We all know “that patient” – the one we may dismissively label “noncompliant.”
The person with diabetes whose HA1C is consistently above normal limits – the one who swears, when confronted with the numbers (yet again) he’ll start eating right and using his insulin as prescribed.
And yet, month after month, the lab work tells a different story. We watch in helpless frustration as patients like these spiral downward, developing complication after complication.
I thought about “that patient” as I read a recent Wall Street Journal article describing Dr. Judith Hibbard’s Patient Activation Measure (PAM), which she and her colleagues at the University of Oregon developed some years ago.
First, let me say I greatly admire the research and work of Dr. Hibbard and her team; I believe that the PAM is a wonderful tool and a step forward in better understanding patients.
While the article, and Dr. Hibbard, argue that the use of the tool can better target the needs of patients – and I agree – I can’t help but worry that the entire premise that patients need to be “activated” misses a point.
Patients are people before they are patients.
We know that when people are sick, they are still part of their broader world of family, friends and finances. We also know that their social, spiritual and psychological selves are every bit as important, and as important to their “cure” as their activation as a patient.
I suspect that Dr. Hibbard would agree with me and even argue that the PAM reflects all of these factors.
PAM is accurately diagnosing the end state – how all these factors impact the patient and the patient’s ability to be involved in his or her own care.
I worry, however, that the PAM may be oversold by healthcare administrators who put it in place as a way of trying to address all the factors that affect patient activation.
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.
Recent articles highlight challenges with holding providers accountable for the care they deliver. One of the major thrusts of efforts to transform the American healthcare delivery system has been to become more patient-centered and to allow patients to provide feedback that matters.
Emblematic of this is the emphasis on patient involvement in the final rules for the Shared Savings Program accountable care organizations (ACO).
Echoing former Centers for Medicare & Medicaid Services Director Don Berwick’s plea on the behalf of patients (“Nothing about us without us”), the ACO final rules emphasize patient engagement in governance, quality improvement and the individual doctor/patient interaction.
Michael Millenson’s white paper provides a summary of the patient empowerment movement.
The development of the patient activation measure (PAM) and the Center for Advancing Health’s 43 engagement behaviors has allowed us to study patient-centeredness with more specificity. Studies have shown that activated patients are less likely to choose surgical interventions, have better functional status and satisfaction, are more likely to perform self-management behaviors, and report higher medication adherence rates.
Healthcare policy experts and payers have embraced the argument outlined above, and patients’ reports of their satisfaction with both physicians and hospitals have increasingly been used to calculate financial rewards.
Patient satisfaction has garnered new attention as an indicator of provider performance and an important dimension of value-based health care under the Affordable Care Act (ACA). Defined in any number of ways, it is often publicly reported to help patients choose among health care providers.
This month, patient satisfaction takes on even greater importance as ACA provisions set to begin October 1, 2012, tie patient satisfaction to Medicare reimbursement, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. HCAHPS scores reflect patients’ perspectives on several aspects of care: communication with doctors and nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment—and are estimated to place at risk an average of $500,000 to $850,000 annually per hospital.(1)There’s a lot riding on patients’ perceptions of the health care experience, our satisfaction with the care we receive. But what do we really know about patient satisfaction, its relationship to patient outcomes and cost—and just what is it we are rewarding?Continue reading…