfaction than those with lower levels of activation—a critical point under MU rules.

The typical health consumer:

  • is able to perform simpler tasks such as making a list of medications, rather than more complex tasks such as participating in treatment decisions.
  • seeks out information about a provider or health plan but tends not to use it.
  • does not research health information until there is a specific need.
  • is quick to cite barriers to care, such as poor health, insufficient knowledge or lack of external support.
  • uses the Internet to learn about a condition or symptoms, but it is less clear whether the newly gained knowledge changes behavior.