Engaged Patients Translate to Better Outcomes and Costs

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 AffairsAuthor disclosure: Judith Hibbard is a consultant to and stakeholder in Insignia Health.

10 replies »

  1. As a person living with a chronic condition, Parkinson’s, the article and discussion misses an important piece of what’s needed when dealing with a complex chronic condition. I routinely see 6 different specialists and that is down from about 9 or 10 depending on how you count. The problem is that I am flooded with so much input about what i should be doing that no one can sort it all out. Imagine getting 6 to 10 different sets of instructions from that many doctors, and in each case they just put on the printout what changed. They don’t give you comprehensive instructions in writing. Somehow as the patient I’m supposed to have compiled all those instructions and I’m supposed to keep the aggregate updated as they are continually changing. Recently we asked in a Parkinson’s support group meeting if people felt overwhelmed with the amount of “advice” they were given by doctors. Every hand in the room went up including both patients and care givers. Between instructions on do this exercise, take these pills, use that anti-constipation paste, remember to use eye drops, and oh by the way don’t drive – I don’t know what I should do. Our health care (not a) system needs to see that it is overloading people.

    It isn’t fair to put all of this on care givers either. It’s almost like someone needs to have a full-time paid attendant in order to be sick in this country. What I find frustrating is that most of the time what is needed by someone with Parkinson’s is very similar to what every other person with Parkinson’s needs. How do we introduce a role where we have a nurse practitioner or even just a well trained nurse who oversees all of this for a group of patients. My guess is that an insurance company could pay for this person out of savings that would be achieved by reduced doctor’s visits, tests, required rehab, and medications. Insurance needs to walk carefully so that this doesn’t end up looking like it is going to be a way to deny services. The point is to help coordinate, not to deny anything.

  2. I agree that increasing patients “activation” can bring about a health care system that can control costs and help patients to become healthier. I also see the problem of getting patients “activated” or involved in their own health care. Patient’s lack of concern for their own health is a major problem in healthcare today.
    I agree we should customize health care delivery in any and every way possible to assist patients to acquire the education and skills they need to efficiently manage their own health. Many patients would benefit from advocating for themselves and gaining more autonomy, but on the other hand it is the patients who portray that they will manage their own care appropriately and fail to do so that increase healthcare costs. Patients are all at different skill and educational levels and at different levels of willingness to tend to their own health care. Assessing which level of involvement the patient is in their own healthcare is where the delivery systems need to focus on to increase patient “activation” which should control costs and create healthier patients.
    Robert and Reta, you are both correct to say that healthcare providers should tailor their questions to the patients and not just to the disease or medical problem. There is a communication barrier in today’s healthcare between the patients and health care providers that is limiting the quality of care received by the patients and given by the providers. An integrated set of questions is what is needed for assessing which patients need the extra assistance getting “activated” in their healthcare and how to keep them involved throughout their care.

  3. Health insurance is something that everyone needs and not enough people have available because of these other financial burdens.

  4. Reta, totally on the same page with you… the example I sited actually teed up follow-up alerting for doc or physician extender to incorporate in “prioritized” proactive outreach and behavior change process (e.g. how “activated” or “ready to change” is a patient and what “path” makes sense for them). The goal isn’t to check the box that the question was asked, it’s creating an ongoing, dynamic interaction with the patient to “course correct,” and giving the right care team member at the right time (across workflows/organizations) the ability to move ball forward.

  5. We have been taking steps to increase patient engagement for years and we have found that the best way to do this is to enable for true transparency. Reading articles by journalist across the country it is clear that what patients need is the ability to truly compare providers, institutions and practices so that they have a better understanding of the care they are receiving. This starts with the coordination of care within your practice first. From our work there, we created the website we use now for uninsured/price-sensitive patients, so that they can compare and shop for the procedures they need. The responses we’ve gotten from patients who were satisfied with the care is unparalleled in comparison to other efforts we’ve made in the past. Allowing and helping your patients to become more engaged, as the controllers of their own care truly does bring about better outcomes, less costs to them and better collections for your practice.

  6. Robert,
    You are correct, we must ask a new set of questions and then use that information to assist the patient. But we may also have to develop a series of questions based on the answers from the original questions.

    The question about tracking blood sugar is good example. Why aren’t they tracking their blood sugar? Is it because they don’t test regularly, they don’t have a simple system for recording the numbers or no one has stress the importance of tracking these numbers? After this first question is settled, then you can teach them how to use these numbers.

  7. Fantastic points! And I believe we’ll see, with increasing frequency, that activating the patient, and remaining engaged with them in a coordinated manner over time, is what ACOs will struggle with–
    different HIT systems, across different workflows, within different organizations will create isolated feedback loops and blind spots in patient “activation.”

    It’s critical to think past the EMR to understand exactly how to “push the activation buttons.” This doesn’t have to be complicated… as a matter of fact our company layers a cloud-based checklist/alerting system over all the systems/workflows to uniformly drive care based on ABBES– patient Attitudes, Beliefs, Behaviors, Environment, and Skills.

    Check out what surfaced with one of our ACO customers when they captured ABBES to gauge a patient’s “activation” level: How do you track your blood sugar (I don’t = 19%), Are you exercising 30 mins/day (no = 80%), Are medication costs an issue (yes = 21%).

    You can imagine how this information helped drive a range of care coordination activities that would have otherwise been missed if relying on same ol’ clinical information. It’s all about asking a whole new set of questions and making sure everyone on the care team knows when it’s time to do their part with the answers.

  8. I have long advocated for educational programs to teach patients about their chronic illnesses and how they can learn to better manage them. This becomes a win-win situation for the doctors and the patients.