Patient Engagement: A Providers’ Challenge

In a complex regulated healthcare world, providers are constantly trying to ensure that they can remain viable and provide the best quality services to patients. However, the ever-changing regulations impact how providers are permitted to provide care, share information, bill for services, document services and where the services can be delivered. While the regulations constantly change the providers’ day-to-day behavior, two themes are consistent throughout the laws. First, providers will soon be paid based upon quality outcomes instead of the volume of patients treated. Second, providers will be driven to reduce costs related to delivering care to be viable. In order to achieve quality outcomes and reduce costs, the provider is not in complete control. In fact, providers can only accomplish quality outcomes and reduce costs when a patient is engaged and accountable for his or her healthcare.

Because of Accountable Care Organizations (ACOs), the hospital compare websites, the soon to come physician compare studies and the changes in the reimbursement models, providers, ranging from the single doctor in his office to the large health system and its multiple hospitals, are evaluating patient engagement strategies. For example, in ACOs and in several Medicare demonstration projects, physicians and hospitals will be paid partially based upon the outcomes of patient satisfaction surveys. Therefore, improving the patient experience is one component of patient engagement. We are starting to see more and more Disney programs, Ritz Carlton training and other customer service training programs being launched within healthcare facilities. These programs are intended to emphasize the customer service side of healthcare and improve the patient caregiver experience. Ultimately, the goal is to improve the patient care survey scores so that providers will continue to be paid for the services rendered. For example, if a provider participates in an ACO, 7 of the 33 quality indicators that the provider will be scored on in order to obtain a share of the savings focus upon the patient caregiver experience. Therefore, the patient caregiver experience is a critical component of ensuring that the reimbursement will be received for services rendered to the patient.

Beyond customer service, other patient engagement strategies range from providing patients with a personal health records to phone apps and text messaging to electronically communicate with the patient about his or her healthcare needs. We are also seeing more information technology systems that are trying to engage the patient to be more accountable for his or her care. Today you may go to the physician receive your medication and then receive a reminder within seven (7) days of your follow-up visit or receive an electronic reminder to take your medication. There are also innovative programs where an individual will have a Bluetooth weight scale that can wirelessly transmit the patient’s weight results back to the physician so that it can be tracked as part of the treatment plan for the patient. By remotely relaying clinical information to the physician, it may reduce the number of times a patient must be seen in the physician’s office which reduces costs and supports patient’s desire for convenience.

Integrating patients with the healthcare providers is another form of patient engagement intended to maintain and secure reimbursement. Historically, patients would go to the provider, receive their medications go home and continue on with their day-to-day routines. Many patients see multiple providers so the patient may have several different types of medications and treatment plans. Unfortunately, this disjointed method of delivering care results in multiple providers ordering lab or diagnostic tests and potentially multiple visits to several providers. Today, in order to reduce costs, the patient’s entire treatment team may be integrated through a multi-disciplinary team that can actually address all of the patient’s needs, reconcile the medications, and ensure that diagnostic and laboratory tests are only performed once and the results shared with all the providers. Integrated care will help cut down on the cost and ensure that the patients’ healthcare needs are being addressed by all of their providers in one treatment plan instead of multiple treatment plans that might conflict. Overall, this integrated delivery model reduces the cost of the delivery of care and ensures that the patient’s entire care is being treated through one patient-centered plan.

Thus, the new reimbursement models are turning the concept of healthcare delivery on its ear. Today, instead of focusing on what type of equipment, surgeries and medication should be used, physicians are focused upon how do I talk to my patient, how do I improve their experience and how do I ensure that the comprehensive care of the patient will be integrated with other patient providers. All of these efforts are intended to ensure a better outcome for the patient and ultimately reimbursement to the provider. However, the patient engagement strategies will only work if the patient participates.

3 comments Add your comment

Nicole Hames

April 28th, 2013
10:12 am

This is an eloquent discussion of reimbursement models designed to create positive reinforcement for patient engagement through positive patient outcomes. I found myself inspired by the upcoming technological advancements and new strategies being used to improve the doctor-patient partnership that drives healthcare improvement forward. Nevertheless, with any change to a system as large and complex as health care, it is important to consider the potential pitfalls that can occur with any intervention, no matter how promising.

First, to reveal my potential biases, I must share my feeling regarding the argument that the deficit in patient engagement is secondary to a lack of physician incentive given current reimbursement models is at least incomplete. Perhaps as young physician in training, my glasses are still tinted rose; however, my experiences in medical school and residency training have had a very different focus. I learned that without engaging my patient, I will not be equipped with a so called therapeutic relationship. I will be less able to arrive at the appropriate diagnosis and prescribe the best treatment plan. I will fail to partner with my patient, and I will fail to become the kind of physician that inspired my decision to pursue medicine.

In the context of this article, I would agree that most physicians may not do a good enough job of engaging their patients and that an outcome-based reimbursement model is one way to facilitate improvement in this arena. However, I would propose that this reimbursement model is not the driving force behind recent efforts to improve patient experience and customer service, but rather that it too is the effect of our larger awareness of this great deficit in our health care delivery system.

Outcome driven reimbursement may seem like the perfect model to make physicians accountable for excellent cost-effective care; however, where are the limitations? How can we best adopt this model in areas of preventive health that are driven by lifestyle and patient decisions which are made outside our office? While patient engagement is necessary for positive outcomes and the improvement ideas discussed in this article are nothing short of excellent, I would still argue that engagement isn’t always sufficient. What happens when patient engagement and motivation are strong, yet the desired outcome is not achieved? How will this model impact the relationship between a provider and their smoking patient who is not yet ready to stop despite efforts at smoking cessation counseling? Or the obese patient who despite their best efforts, is unable to lose weight? We must think carefully about how to best implement this model in areas such as weight loss, diabetes control, sexual health, and smoking cessation.

Additionally, if physicians are rewarded only for positive outcomes, will we pursue more aggressive treatment strategies with higher success rates and higher associated risks earlier in management? As you mention, the desire to reduce cost while delivering the positive outcome may curb decisions to pursue such aggressive treatment options. The subtleties of how we define our positive outcomes may impact what the physician considers successful management of a patient problem. If we are reimbursed for weight loss, will physicians have the patience to give lower risk treatment options time to work knowing we will achieve better “success” with a referral for bariatric surgery? How do we account for exposing the patient to potential post-operative complications, nutritional deficiencies, and other long term consequences of bariatric surgery?

Lastly, where does this system leave the “high-risk” patient? Though surgery is not my specialty, I can imagine the spectrum of emotions one might experience when a family, fully informed of the risks, desires what may be a high-risk surgery or perhaps a simple surgery in a patient with other health problems which make them a high-risk patent? Will our surgeons perform the same surgeries knowing that the nuances of this decision will ultimately be reduced to an unexplained increase in his or her reported complication rate? I’d like to think that most of us will still decide together with our patients and families what is best for the patient in each unique scenario, but the skeptic in me is doubtful.

Again, make no mistake about it, I believe strongly that we should be demanding better outcomes from our doctors. I believe physicians practicing the best medicine should be rewarded for their efforts and expertise. I believe in transparency of medical error and that physicians should be held accountable for their mistakes. Nevertheless, I think we should treat each proposed health care model with similar scrutiny. No doubt, there will be no perfect health care reimbursement model, but we must make ourselves keenly aware of each potential adverse effect.

Nicole Hames, MD

[...] often-complex health care world is moving towards a model where doctors will be paid based on the quality of outcomes – instead of the volume of patients [...]

Evette Simmons

May 2nd, 2013
10:46 am

Health care is a billion dollar industry and, governmental regulations of the cost of medical care should aim to reduce the lay persons medical costs. As an adult practitioner I teach patients the benefits of health education and healthy life-style changes resulting in reduction of hospital admissions, less dependency of prescibed medications and, reduction of mortality rates.
Evette Simmons ANP, R.N., M.S.N.