The expansion of health insurance coverage may be the most visible aspect of health reform, but other elements will ultimately have a significant impact on how we all experience health care. One pivotal change is how health care organizations are paid. New payment approaches will reward providers based on whether services actually improve patients’ health and keep costs down versus simply incentivizing them to provide more care.
One of the more consequential changes will be a greater focus on helping patients to be more involved in their care. There is ample evidence that the behaviors people engage in and the health care choices they make have a very clear effect on both health and costs, positively and negatively. The most innovative health care delivery systems recognize this and see their patients as assets who can help them achieve the goals of better health at lower costs. From this point of view, “investing” in patients and helping them to be more effective partners in care makes good sense.
Our study, reported in the February issue of Health Affairs, highlights this role that patients play in determining health-related outcomes. We found that patients who were more knowledgeable, skilled and confident about managing their day-to-day health and health care (also known as “patient activation,” measured by the Patient Activation Measure) had health care costs that were 8 percent lower in the base year and 21 percent lower in the next year compared to patients who lacked this type of confidence and skill. These savings held true even after adjusting for patient differences, such as demographic factors and the severity of illnesses.
Even among patients with the same chronic illness, those who were more “activated” had lower overall health care costs than patients who were less so. Among asthma patients, the least activated patients had costs that were 21 percent higher than the most activated patients. With high blood pressure, the cost differential was 14 percent.
We know from previous research that interventions can successfully increase patients’ level of activation, so the question now is, “How can health care delivery invest in their patients to create a higher level of activation in their own care?” We offer two suggestions: 1) build into every step of the care process a meaningful role for patients and their families; and 2) tailor and customize care in a way that helps patients acquire the knowledge and skills they need to effectively manage their health.
In practice, this means giving patients, who desire it, more autonomy and control. When pediatricians give parents kits to test for strep throat at home, it saves on costs, is more convenient for patients, and makes them an actual partner in care versus just a recipient of it. When families are given tools to help monitor a loved one’s progress while in the hospital, it gives them a clear role in the health care process and helps to guard against medical errors. In Sweden, they are experimenting with self-service dialysis care for kidney patients, offering more control to patients and a lower cost option. The key is that health care delivery systems, along with patients, need to identify these opportunities and organizational structures need to enable it to occur.
At the same time, there are some patients who are not prepared to take on new roles in their care and are unable to cope with the demands of their illnesses. This is a particular concern with chronic disease patients who often need to manage their day-to-day health with tasks such as medication management and self-monitoring. When patients are unable to manage these often complex tasks, the result is higher health care and human costs.
So an important step is tailoring care. By understanding the activation levels of individual patients, health care providers can determine the amount and type of support they need to give to help patients gain the skills to manage their health conditions successfully. Diabetes patients, for example, need to manage medications, monitor glucose levels, and change their diets. Changing eating habits requires knowing how to shop and cook differently, and how to order the right foods in a restaurant. The process of mastering these new skills is like learning to swim; the swimmer acquires basic competencies (face in the water), practices, and gains confidence before doing his first lap. Patients, like swimming students, are starting at different levels. Yet in health care, we tend to throw everyone into the deep end of the pool and assume they can swim.
Even though it is popular to assume that financial incentives can change difficult and ingrained unhealthy patient behaviors, the evidence for this approach is lacking. Neither greater cost-sharing nor direct financial incentives to patients seem to be able to spark long-term behavior change, and they are not likely to work as intended. More highly activated patients with the skills and knowledge to respond will more likely take advantage of incentives and avoid penalties, while lower activated patients will more likely accept the increased costs and forgo the incentives.
We need a common approach that can work for everyone along the continuum. The evidence suggests that increasing patient activation can work to achieve what we all want to see from reform: a health care system that can control costs and help patients to become healthier.
Judith Hibbard is a Professor Emerita in the Department of Planning, Public Policy, and Management at the University of Oregon and Jessica Greene is a Professor and Director of Research in the School of Nursing atGeorge Washington University. This is a companion piece to their study published in the February 2013 issue of Health Affairs. Author disclosure: Judith Hibbard is a consultant to and stakeholder in Insignia Health.