S. Lawrence Kocot, Ross White, Carmen Diaz and PratyushaKatikaneni|November 13, 2014 12:00pm

Why Patient Engagement is Key to Improving Health, Reducing Costs

The EngelbergCenter for Health Care Reform recently hosted “The State of Accountable Care: Evidence to Date and Next Steps” to discuss the development, challenges, and potential future for accountable care efforts across the country. Sean Cavanaugh, Deputy Administrator & Director of the Center for Medicare at CMS, kicked off the event, and highlighted progress and challenges of the Medicare ACO program and potential regulatory changes that could be included in the soon to be released Medicare Shared Savings Program (MSSP) proposed rule.

A Key Takeaway: Patient Engagement is Critical to the Success of ACOs
The need for greater patient engagement was a prevailing theme of the day for ACOs at Brookings. Patient engagement is viewed as a key to improved health outcomes and lower costs; well-designed patient engagement strategies can also improve patient experience by allowing individuals to become more active participants in their care. For example, shared decision making and patient activation are proven strategies for engaging patients at the direct care level. These approaches help providers and patients to recognize that a clinical decision is necessary, understand the evidence on best available interventions, and ensure patient preferences are built into treatment decisions and plans. A recent study by Jennifer Sweeney and colleagues highlights some successful examples.

Several examples of effective strategies for engaging patients with chronic disease were highlighted at the Brookings event. Kelly Taylor, Director of Quality Improvement at Mercy Clinics, highlighted Mercy’s chronic disease outreach program, which employs health coaches to motivate patient behavior change. The program creates actionable lists for patients due for hospital visits, helps with coordinating care transitions, and conducts pre-visit and post-visit assessments. Patients that receive these services typically score in the 90th percentile for HEDIS measures, such as control of blood pressure and blood sugar levels. A financial analysis demonstrated that for every dollar spent on the health coaching program, four dollars in revenue is received.

Morey Menacker, President and CEO of Hackensack Alliance Accountable Care Organization discussed Hackensack’s remote monitoring and care management tool that allow patients to monitor their diseases in their own homes. This program has contributed to a reduction in unnecessary hospital visits and improvement in patient self-management.

A number of organizations have also used web-based tools such as online or smartphone applications for patient engagement purposes. For example, Beth Israel Deaconess Medical Center developed patientsite.org, an interactive web-based portal decision aid giving patients access to their clinical records and the ability to check accuracy of allergy and medication lists. A recent study of 30,000 patients found that even after adjusting for health status and other factors, patients with the lowest activation scores incurred costs of 8 percent to 21 percent higher than those with the highest activation scores. Despite these encouraging innovations, more work is needed to empower patients in health systems across the country.

ACO Attribution: A Challenge for Engaging Patients
Over the next twenty years, we will see the baby boomer population inflate the number of Medicare beneficiaries by 60 percent; increasing from 50 million to 80 million. This statistic, emphasized by Cavanaugh, underscores the need to engage these patients in their care through more innovative approaches. If not, “slipping through the ACO cracks” will become all too real for too many patients.

While ACOs acknowledge they have work to do to more fully engage patients in their care, they also point out that program design issues need to address patient engagement. For example, a major fault in the MSSP patient attribution process is that some patient may not be aware they have been assigned to an ACO. In this case, they may seek care outside the ACO network of providers and in fact be assigned to a different ACO from year to year. Most importantly, there are no incentives for patients to remain loyal to an ACO when the attribution process does not reflect patient preferences.

Recent research highlights concerns with current approaches to patient attribution in ACOs.A recent study by Harvard Medical School researchers analyzed whether, over a two year period, Medicare beneficiaries would continue their care within their attributed ACO, or seek medical attention outside the network. Approximately 80 percent of beneficiaries would have chosen to remain with doctors inside their ACO. Not surprisingly, the research indicates that primary care doctors have more “sticking power” than specialists, who would have lost 66 percent of their beneficiaries to competitors outside the ACO. More worrisome, however, was the finding that most of the beneficiaries that strayed from the ACO were those with chronic conditions. ACOs need to address the fragmented system and consider why they are unable to retain so many high-risk patients.

The potential turnover of ACO-attributed patients from year to year (or patient churn) warrants attention, but little evidence exists to suggest that patient dissatisfaction is the cause. In fact, Medicare ACOs are achieving overallhigh performance on patient satisfaction measures to date. So far, there is no clear relationship between patient satisfaction measures (CAHPS) and turnover. However, it is not unreasonable to assume that more direct patient engagement in selecting an ACO might reduce patient turnover.

Policy and Regulatory Solutions
There are a number of structural adjustments that CMS could make to the MSSP program to more effectively engage patients through financial and other incentives.

  • Provide financial incentives for beneficiaries: These incentives may include reduced co-pays or deductibles for choosing providers within the ACO network or other high-performing or high-value providers. ACOs could also provide rebates or extra benefits to patients who successfully adhere to medications or provide additional discounts to patients who meet specific outcomes, such as reduced BMI or blood pressure control. Finally, beneficiaries could potentially share in some of the savings generated by the ACO, assuming that they meet a set of patient requirements or compliance metrics. While allowing patients to share in savings would be a more complex and controversial proposition, it could transform how patients think about ACOs and their own personal behavior to improve their health.
  • Implement “Welcome to ACO visits” (similar to a “Welcome to Medicare visit”): These visits could provide an opportunity for ACOs to educate patients about the benefits of being in an ACO. Patients could learn how an ACO model will affect the care they receive, and how patients can become more activated and engaged.
  • Transition away from the current attribution model to allow beneficiaries to actively and directly enroll in an ACO:Active enrollment could enhance patient commitment to organization, and help them better understand the implications for their care. Potential challenges to this approach include increased opportunity for adverse selection (unhealthy patient disproportionately enrolling in the ACO, thereby disrupting the overall risk pool) and not enough beneficiaries agreeing to join the ACO. While adverse selection could be addressed through additional technical changes to the program (e.g., more frequent updates to benchmarks, etc.), without a sufficient patient population, the ACO would likely not succeed. Furthermore, it is not clear how such a model would differ significantly from current Medicare Advantage and why patients would choose to join an ACO over an MA plan. We may soon have a better idea of whether an enrollment model will work; the CMMI has launched a demonstration program with a selected number of Pioneer ACO participants to test whether and to what extent beneficiaries will elect to enroll in an ACO, and what the consequences may be on the ACOs population and performance.

Conclusion
Patient engagement interventions and programs highlighted during the recent Brookings event are encouraging, but much more work needs to be done. Effectively engaging patients will require ACOs to think differently about what patient engagement really means; it will also require a willingness and desire on the part of patients to become more engaged as active participants in their care. A regulatory environment that encourages provider organizations to pilot new approaches to patient engagement, including innovative financial and other incentives, could be a starting point for innovation in patient engagement. The health care system will not be transformed without the patient; moreover, the real promise of ACOs—continuous improvements in quality and reduced costs—cannot be realized over the longer term without more active involvement of patients in their care.

Brigham and Women's opening access to the medical record

Nov 13, 2014, 4:54pm EST Updated: Nov 17, 2014, 4:03pm EST

Jessica Bartlett

Dr. David Bates, senior vice president for quality and safety at Brigham and Women’s Hospital, shows off a new pilot program bringing tablets into patient rooms.

Jessica Bartlett

Reporter- Boston Business Journal

Dr.David Bates clicked through the app's many functions – test results, care team, medications, food – each a snapshot into a patient's needs and status.

But the program, unlike most electronic medical records, wasn't designed for the doctor. This platform was created for patients.

"The notion is to change the way care is delivered," said Bates, senior vice president for quality and safety at Brigham and Women's Hospital.

The pilot program, available to every ICU and oncology patient in the hospital, is opening up access to the medical record.

With tablets installed with the app at the bedside, doctors are providing patients and their family with information, widening the lines of communication, and creating clear goals and expectations for patient care and progress.

The work has been ongoing since last September thanks to a $2 million grant from the Gordon and Betty Moore Foundation and $700,000 from the Brigham.

Patient advocacy groups, clinicians and patients have all had a hand in developing the platform, which today allows patients or medical proxies to view a patient's status, look up medications, or communicate questions to a patient's doctors and clinicians in a chat room-like setting.

"The care team owning the medical record — those days are over," said Patricia Dykes, program director for the Center for Patient Safety Research and Practice and also program director for the Center for Nursing Excellence. "The patient knows it's their information, they want access, and we believe if patients have access in a way they understand, that they can partner with us for better outcomes."

Studies at the hospital have shown that by talking about patient expectation, patients stayed in the hospital on average half a day less.

Over 100 patients and families in the hospital's ICU and oncology have used the program since it was implemented in the beginning of July. The hospital plans to study the outcome of those patients over the course of a year to understand if increased communication can affect patient outcomes.

Though some may worry about security, the team says they have lost only one of the 55 iPads purchased since July. The tablets are set up to be inoperable outside of the hospital's IP address. Even if the device was wiped clean, it wouldn't function.

"We've educated people about that fact. We've put signs everywhere, we've issued one per room … we ask people to help keep them there for the patients," Dykes said.

The tablets have also been formatted to only operate the app. When the device is turned on, the screen goes immediately to the login portal.

The login, designed around HIPAA compliance with the hospital's security team, also ensures that the patient's information is secure. Only the patient or a medical proxy will be given login information. If a patient wants others to have access, he or she will need to sign off.

The goal is to eventually offer this program to other hospitals, with the noted benefits attached. The Brigham is part of the Libretto Consortium, along with Johns Hopkins Medicine, Beth Israel Deaconess Medical Center, and University of California San Francisco (USCF) Medical School, where each provider is tasked with taking on a different role in bettering patient outcomes.

The Moore grant was given with that goal in mind.

"The notion is to spread this very broadly," Bates said. "The Moore Foundation is thinking big in terms of transforming care."