Pay for Engagement: A New Framework for Physician Reimbursement

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A thousand channels, and nothing’s on. “Patient engagement” has become an increasingly used buzzword in which healthcare finds itself awash. Yet little around patient engagement has been operationalized into any sort of enduring clinical reality. In part, this is due to the lack of convergence, until recently, of three major and arguably requisite ingredients: 1. A practical, operational definition of patient engagement that allows us to measure it continuously and treat it just as we do a vital sign, 2. A manner by which to connect the two most important parties in the patient engagement equation -­‐ the patient and physician – between visits in a way that is clinically compatible and meaningful, and 3. An incentive that helps honor and reward a key missing ingredient – the physician -­‐ for the time needed to promote engagement directly with his or her patients. We will discuss these three elements and highlight two current pilot studies that are beginning to break through these barriers.

Screen Shot 2014-11-10 at 5.27.58 AMUse of the term “patient engagement” in the media and the gray literature (Figure 1), and in the peer-­‐ reviewed literature (Figure 2), has skyrocketed in recent years. One of the biggest problems with the term “patient engagement” is that although many conceptual definitions have been put forth, very few operational definitions exist that can help us turn ideas into action. Without a common currency of exchange for this thing called patient engagement, we are limited in terms of what we each believe it is, and what we can do to promote it. As Stan Berkow eloquently stated in his March, 2014 Huffington Post blog, “While everybody wants patient engagement, nobody really knows what it is or how to measure it.”1 We chase our tails looking for a good thing, not knowing how to get there, or whether we’ve arrived.

Why do we need an operational definition of engagement? A growing body of evidence demonstrates that patients who are involved in their own healthcare experience better outcomes and incur lower costs.2 But if we are going to develop programs to promote and even to incentivize this wonderful thing called engagement, we must be able to measure it. Hibbard et al.3 have done a terrific job bringing patient activation from a research metric to practical clinical utility with the Patient Activation Model (PAM). An activated patient is someone who has the knowledge, skill, and confidence to take on the role of managing his/her health and healthcare. The PAM score may predict behavior, but behavior change, as we know, requires sustained action. Engagement is a more dynamic measurement of how involved the patient chooses to be, and continues to be in his or her care. Engagement is not a point-­‐in-­‐time survey measurement, or an outcome; rather, patient engagement should be viewed as a vital sign of both the patient and of the parties involved in the delivery of healthcare. Just as a normal and sustained blood pressure correlates with a whole host of long-­‐term beneficial health and economic outcomes, so too does engagement.

Why pay doctors for patient engagement? The concept of paying for engagement is not new. A number of studies have explored offering financial incentives from health plans to members (who are often patients) for engaging in healthful behaviors.4 5 Unfortunately, these studies have had mixed results, and it’s unclear if any long-­‐term behavior change can result. Why is this? The answer may be simple. Who amongst us, if asked to engage with an entity or organization rather than a trusted person, is likely to sustain engagement? Engagement is not optimally facilitated through an administrative program; nor is it merely achieved by having a patient log in through a portal. It is created through a contextual experience with a trusted individual – often our doctors -­‐ around a health-­‐related issue to achieve a goal. Substantiating this concept is a study on patient engagement by the National Institute for Health Care Reform that stated, “Lesson one is that people trust their doctors, and if it’s anyone else that the patient is not familiar with, the outreach does not work.”6 One reason among many that the task of engagement has been relegated to organizational and programmatic activities, rather than to the physician him or herself, is that the physician has neither the protected time, nor the efficient tools to proactively reach out to patients in an enduring and sustainable way.

Pay-­‐for-­‐engagement (P4E) is a new reimbursement model that aligns physician compensation with patient engagement. Rooted in the principles of Narrative Medicine7 and Relationship Centered Care,8 P4E incentivizes a strong doctor-­‐patient relationship, promotes the inclusion of actionable patient-­‐generated data, and serves as an economic catalyst to capacitate new proactive, longitudinal, and contextual practice in medicine.9 The P4E model directly compensates doctors for the time, attention, and care they provide in the context of patient engagement, which includes activities such as proactive communication, monitoring, analysis, and interventions that take place outside of (and between) traditional episodic visits.

In this model, compensation may take the form of a one-­‐time payment based on activities sustained through an acute recovery period, or it may be a recurring payment for continued proactive management of a chronic condition. In either case, the emphasis is placed on the immediate importance of sustaining a strong doctor-­‐patient relationship, as opposed to tying the reward to a distant outcome metric that may or may not be achievable. The P4E model anchors the broader ideals of patient engagement in the pivotal trust relationship between doctors and patients, encouraging new methods of communication that extend the partnership beyond the boundaries of the exam room, and into the enduring context of day-­‐to-­‐day life.

The   Impact   of   Proactive   Communication

As described by Laura Landro in the Wall Street Journal, communication in the physician-­‐patient relationship has long been thought of as a “soft” science, but is increasingly understood to be at the root of many of health care’s failures and rising costs.10 Bre a kdow ns in physicia n -­‐pa tie nt com m unica tion a re cite d in 40% o r m o re o f m alp ractice claim s. Research by Texas State University and the University of California has shown a 19% higher risk of non-­‐adherence among patients whose physicians communicate poorly than among patients whose physicians communicate well.11 The notion of a communication partnership sitting at the heart of patient engagement is further reinforced within the framework of Relationship-­‐Centered Care, which recognizes that the “nature and the quality of relationships are central to health care and the broader health care delivery system.” 8

P4E  aims     to   be   a   catalyst   for   this  doctrine    by    directly    remunerating     physicians   for   fostering   partnership   with  their   patients,  particularly    for    activity    that    may    lie    outside    of    and    between    traditional    clinical    encounters.

Patient   Engagement   and   Doctor   Engagement

While   emphasis   has   lo n g   b e e n   placed   on   engaging   the   patient,   an   argument   can   be   made   to   actively    cultivate     physician   engagement   as   well.        At   the   frontlines   of   the  U.S.     healthcare   system,  doctors     are   bearing    the     brunt   of   regulatory   upheaval,   technology   adoption,   and   reimbursement  reform.     As   delegates   of   the    healthcare     system   at   large,   doctors   are   often   the   targets   of  frustration     and   resentment,   stemming   from  systemic   inequities   that   are  often     beyond   their  control.     This   has   created   a   tenuous climate   for   physicians  and   taken   a   toll   on   job   satisfaction,  stress,     and   perhaps   quality   of   care.

In  this    challenging    context,    how    do    we    motivate    the    doctor    to    take    that    extra    step    towards    patient-­‐ centeredness    when    his    or    her    schedule    demands    more    and    more?       With    the    emergence    and    proliferation    of    secure    electronic    messaging    through    patient    portals,    physicians    are    increasingly    being    tasked    with    managing    high-­‐volume    electronic    in-­‐baskets    without    any    additional    reimbursement.       In    one    study,    over    75%    of    physicians    reported    that    lack    of    reimbursement    was    a    barrier    to    engaging    with    their    patients    through    secure messaging.  12    A    2003    policy    paper    of    the    American    College    of    Physicians    entitled,    “ACP    Analysis    and Recommendations  to    Assure    Fair    Reimbursement    for    Physician    Care    Rendered    Online,”    urged    the    Centers    for    Medicare    &    Medicaid    Services    (CMS)    to    reimburse    physicians    for    electronic    care    delivered    through    emails    and    electronic    consultations.13        Former     CMS   Administrator   Donald   Berwick  suggests     that   “communication  between     clinicians  and    patients    can    be    far    easier    and    multimodal,    making    the    former    mainstay    of    care    -­‐        the    “visit”    -­‐    only    one    among    the    ways    to    get    and    give    help,    and    not    often    the    best    one,    at    that.”14        Gradually,    CMS    has    added    billing    codes    that    may    make    reimbursement    for    telehealth    (also    called    non    face-­‐to-­‐face    care)    possible    in    limited    contexts    including    transition    care    management    (TCM)    codes,    and    chronic    care    management    (CCM)    codes,15    but    there    is    still    a    long    way    to    go.    As    Crotty    et    al.    indicated    in   their    recent    Health    Affairs    article,    “As    the    use    of    secure    messaging    becomes    more    prevalent,    a    mechanism    for    reimbursing    physicians    and    accounting    for    the    workload    of    electronic    messaging    will    be    important.”    16       Crotty    further    indicates    that    most    payers    continue    to    use    fee-­‐for-­‐service    reimbursement    systems    that    don’t    include    compensation    for    time    spent    on    patient    email,    with    the    gloomy    forecast    that    this    is    unlikely    to    change    in    the    foreseeable    future.       P4E,    however,    specifically    challenges    that    barrier.

By  focusing    a    financial    incentive    on    engagement    -­‐     the  act    of    participating    in    an    important    activity    -­‐   P4E    aligns    patient,    physician,    and    payer    incentives.       Pay-­‐for-­‐engagement    demands    proactivity,    whereas    fee-­‐for-­‐service    is    reactive    by    design.    P4E    is    also    fundamentally    different    from    pay-­‐for-­‐performance    and    other    value-­‐based    models    that    tie    physician    compensation    to    downstream    process    of    care    measures,    efficiency    standards,    and    quality    metrics.     And   although   P4E   is   a   departure   from   traditional   reimbursement   models,   it   is   not  mutually    exclusive     and   can   be   combined   with   almost   any   framework.      As    such,    P4E     can   complement   popular  incentive     programs     such   as   Patient   Centered   Medical   Home  and     Accountable   Care   Organizations,   which  emphasize     coordination   and   share   a   similar  patient-­‐centered    philosophy.

The Era of Patient-Generated Health Data

If  we    are    to    expect    physicians    to    respond    positively    to    reimbursement    for    engaging    their    patients,    we    should    equally    expect    that    the    engagement    take    a    form    that    is    both    meaningful    for    the    patient    and    efficient    and    highly    actionable    for    the    physician.          Biomedical     sensors,   mobile   health   apps,   and   bluetooth-­‐enabled     devices  are     rapidly  becoming     integrated   with   each   other   and   with   clinical   systems   through   interoperable  frameworks.        Apple’s    HealthKit    is    just    the    most    recent    entrant    to    this    space.          There    are    so    many    patient    engagement    related    data    streams    demanding    the    potential    attention    of    the    physician,    that    the    doctor    simply    can’t    take    them    all    in,    and    as    a    result,    often    chooses    to    take    none    of    them    in    at    all.          The    call    for    engagement    is    everywhere,    but    in    the    clinic,    there    is    not    a    drop    to    drink.

In  this    era    of    patient    generated    health    data,    increasing    opportunities    for    engagement    and    communication    carry    the    risk    of    burying    the    physician    under    an    abundance    of    data    that    are    so    voluminous    that    the    actionable    bits    are    hidden    like    the    proverbial    needle    in    the    haystack.       Ultimately,    if    we    are    going    to    use    technology,    SMS,    secure    messaging,    and    sensor-­‐based    devices    to    enable    patients    to    track    and    share    their    own    health    data,    we    must    provide    the    data    in    filtered,    meaningful,    and    actionable    formats    to    members    of    the    care    team.      Using    patient-­‐reported    outcome    metrics    such    as    those    being    developed    by    the    Patient    Reported    Outcomes    Measurement    Information    System    (NIHPROMIS.org)    for    subjective    metrics,    and    using    smart    algorithms    to    interpret    objective    data,    we    can    reduce    inbound    noise    to    the    clinician,    render    the    data    both    efficient    and    actionable,    and    thereby    facilitate    physician    engagement.

Putting  it    all    together    

Returning  to    our    opening    paragraph,    achieving    engagement    is    about:    being    able    to    implement    an    operational    definition    of    engagement,    giving    the    right    people    (physician    and    patient)    the    right    tools    (convenient,    efficient,    actionable)    to    enable    them    to    execute    on    an    ongoing,    contextual    care    plan,    and    providing    incentives    (reimbursement)    that    honors    the    work    involved    in    maintenance    of    engagement.

We  can    illustrate    the    pay    for    engagement    model    in    action    by    describing    two    pilot    studies    underway    in    California    in    which    a    large    national    payer,    and    a    medical    malpractice    carrier    are    reimbursing    orthopedic    surgeons    for    successfully    maintaining    a    target    level    of    patient    engagement    over    episodes    of    peri-­‐operative    care.       Although    results    from    these    pilots    may    not    be    known    for    1-­‐2    years,    better    outcomes    and    lower    costs    of    care    as    functions    of    patient    engagement    are    among    the    most    interesting    results    that    may    emerge.       Certainly,    the    findings    of    these    studies    may    have    significant    translational    implications    to    other    medical    specialties.

In  these    pilot    studies,    patients    are    enrolled    in   procedure-­‐specific    electronic    care    plans    that    consist    of    schedules    of    automated    electronic    check-­‐ins    served    through    HIPAA    compliant,    secure    messaging    (such    as    secure    email).        These    automated    check-­‐in    requests,    coming    directly    from    the    physician    to    the    patient,    honor    that    unique    trust-­‐relationship    and    contain    mutually    agreed    upon    reminders,    guidance,    care    instructions,    and    calls    to    actions.       Pre-­‐operatively,    these    may    include    tasks    to    get    medical    clearance,    guidance    to    make    medication    adjustments,    suggestions    to    prepare    the    home    for    post-­‐operative    recovery,    and    reminders    to    arrange    for    a    ride    home    after    surgery.       All    of    these    activities    focus    on    the    notion    that    the    best    post-­‐operative    outcome    is    achieved    through    the    best    pre-­‐operative    preparation    not    only    by    educating    the    patient    about    what    to    expect,    but    by    providing    timely    reminders    about    clinically    important    actions    that    can    be    taken.      Following    surgery    and    after    discharge,    the    automated    schedule    of    ongoing    electronic    check-­‐ins    may    include    messages    of    encouragement,    guidance,    and    symptom    assessment    through    validated    scales    to    monitor    clinical    concerns.

(1)    Operationalizing    engagement:    In    a    model    in    which    there    is    a    mutually    agreed    upon    schedule    of    valued    activities,    the    execution    of    which    can    be    measured    digitally,    engagement    as    a    continuous    vital    sign    is    measured    as    a    running    percentage    of    electronic    care    plan    actions    carried    out    by    the    patient.      But    engagement    is    not    capped    by    those    activities    that    are    pre-­‐scheduled.       In    the    pilot    studies,    a  patient    who    goes    above,    by    proactively    carrying    out    more    than    only    those    scheduled    items,    will    increase    his    or    her    engagement.       The    first    of    the    two    pilots    has    already    achieved    high    degrees    of    engagement,    particularly    –    and    interestingly    -­‐    among    those    individuals    in    the    65-­‐75    year    old    age    cohort.

(2)    Making    engagement    clinically    compatible    and    meaningful:    Through    automation,    the    physicians    in    the    pilot    are  enabled    to    concurrently    manage    many    patients    asynchronously    between    visits    with    minimal    impact    to    their  clinical    workflows.        Through    analytical    algorithms,    exception-­‐based    rules    surface    the    patients    with    clinical    concerns    -­‐    the    “needles    in    the    haystack”    -­‐    to    the    attention    of    the    care    staff    and/or    the    physician,    and    similarly    provide    reassurance    that    the    majority    of    other    patients    are    on    track.

(3)    Creating    incentives:    Real    reimbursement    based    on    real    engagement    metrics    honor    the    physician    for    engaging    with    his    or    her    patients,    especially    so    for    the    ones    requiring    attention    due    to    questions    or    evolving    clinical    concerns.        By    treating    poor    engagement    as    a    vital    sign,    practices    can    proactively    reach    out    to    low-­‐ engagers.     And    by    having    a    finger    on    the    pulse    of    patients    between    visits,    practices    can    intervene    earlier    than    ever    before    for    those    patients    who    develop    clinically    concerning    issues.

Many  companies    including    HealthLoop,    Wellbe,    Ginger.IO,    Conversa,    and    RoundingWell    (just    to    name    a    few),    are    entering    the    space    of    the    digital,    asynchronous    visit,    connecting    patients    and    physicians    in    increasingly    meaningful    ways.       P4E,    developed    in    part    by    Dr.    Jordan    Shlain,    founder    of    HealthLoop,    is    a    new    and    powerful    approach    to    bringing    patient    engagement    into    clinical    reality.       With    the    emergence    of    meaningful    digital metrics  of    engagement,    and    with    the    recognition    by    more    and    more    risk-­‐bearing    entities    that    engaged    patients have  better    outcomes    and    lower    costs,    the    incentives    of    patients,    physicians,    and    payers    may    increasingly    align.        And    when    that    happens,    we    may    finally    be    turning    the    corner    on    the    promise    of    a    blockbuster.17

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26 replies »

  1. Rosener et al’s central premise that patient engagement occurs between two human beings – the doctor and patient – versus technology and patients, is correct. Health care is after all a “social” interaction. All the text messages, patient portals and emails in the world cannot compensate (in terms of engagement potential) for a physician-patient relationship characterized by dislike, distrust or poor communications.

    The real challenge for physicians and their stakeholders today is “not how to engage more patients.” Rather the challenge for physicians et al “is how to be more engaging to patients” (who are already engaged

    Before a patient shows up in the doctor’s they research their complaints online and with their family/friends. They decide that a doctors visit is necessary and take time to schedule, take time off, and show up for their appointment. While waiting to be seen we make mental lists of what we want to discuss with the doctor.

    By definition, people waiting to be seen in the doctors office are engaged in their health. They are 1) interested in the subject matter enough to have schedule the appointment and shown up and 2) they are cognitively and emotionally engaged in the subject of their own health. Showing up constitutes engagement.

    Depending upon how engaging the clinician’s “bedside manner” is will determine whether the patient remains fully engaged or becomes disengaged. Most would agree that being interrupted or ignored do not make for an engaging patient experience. Nor does not being able to ask more than one question/visit. The average PCP spends <60 seconds educating patients when prescribing a new medication. Lack of information and health literacy – not a lack of engagement – explains why so many people walk out of the doctor's office not understanding what they were told.

    Physicians were taught in medical school that they – not the patient – are in charge of the visit. Their job is to get patients to give them the diagnosis – not be engaged. In fact patients are expected to assume a passive sick role once the exam room door closes which indicates that patients were never supposed to engage in prolonged conversations with doctors.

    A clinician's ability "to be engaging" can be measured. My company does it right now by evaluating audio recordings of doctor-patient exam room conversations. We can tell you who does the talking, what is talked about, the role of Health IT, who asks the questions, who sets the visit agenda, who makes the decisions, etc…

    Meaningful patient engagement takes place between physicians and their patients beginning in the doctor's exam room. Technology can help enhance that relationship between visits.

    Stephen Wilkins, MPH

  2. “Lower costs for the health care system”

    For a health care system run for the benefit of for-profit insurers and their shareholders.

    I’ve been involved in a lot of cost-control programs over the years, and I’ve never seen a penny returned to the enrollees.

    Count me out from here on.

  3. Stephen, thanks for your comment. You are absolutely right. The literature shows that often, by the time a patient reaches the parking lot after discharging from the hospital or the clinic, they have forgotten 80% of the instructions provided to them.

    So, the idea is to provide the patient the rift information at the right time, in bite sized pieces (rather than just as a large bolus at the time of discharge). Particularly in the case of hospital discharge, this is believed to help keep the patient on track and reduce potentially preventable causes of readmission. One of the pilot studies underway is exploring that specific outcome.

  4. Lower costs for the health care system. Engaged patients have fewer potentially avoidable visits to the emergency room, fewer preventable hospital readmissions, etc. Please see article references such as #2 and #17, or anything by Hibbard et al.

    Also in references (#4, #5) are studies in which the payers offered financial incentives to patients who were engaged…So yes, there can be mechanism for profits to get back to patients. The problem with those studies was that the engagement was not between a patient and doctor, it was between a patient and a program or a patient and a third party, and the literature has shown (reference #6) that to get patient engagement, the doctor must be involved, not another party.

    So, P4E opens the possibility for every party involved to enjoy benefits and to help keep costs – especially costs around preventable/avoidable utilization – controlled. If your doctor knew every day how you were doing after your visit, and could intervene as soon as there was any sign of problem (rather than intervene only after the problem got much worse), then you could avoid that problem landing you in the emergency room or in the hospital.

  5. I’m a big fan of P4E solutions for another reason: the way patients are discharged from hospitals is all too often inadequate (frankly often atrocious). We know this to be true based upon patient satisfaction levels but also due to sizable number of preventable readmissions. P4E is the means to reduce risk of readmission and now, associated financial penalties.

    But don’t believe me… here’s what AHRQ says: “No consensus exists on how to ensure patient safety after hospital discharge, but some evidence indicates that comprehensive, multi-modal interventions may be more effective at preventing rehospitalization than targeting individual components of the discharge process.”

    And while there’s no specific evidence that P4E is the exact type of “multi-modal intervention” referenced, intuitively, texting with your doctor is better than being handed a brochure and five pages of discharge instructions to follow. All too often patients simply ignore that junk and end up panicking on what to do, so back to the hospital they go. Or how many times does a patient call their doctor’s office only to be told by the staff or nurse that “I can’t answer that question, you’re going to need to see the doctor.”

    The penalties will certainly motivate experimentation and P4E is going to be an approach that many should be willing to try.

  6. “You don’t think any of the savings will get back to the patients, do you?”

    My cynical nature says NO because this system is only about higher profits for everyone except the patient, but the ACA is supposed to limit insurance profit % – isn’t it?

  7. Remember, “lower costs” is always a euphemism for “higher profits for United, Aetna, and Cigna.” You don’t think any of the savings will get back to the patients, do you?

  8. “…high patient engagement is show to lead to better outcomes and lower costs.”

    Lower costs for the doctor? How is that an incentive? I get you on docs would want better outcomes, but spending 30 minutes with the patient instead of 15 minutes probably would also.

  9. Physicians still make money the same way as they currently do, but they are given an added incentive for engagement because high patient engagement is show to lead to better outcomes and lower costs.

  10. Communication is key and sometime needs a advocate to step in and bridge the gap between the patient and physician. Most of the time it only take an appointment or two to get them going on the same page. It’s a beautiful moment when that happens. http://www.viveesa.com

  11. Being engaged sounds like a lovely relationship but how are the providers going to make money?
    What compares to surgeries and expensive relatively useless lab tests and drugs?
    Don Levit

  12. these are not computer generated.
    They are narratives that are thought out by medical teams.
    No off-shoring. Doctors need to be on the other end of the responses to give contextual, exception based information about who they should be worried about NOW…

  13. No third parties. We need to connect doctors to patients directly. Get everyone else out of the way. They are complicit in the Principal Agent Problem.

    We need to measure engagement; which is another way of saying ‘communication’.

    We wake up and all we do is communicate…all day long….so let’s lubricate the communication, in a meaningful way, between doctors and patients.

    It’s good medicine.

  14. One cannot oursource relationships. You can try, but show me where it has succeed. The magic of pay for engagement (via a digital medium) is that you are proactively, contextually checking in with patients that goes right back to the medical team that takes care of you.

    Trust is built on being valued and being included….and this is a critical factor in relationship building. Furthermore, where there is trust, there is a higher liklihood to change behavior.

  15. In medicine today, a lot of quality measures are already implemented. These are often determined at an administrative level and include measures such as HEDIS, PQRS, NSQIP, etc. In many settings, physician incentives are tied to performance on such measures at points downstream of the clinical encounter. So to say that the old fashioned doctor patient relationship should be left unfettered is neglecting that that horse has already left the barn. And in truth, some of these metrics have resulted in much better care, better outcomes, and lower costs.

    That’s the good news. The down side is that to date, we have not provided the doctor with any tools or incentives to remain engaged with the patient after the clinical encounter (even though most patients would gladly welcome an ongoing contextual relationship). P4E is one such mechanism to do so because it aligns many incentives, and it reduces the disconnect between the encounter and the outcome measure of many of the current metrics that are already in place. There is no “off shore” outsourcing or customer service lines with P4E. P4E starts with the face-to-face encounter, and continues with ongoing electronic check-ins between the same two people – the physician and patient – who had the encounter together. It is an ongoing dialogue between those two parties – not a third party. As the evidence has shown, introducing a 3rd party breaks down the trust relationship between the doctor and patient. P4E honors the relationship between the two most important people, the doctor and patient.

  16. Sorry, but computer generated electronic reminders are not the engagement I was looking for – Granpappy has a point. Why would the doc be paid extra for the computer’s work. Would off-shored (or other) doctor associated chat lines be engagement? The further from the source the worse it gets – just like our food.

    I don’t know about the rest of you but my experience with “customer service” chat lines or emails are not handled by anyone with knowledge or engagement – they just read the product manual.

  17. Perry:
    I agree with you.
    Why should we measure a quality which already should be part of the process?
    We want to measure things, for we feel we have a sense of control by doing so.
    If the doctor and patient are engaged and they are happy with their relationship, why not have the patient pay the doctor a bonus?
    Why not have the doctor provide the patient a gift?
    Why get a third party involved?
    It merely invites fourth and fifth parties to do the “measuring” and the “adminisrtation.”
    Don Levit

  18. ??????????????????????

    If you read the original post and then my comments, you’ll understand that my scorn is entirely directed at the numbnuts in California who think that sending out spam-like e-mails with a doctor’s name at the end constitutes patient engagement.

  19. The emails follow the face-to-face visit in which the doctor indicates to the patient that there will be follow up together, facilitated by electronic check-in requests (via secure messaging). This keeps the patient engaged in a real personal relationship initiated in the clinical encounter, and these ongoing interactions continue to strengthen that relationship over time.

  20. I’m done with the racist comments on this blog. From now on grounds for banning.

    Why don’t you mention your views to the indian specialist you refer your patients to? Just attach a nice note to the patient

    Since your views on cusotmer service are so well thought out, maybe try calling your local HMO or cable company and see what kind of customer service you get

  21. I’m confused. It seems like in the course of old-fashioned medicine, the patient would see the doctor, doctor would make an assesment, make recommendations and discuss with patient, the patient would pay the doctor.
    Then came all kinds of insurances, HMOs, PPOs, review boards, etc, etc, to decide what is best for the patient (or at least what they will pay for).
    Then the government comes up with EHR, MU, PQRS. We have ACOs, P4P now, P4E. The way I see it old-fashioned doctor-patient relationships are being subsumed by all these other entities and requirements.
    What we’re looking to do is pay doctors for what they should be doing anyway but they’re too busy doing other required stuff to do now. Amazing.

  22. “These automated check-­‐in requests, coming directly from the physician to the patient, honor that unique trust-­‐relationship”

    That the e-mails described in the California trial could very easily be outsourced to where labor is cheaper and just have the patient’s and doc’s names filled in. Not my idea of a “unique trust- relationship.”

  23. Excellent and important. Many many years ago during physician advisory boards we would hear about how there needs to be pay for cognitive services so physicians could counsel and speak with patient. I’ve completed a post on this “The Office Visit is Not a Drive By”



    “Changing the Office Visit From Transaction to Value Experience”


  24. Let’s see:

    If the doc calls the patient and they have a lengthy discussion about medical concerns, that’s not engagement and shouldn’t be paid for;

    But if someone in Bangalore sends the patient a boilerplate e-mail with the doc’s name on it, that is engagement and should be paid for.

    Got it.