Patient-centered care is a cornerstone of any accountable care organization, but creating or joining one doesn't necessarily make patient engagement any easier. In the world of healthcare business, patient engagement may sound like a "soft" concept, but its difficulty is nothing to underestimate.
David Muhlestein, PhD, director of research at Leavitt Partners in Salt Lake City, says a minority of patients want to be engaged with their care teams in actively managing their healthcare. The high majority — likely approaching 70 percent — want to turn their care over to their physician and have them take the reigns. The rest of patients do not want to share decisions about their healthcare with physicians at all — they prefer to decide on their own.
"ACOs are finding it's really hard to get people engaged," says Dr. Muhlestein. "Some are proactive or are really trying to engage patients in different ways, but they're not particularly seeing more success than anyone else."
What is working for ACOs' patient engagement? What are the biggest roadblocks? As it turns out, there are several definitions of patient responsibility, high-deductible health plans are bad news for accountable care and no ACO provider will be successful on a high horse.
Seven degrees of engagement
There are numerous buzzwords for patient responsibility — patient engagement, accountability, skin in the game. It's easy to lump these ideas together as synonymous, but Dr. Muhlestein says there are some nuances.
For example, patients and physicians may arrive with different expectations for patient engagement. Patients see it as shared decision-making, or talking to a physician before a decision is made about their treatment to learn about the pros and cons, then making the ultimate decision in conjunction with the physician. It's a behavior largely reserved for the visit to the physician.
Physicians, on the other hand, see engagement as active condition management. This includes lifestyle changes, adherence to medications and regular dialogue with the care team to ensure the care plan is going smoothly. Essentially, this version of patient engagement involves the patient taking on more responsibilities that traditionally belonged to clinicians and carrying them out between physician visits.
People who have used accountants to complete income taxes may see where patients are coming from. Instead of doing a few tasks on a daily basis, many people find it easier to drop off their financial paperwork and receipts at the end of the year and let someone else do the math. The same is often true for patients' expectations for healthcare.
"You want to say, 'Here, you deal with this. I'll come back next month and you'll tell me how to change the doses of my meds,'" says Dr. Muhlestein.
How having "skin in the game" could muddle accountable care
There's another shade of patient responsibility, one that is a little greener in hue. More patients are taking on more financial responsibility for their healthcare. Recent years have brought a boom of high-deductible health plans, which cut businesses' health benefit costs by shifting more responsibility onto their employees. This is not the best news for people trying to advance accountable care. Some ACO leaders simply call these health plans outrageous, even immoral.
"It's something we're concerned about," says Marcia Delk, MD, chief quality officer with Marietta, Ga.-based WellStar Health System, a five-hospital system participating in the Medicare Shared Savings Program. Dr. Delk spoke about the trend more generally, as high deductibles don't pertain to Medicare beneficiaries. "Those individuals with more of a responsibility to their bills are very price sensitive to whatever healthcare they're buying." And this sensitivity extends to basic preventive care — a huge component of population health — that is covered by their plans.
A 2012 study conducted by Rand Corp., Towers Watson and the University of Southern California examined families' use of care in the first year after switching from traditional plans to high-deductible health plans. These families spent, on average, about 14 percent less on their healthcare than those enrolled in traditional plans. But they also cut back on beneficial preventive services — such as cervical and colorectal cancer screenings, mammograms, and blood tests for glucose and lipids — even though most of these preventive services are covered under consumer-directed plans.
These findings are worrisome to healthcare leaders not only involved in ACOs but those aiming to deliver population health more broadly. High-deductible plans will not fall by the way side any time soon. A study released in August 2013 by an association of large U.S. employers found 22 percent of U.S. companies plan to offer only high-deductible health plans to employees next year as a way to rein in the costs of providing health coverage.
Much like the financial case providers must make for investments in population health management — linking initial costs to long-term gains — physicians and care teams may need to take a similar approach with their patients. Robust communication and patient education can help them understand the value of their vaccinations, mammograms and other preventive measures, and how these are not the measures to skimp on.
"If we engage patients properly and work with them to understand the benefit of taking care of a chronic condition, or getting a colonoscopy, and how that will reduce costs later on, it can work," says Dr. Delk.
Reaching instead of preaching
That seems to be the main job description for ACOs today — finding what works.
Nashville, Tenn.-based Saint Thomas Health launched its ACO, MissionPoint Health Partners, in January 2012. With more than 50,000 ACO members, MissionPoint has a perquisite relationship with the YMCA of Middle Tennessee. Members who complete their health risk assessment and are in need of more exercise use coupons to visit the Y free of charge.
But Mike Schatzlein, MD, CEO Saint Thomas Health, noticed few people were using these coupons. He asked people at the Y how to better activate people. Experts at the Y, one of the largest of its kind, told him a 20 percent activation rate for exercise as part of self-care is about all you can expect.
Dr. Schatzlein, a former heart surgeon, tells this story pragmatically. His philosophy is one shaped by years spent treating patients whose heart disease was caused by smoking. He would urge them to quit, only to see how "dreadfully hard" it was for them to do so.
"I am not beating the drum about patient responsibility," he says. "Yes, we offer all the opportunities for people to try to take responsibility, but I'm not going to be preachy about it and MissionPoint isn't either. We need to be with people where they are."
ACO leaders stress how the simple measures can have the largest impact. Sometimes it means educating a patient about the health resources available to them. It might involve arranging transportation for patients who don't own cars. Leaders, again and again, say ACO providers must take the time to see the healthcare system from the patient's perspective.
MissionPoint's health partners did just that with one woman. She was a Medicare patient who visited Saint Thomas' emergency rooms 17 times in the year before she was attributed to the ACO. It wasn't because she wanted to go to the ER a lot, says Dr. Schatzlein. She just didn't know any other way to deal with her diabetes.
One of the ACO's health partners spent some time with the patient, "and not a lot," says Dr. Schatzlein. The health partner helped her gain access to swim at the Y, moved her onto a diabetic diet, showed her where to buy the food she needed and introduced her to a dietician. The woman dropped four dress sizes, was taken off her diabetes medications and hasn't visited the ER in more than a year.
"So you could say, 'Well she was irresponsible, getting all of her care from the ER.' But it didn't take very much to turn her into a responsible [patient]," says Dr. Schatzlein. "I think we need to tell people what they need to do and guide them and help them, but it's hard for me to know where to draw the line in punishing somebody for not taking care of themselves."
Providers at HackensackAlliance ACO, based in Hackensack, N.J., echo this sentiment. They have learned that, sometimes, it doesn't take drastic measures to change patient behavior.
The ACO recently gave 4G tablets to a group of its high-risk Medicare patients to manage their chronic conditions. The tablets are individualized to each patient with their medication, medication times, educational material and device parameters, such as those for a blood pressure cuff. Patients then check off each medication as they take it, while the while the prescribed device information is automatically transferred to the tablet via Bluetooth. If patients do not log in that they've taken medication after a pre-set limit — usually missing more than 50 percent of medications within a 12 hour period — or if the device provides an alarming reading, an alert notification is sent directly to a nurse's cell phone.
Denise Patriaco, RN, APN-C, director of the ACO, says she's been surprised by how much the tablets help patients organize their healthcare and link behaviors like poor eating to their vitals.
"On Sunday, they may go to a birthday party, eat three hot dogs, drink a soda and eat a bag of chips. The next day they're up three pounds, and they see their feet are swollen," says Ms. Patriaco. "Our navigators see this number, and they will call to say, 'Hey, what's up? What are you doing?' It's the first time [patients] are associating their behaviors with poor healthcare outcomes."
Conclusion
The normal fee-for-service environment does not have financial rewards for patient care coordination or care management programs. Even though ACOs are one of the most progressive steps toward pay-for-performance reimbursement, joining one doesn't necessarily provide direct reimbursement for patient education and engagement.
"Most hospitals are really operating on razor-thin margins, and many are at a loss," says Ms. Patriaco. "Even in the ACO model, unless there's a distinct return on investment, patient engagement programs will be overlooked."
ACOs haven't completely disrupted the conventional American thinking of "doctor knows best," either. Even the way some ACOs describe themselves can make patients seem like bystanders. Most ACOs say their prime goal is to "keep people healthy," but that wording isn't far from what a homeowner might use to describe a relationship with his house plants.
"I feel very strongly that the system of reimbursement that evolved in this country has created an environment where the patient is a passive participant," says Morey Menacker, DO, an internist and president and CEO of HackensackAlliance ACO. "Doctors' knowledge of the human body enables us to make suggestions so people can do the best they can."
For ACOs and other care delivery models to further population health in a lasting way, providers will need to intensify their communication and education efforts with patients, redefining what it means for them to be "engaged" in healthcare today. Successful ACOs will be those that see the healthcare environment through the eyes of their patients and find practical, helpful ways to interact with them.
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