Does patient engagement lead to success under value-based payment models?

Healthcare is often delivered through the lens of the “system” – an approach to providing healthcare based on what professionals prioritize without input from the people receiving care. Care plans are frequently based on an outside-in (system-to-person) rather than an inside-out (person-to-system) perspective. In theory, individualized, person-centered care should generate better patient experiences and lead to better health outcomes, reduced avoidable costs, and, with a sufficient time horizon, reduced total health expenditures. Let’s take a look.

Definitions

The Picker Commonwealth Program for Patient-Centered Care defines patient-centeredness as:

Health care that establishes a?partnership among practitioners, patients, and their families…to ensure that decisions?respect patients’ wants, needs, and preferences?and that patients have the?education and support?they need to?make decisions and participate?in their own care.

Patient- and Family-Centered Care (PFCC) is another term for respecting patient autonomy and preferences and viewing all healthcare experiences through the eyes of patients and families. Interestingly, when implemented appropriately, clinicians and their teams are often more satisfied with their work because PFCC addresses issues that frustrate patients and clinicians, such as inefficient workflows and non-value-added processes.

The esteemed Barbara Starfield emphasized the importance of recognizing patients’ health problems as they see them. She distinguished between patient-centered and person-centered care .

Primary care is person-focused, not disease-focused, care over time. To be person-focused, it must be accessible, comprehensive (dealing with all problems except those too uncommon to maintain competence), continuous over time, and coordinating when patients have to receive care elsewhere. The essence of person focus implies a time focus rather than a visit focus. Inherent in a person focus is the notion that attention to patients' problems in the context of their multimorbidity (multiple coexisting diseases) is at least as important as appropriate care for their individual diagnoses. Good primary care is not the sum of care for individual diseases.

Implementation

Many tools, resources, and guides are available to help organizations and practices implement patient-centered care strategies, including shared decision-making and patient—and family-centered care. Here are a few.

In a National Academy of Medicine discussion paper titled “The Democratization of Health Care: A Vital Direction for Health and Health Care ,” the authors describe several changes needed to achieve person-centered and family-centered care, including to:

• Accept, value, and promote genuine collaboration with patients and families in the design of care processes, policy development, and governance.
• Build trusted partnerships with communities.
• Provide transparency around costs and quality.
• Customize engagement strategies to patient’s needs, preferences, and motivations.
• Implement payment policies that support primary care and the work needed to foster person-centered care.
• Develop measures that leverage existing data and patient-generated information to assess patient experiences and patient-reported outcomes.
• Provide feedback into the clinical workflow to guide individual- and population-level improvements.
• Address health literacy issues and access to well-designed and accessible online information.

Shared Decision-Making (SDM) is a well-described method of engaging people in a collaborative process to make informed decisions. Ideally, this process considers the person’s values, goals, preferences, and situation and includes family and caregivers when appropriate. The Agency for Healthcare Research & Quality (AHRQ) provides implementation tools and resources for SDM, including clinical decision support modules. The AHRQ resources for SHARE (Seek. Help. Assess. Reach. Evaluate) can be used to train staff on SDM, and the SHARE Approach Fact Sheet is a simple way to help remind clinical team members of the key steps in the process.

Section 5 of the Office of the National Coordinator for Health Information Technology (ONC ) HealthIT Playbook provides a technology-oriented approach (e.g., electronic health record patient portals) to support patient engagement.

Do these strategies produce better outcomes in terms of quality and cost?

While there is no disagreement about the value of person-centered care in promoting the patient-clinician relationship and meaningful involvement of patients and families, the evidence for demonstrable effects on healthcare quality and costs is mixed.

For example, one systematic review did not demonstrate a consistent connection between using SDM and patient decision aids and healthcare costs. The authors postulate that the different results across the included studies may have reflected the differences in study purposes, designs, and outcomes assessed. Another review found that studies with the strongest evidence focused on self-management support, particularly for people with diabetes. Here are a few examples of positive results.

• Shared decision-making lowered annual total health expenditures for all racial-ethnic groups. The effect was greater when there was racial/ethnic concordance for Black and Hispanic patients seen by Black and Hispanic clinicians, respectively.
• Using a mobile health patient engagement platform improved perioperative outcomes for gynecologic oncology patients (decreased length-of-stay and lower readmission rate).
• Post-stroke remote encounters with patients by a nurse navigator reduced readmissions, improved adherence to follow-up appointments, a lower rate of recurrent events, and greater functional ability at 90 days.

One interesting study published in Health Affairs (2020) found that compared to patients not exposed to decision aids, those exposed had two-and-a-half times the odds of undergoing hip replacement surgery and nearly twice the odds of knee replacement surgery within six months of the consultation. The authors note that the interventions were heterogeneous and deployed across diverse healthcare systems participating in a collaborative. Read the study for more analysis of the results. In contrast, this study demonstrated that introducing decision aids for hip and knee osteoarthritis was associated with 26% fewer hip replacement surgeries, 38% fewer knee replacements, and 12-21% lower costs over six months.

Despite the varying clinical and cost outcomes, other research points to the benefits of decision aids on patients’ perspectives. This Cochrane Review concluded that:

Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values‐congruent choices. There are no adverse effects on health outcomes or satisfaction.

Commenting on the Cochrane Review in a JAMA editorial , the authors wrote that the review:

…found inconsistent effects of PtDAs [patient decision aids] on health care use, outcomes, and costs. In particular, use of PtDAs did not consistently reduce the use of invasive or expensive treatments. Thus, the extent to which these tools can reduce costs remains unclear.

The authors conclude with the following statement:

Future research should discover and evaluate new ways to promote patient involvement in making important health care decisions that rely on, rather than eschew, meaningful conversations between patients and clinicians. This work should not prioritize cost savings, a welcome byproduct, but foster, against all forces, careful and kind patient care.

Does improving patient engagement improve performance under value-based care?

Probably. Maybe. More importantly, whether it reduces costs or not, engaging people helps them feel more knowledgeable, helps clinical teams understand their preferences and needs, and leads to more involvement in decision-making based on personal values – an important yet underappreciated aspect of value-based care.

Consumer engagement is a top three priority of PHA’s Quality and Research agenda. If you are a member and would like to join PHA’s Quality and Research Steering Committee, please email me [email protected]. If you are not a PHA member, please?join?us.?

Registration is open for the 2024 PHA Innovation and Adoption Summit.? The event is both in-person and webcast.?https://phainnovationsummit.com/

Michael S. Barr, MD, MBA, MACP, FRCP

Sr. Director, Population Health Improvement

The Population Health Alliance (PHA) is committed to Quality and Continuity of Care.?Our key priorities are advancing value-based care, improving consumer engagement, and addressing social determinants and health equity.