Although we have seen some progress through the proliferation of patient-centered medical homes, most clinicians have not fundamentally altered their basic approach to engaging with their patients.
When the Institute of Medicine (IOM) released its landmark 2001 “Crossing the Quality Chasm” report, it called for providers to support continuous healing relationships” with their patients. Although we have seen some progress through the proliferation of patient-centered medical homes (PCMHs), most clinicians have not fundamentally altered their basic approach to engaging with their patients. In most cases and in most places, PCMHs have tinkered around the edges to meet specific new requirements, but most primary care physicians generally remain on the proverbial treadmill, trying to treat a high volume of patients in the typical fee-for-service payment model.
The PCMH is a good start as an organizing framework for a care delivery model, but achieving true care transformation remains elusive in the context of traditional approaches to payment that simply add on small bonus payments around the margins. Conversely, primary care practices that have entered into alternative payment models (APMs) that hold the practices accountable for a global budget have been more transformative. In some cases, these APMs have generated a fundamental reorientation from episodic, sick-care encounters with the delivery system to a continuous cycle of care.
Fundamentally changing the payment model is a necessary but insufficient step. Alignment of incentives is a prerequisite, but providers still need a lot of additional support to reorient, reorganize, and reshape the care paradigm. Primary care providers, especially those operating in small practices, need substantial technology and infrastructure support. However, before an organization invests in that core support, it’s imperative that they know what patients want. To paraphrase Yogi Berra, “If you don’t know where you’re going, you might not get there.”
Ultimately, ensuring that the payment model squares with patient needs and preferences also affects the long-term legitimacy and viability of the APM. For anyone who lived through the rise and fall of managed care in the 1990s, the need to engage consumers in the evolution of new payment models is abundantly clear—both in terms of perceptions and reality. Even at that time, plans denied only about 1% of recommended hospitalizations, slightly more than 1% of recommended surgeries, and just over 2.5% of specialist referrals.1 Furthermore, consumer concerns with managed care products were mostly not based on personal experience, but instead on external influence, as 54% of Americans who said managed care did a bad job were largely influenced by family, friends, and the media.2
What then, was the root cause of the managed care backlash of the 1990s? Was it a lack of access to essential health care or the opaqueness of the health care decision-making process and the patient’s role in it? If health care stakeholders can learn one lesson from the 1990s managed care backlash, it is the central importance of engaging and communicating with patients. Ultimately, patients are skeptical of any model that does not directly solicit and value their input in critical health care decisions.
The Increasing Financial Burden for Patients
Escalating health care costs have caused purchasers to gradually shift more costs onto patients. Whether one refers to this as “more skin in the game” or a “heavier patient financial burden,” the trend has placed greater responsibility on consumers to understand and manage the costs of their care and to understand the risks and benefits of the care they are receiving.
The popularity of high-deductible health plans (HDHPs)—for which individuals generally pay lower premiums for higher deductibles—and their accompanying health savings accounts (HSAs) to pay for the costs that HDHPs do not cover, has grown at an accelerated pace. HDHPs barely existed at the turn of the millennium; however, between January 2011 and January 2014, the number of enrollees covered by HDHPs/HSAs rose at an average annual rate of 15%, from 11.4 million to 17.4 million,3 with approximately 75% of these patients covered in the large-group market.
HDHPs affect consumer behavior, but research suggests they can be a blunt instrument. When seeking health care, HDHP/HSA enrollees spend more in out-of-pocket (OOP) costs before their insurance kicks in, causing individuals with high deductibles to be more concerned about higher-cost care and services.4 Overall, patients in HDHPs decrease their use of health care services. A large study found that patients in HDHPs significantly decrease the amount of preventive care they seek, such as colorectal and cervical cancer screenings and child immunizations, although the Affordable Care Act (ACA) prevents these plans from charging co-pays for preventive services.5 Another study showed that low-income HDHP enrollees are less likely to use high-severity emergency care due to unaffordable OOP costs.6
With these trends, it is especially important that providers understand their patient’s context and needs—such as whether they are aware of their plan’s policies, the OOP costs they can incur, and the potential consequences of avoiding care—so they can address them up-front and ensure better adherence to appropriate tests and treatment. This context is important as purchasers, both public and private, try to guide consumers to effective decision making regarding health plan selection and the use of services within the constraints of those plans.
Understanding Patients’ Needs
Financial context is important for the average consumer, but it does not change the priorities of what patients are looking for from the care delivery system. One way of understanding and addressing patient needs is to put them at the center of the care redesign process. Patient needs can best be understood by asking patients questions and then observing them.
The National Partnership for Women and Families has conducted some of the most important research to date that employs both quantitative and qualitative techniques. Specifically, Bechtel and Ness described in Health Affairs in 2010 the 4 key attributes that patients seek in primary care: whole-person care, comprehensive communication with and between providers, support in improving self-management, and 24/7 access to providers and care.7 Clinicians need to focus on each patient as a “whole person rather than a collection of body parts” or a list of conditions or diseases. Disease-oriented care management often fails to address the underlying, connecting, and defining needs that people face—some of which may not even be clinical in nature.
The US health care system suffers from silos of clinical interventions, where the only constant is the individual in need of care and support. That places an enormous burden on the patient and his or her family to coordinate, manage, and communicate about care needs. Effective primary care needs to relieve that burden and develop effective ways to communicate with patients on a continuous basis and among the appropriate providers.
Patients also seek support and empowerment in building their capacity to manage their own health in collaboration with their personal caregivers and providers. That support should include partnership, guidance, and tools for self-management, and an environment of trust and respect.
Successful primary care requires ready access, especially for those with chronic conditions or complex health care needs. Most health care happens outside the 4 walls of a clinic or hospital, yet most providers have no mechanism for integrating observations of daily living into the care management process. This has been well described by Project Health Design, a Robert Wood Johnson Foundation-funded multiyear effort.8
Creating Truly Patient-Centered Care
What does the future look like in terms of how primary care is organized, what services they provide, and the experiences of patients and families? The idea that new technology could help transform the patient experience has often hit a wall because the historic payment model separates the financial beneficiaries of these advances from those who have to make the up-front investments in them.
The move away from a turnstile, volume-based health care economy to one that focuses on value has created a strong business case for the provision of patient- and population-centered care. A variety of health information technology (HIT) tools can help providers better manage care and population health,9 starting with a foundation of patient registries and electronic health records (EHRs).
Patient registries are fundamental to population health management as a means of conducting patient monitoring and outreach, and identifying high-risk patients. EHRs can be used to capture the data necessary for advanced analytics, such as vital signs, diagnoses, and medications. More sophisticated HIT tools include automated outreach technologies, which use data analytics to identify and notify patients in need of preventive or chronic disease care, and platforms that can remotely monitor high-risk patients in need of continual care management and allow providers to intervene before their health deteriorates. More complex applications include advanced analytics and data warehouses to identify high-risk segments of the population, aid clinical decision making, and measure performance and clinical outcomes in real time. New payment models change the incentive structure for deploying these tools, although several barriers still exist, including lack of data standards, insufficient skills in data and analytics, and noncompatible HIT systems.10
These new technologies will have even more impact when they are combined with patient-facing HIT to deliver the right information to the right person at the right time. Sometimes described as information prescribing, information therapy (Ix) uses algorithms to identify patients’ information gaps, target information to particular moments in care, tailor the content to patients’ particular circumstances and needs, and deliver it in a way that the information is understandable, actionable, and meaningful. Much of health care relates to the transmission and use of information, but the average patient forgets 40% to 80% of everything he or she hears in the doctor’s office by the time he or she gets home.
Ix leverages new technology to support people throughout their ongoing care needs. For example, aspects of Ix are prevalent in the objectives of meaningful use of EHRs, such as patient reminders for preventive or follow-up care, after-visit summaries, and the provision of patient-specific education resources. When you provide timely information in advance and follow up on in-person encounters with the delivery system, you begin to create a more continuous cycle of care (see Figure).11
Figure: Information Therapy Helps to Promote a Continuous Cycle of Care
Ix = information therapy.
There are many other ways to deploy patient-facing HIT to better support patient-centered primary care. One of the most basic ways of engaging patients is allowing them to easily schedule appointments, request prescription refills, access their medical records, pay their bills, and exchange information with their providers. Online patient portals, provided by many medical practices/providers, are recognized as a promising way to address these needs and they have become the focus for providers trying to achieve stage 2 meaningful use.
A recent Athena Health analysis found some surprising results about factors that hinder—or rather, do not hinder—patient portal adoption12:
The analysis found that patients are much more likely to create portal accounts if they begin registration in their provider’s office. Patients are much more likely to engage with technology if they know it helps them connect with their personal clinicians and those providers support it. Providers have also noted that practical functionalities, such as self-service appointment scheduling and bill payments, are key in attracting patients to portal use.13
The uptake of telemedicine to engage patients beyond the 4 walls of a practice or hospital is growing. Recent analyses have shown that 27 states and Washington, DC, currently have telemedicine parity laws in place. In addition, in 2014, the Centers for Medicare & Medicaid Services reimbursed nearly $14 million in telehealth claims.14 According to a recent survey conducted by the National Business Group on Health, 74% of employers plan to offer telehealth benefit options to their employees in 2016—a notable increase from 48% in 2014.15
Studies show that telemedicine can help patients better engage in their care. For example, a remote monitoring program for patients suffering from heart failure, the Connected Cardiac Care Program, was developed by Partners HealthCare to improve self-management among patients at high risk for hospitalization. Participants in the program used a remote monitor to track their health information, such as blood pressure, weight, and heart failure symptoms, at home and send it to a nurse electronically in real time. Participating patients were also provided with telephone-based education sessions for 8 weeks. Overall, findings showed that the program significantly decreased hospitalizations for up to 90 days post discharge and mortality rates for up to 120 days.
Having access to various types of patient information can help providers better engage their patients in their treatments and overall health. However, patient data collected at different points of the care continuum largely remain locked in different silos of the system, making it difficult for a provider to gain full view of a patient’s experience and information. Moreover, other useful behavioral, socioeconomic, and daily-life data often lie outside of a health care provider’s purview.
The American Heart Association recently claimed that the use of wearable devices (wearables)—such as fitness bands and smart watches that track fitness and wellness data—can improve health behaviors.16 Consumer demand for these devices reached a record high in January 2015; however, their overall lack of integration with the health care sector could be a missed opportunity.17 In recent months, the demand for wearables has experienced a sharp decline. One speculation is that patients are expecting these devices to be more actionable in improving their health rather than just tracking their data. Better connecting the wealth of data collected by wearables to a patient’s interaction with their provider might be one way of meeting this demand and improving patient engagement.
The Critical Role of the Pharmacist
What is the role of pharmacy in proactively connecting and engaging patients in a world of new care delivery models and HIT advancements? There are many examples of pharmacists taking an expanded role to facilitate appropriate medication use, especially with patients who have chronic conditions.18
As we move into value-based payment models, it becomes important to proactively partner with patients in a longitudinal way to assist them with comprehensive medication management (CMM). CMM is defined as taking a holistic, patient-centered approach to optimizing medication use. The goal is to achieve positive clinical outcomes and lower overall health care costs. Existing medication management approaches typically focus on drug cost minimization, not achieving value. CMM aligns the goal of value-based payment models, which are focused on better outcomes, with the goal of the patient, which is to better understand their complex medication regimen. This proactive, holistic engagement with the patient produces an informed patient who comes to rely on coaching, technology, and coordinated care to actively participate in managing their own health.
To bring this concept to life, GlaxoSmithKline collaborated with Community Care of North Carolina (CCNC) to build and test a medication management predictive analytics model that helps a provider identify patients who are at risk for negative outcomes. Not only does the model, called Care Triage, predict patients at risk for hospitalization due to drug therapy problems, it also recommends care guidance to the appropriate caregiver in the optimal setting at the right time to facilitate the proactive care mentioned above.
The collaboration’s pilot finding to date has been fascinating. Usage data showed that patients with chronic diseases were seeing their primary care physicians about twice a year, but were visiting their community pharmacy an average of 30 times each year! Because a population health strategy should engage patients where they are, these insights helped CCNC build a community pharmacy—enhanced services network, which is moving the role of the pharmacist beyond dispensing medications. As a result, CCNC received a $15-million federal grant to study community pharmacy within a medical neighborhood. The University of North Carolina Eshelman School of Pharmacy is managing the evaluation of this grant and helping to identify the best practices of these services. We believe this new population health venue can be a powerful resource for meeting patients at a time and place that is convenient for them, which will facilitate true patient engagement.
Truly putting the term patient-centered into the patient-centered medical home will transform PCMH from an overused—and sometimes misused—acronym into a care delivery model far more capable of delivering on IOM’s 15-year-old call for continuous healing relationships. Whereas reimbursement hardly rewarded—and, in fact, may have discouraged—this care delivery approach at the turn of the millennium, the conditions are gradually changing. As the payment innovations of the ACA and the Medicare Access and CHIP Reauthorization Act of 2015 transition from demonstrations and pilots to fixed elements in Medicare reimbursement policy, and similar private-sector models also become the norm, value-based payment will become increasingly entrenched into the US health care system. In the context of that evolution, the demands of new payment models will finally reward providers that can deliver on the IOM’s promise.
Josh Seidman, senior vice president at Avalere Health, advises clients on health delivery and payment innovation, with a focus on using information technology (IT) to guide value-based care models. He applies his background in quality, health IT, and patient engagement to accountable care, delivery system transformation, and new payment models. Josh holds a PhD and an MHS in health policy and management from Johns Hopkins Bloomberg School of Public Health and a BA from Brown University. Josh is immediate past president of the Society for Participatory Medicine and was a William B. Ziff fellow for patient engagement with the Center for Advancing Health.
As senior director, payment and delivery reform at GlaxoSmithKline (GSK), Jon Easter leads a team that is focused on shaping the external health policy environment. Specifically, his team works to facilitate the adoption of evidence-based quality measures and to improve the delivery of care through better coordination and medication management. Jon has spent 20 years in the pharmaceutical industry. In addition to his public policy experience, he worked in GSK’s Care Management Division and covered the Pacific Northwest for the state government affairs organization. John’s experience also includes a stint in the health information technology industry, fueled by a passion for health care transformation, where he worked to advance the adoption of electronic health record and e-prescribing systems. Jon has a BS in pharmacy and is a licensed registered pharmacist.
Tanisha Carino is vice president of US Public Policy for GlaxoSmithKline (GSK). She leads public policy strategy development and execution, ensuring GSK plays a positive role in shaping US legislation, regulation, and the public payer environment. A Fulbright scholar with more than 15 years of experience in health policy and strategy development across government, industry, and academia, Tanisha is recognized as a thought leader in market access, commercial trends, health technology, evidence-based medicine, and the evolving US regulatory environment. Tanisha earned her PhD in health policy from Johns Hopkins University and serves as an associate faculty member in Johns Hopkins Bloomberg School of Public Health. She is on the board of directors for Bread for Washington, DC.