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.
Use 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 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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