By Matt Phillion
As the industry looks for ways to encourage the success of value-based care initiatives, eyes often turn to improved operational efficiency and cost control. But patient engagement is also pivotal to the success of these programs: care coordination and management are far more challenging, and optimal outcomes are harder to achieve without a fully engaged patient population.
A Commonwealth Fund study found that “patients who did not feel competent to manage their own health or navigate the healthcare system were more likely to develop a chronic disease over a three-year period than ‘activated’ patients with good self-management skills.” Researchers found that patients with low activation levels were “linked to significantly greater likelihood of hospitalization and emergency department use for ambulatory care-sensitive conditions (conditions that are avoidable if properly managed).”
Most patient engagement initiatives focus on improving provider understanding of the patient’s status, which involves stratifying a patient population to identify pockets of disease and polychronic patients. This enables providers to educate patients about how to manage their conditions and offer outreach opportunities.
So how can we encourage a culture of engaged, empowered patients so they can take a more proactive and effective role in their care management?
“Ask any given patient, or any person on the street what value-based care is, and you’ll get 4 million different answers. Part of understanding what we’re talking about in healthcare, whether it’s value-based or not, is how do you integrate the patient into not only the decisions that impact their own health and wellness, but also empower them to be able to take action themselves,” says Lynn Carroll, chief operating officer and head of strategy with HSBlox. “This becomes more important to providers in value-based care when they start to take on risk in a given population.”
When providers enter into a value-based purchasing arrangement, they need to understand the degree of empowerment or engagement of patients assigned to them under the program.
There will be a cohort of patients eligible for a given program based on patient qualifiers depending on the program (diabetes, mental health, COPD, any other number of conditions). Inside that cohort is a range of patients running a whole spectrum of engagement; some will be highly engaged and empowered, ready to take action regarding their own care, while others are going to be high-touch patients that require a more hands-on approach by providers. Stratifying these patients helps providers find success in a value-based program by identifying not only the medical risks attached to each patient but also behavioral or social risks and challenges.
“There’s an activation component: how motivated or engaged are they in their own care?” says Carroll. “You want to look at those two components and understand which patients are going to be the most high-touch, and also those who have a degree of engagement and self-empowerment. If they’re engaged, there’s going to be things those patients tend to do, like self-reporting, participating in self-assessment surveys, remote monitoring. They’ll be more compliant with pushing readings back to the provider.”
Polychronic patients with two or more diseases will be more high-touch, high-need, and require more follow-up, but these are also patients who providers will need to fully understand their levels of engagement to ensure compliance with their care programs.
“If you’re under a medication adherence program where it’s imperative they take their meds as prescribed, you’re dependent upon the patients to monitor that, so they better be pretty engaged,” says Carroll.
Part of what the engagement aspect gets at is how well the patient navigates the system in the first place.
“A big piece of this, when you think about the value-based care arena, is you have a shift from what has traditionally been a utilization management approach to more of a care coordination approach,” he adds.
What’s in it for the patient?
As you get into a value-based program there’s usually a degree of reduced choice for the patient, which can sometimes lead to complaints: will my provider be in the network, will my preferred providers be available to me? But it also offers the opportunity to reduce the incidence of care fragmentation.
“The tight relationship between the provider and the patient and understanding the needs and motivations of the patient to be able to comply with the care plan, those are the things you end up talking about when you think about being successful in a value-based program,” says Carroll. “How does the patient engage, and how does the provider ensure they’re engaged for better self-management?”
Assessing that cohort of patients begins with making sure you’ve got the appropriate data from the payer to enable you to understand what the cohort looks like. Who are the polychronic patients? Who is healthy? Who is highly engaged already?
“Survey tools like patient activation measure scores can try to assess the degree of self-empowerment and engagement a patient might have, and that can lead you to understand how much education you’ll need to provide to help them be on point with their condition,” says Carroll.
With polychronic patients, usually there are multiple providers managing one patient’s care band, while the PCP might take overall responsibility for the patient. The reality is the amount of spend on that patient is driven by the specialists.
“It’s helpful if the primary care physician or care coordinator can educate the patient to what it means to be polychronic and what it means to take action over your own health,” says Carroll. “In a fragmented system, you may have different opinions or directions from specialists. Patients need to know the questions they should be asking, and also that it’s okay to ask their providers to speak to each other.”
When someone is experiencing a specific acute condition—advanced kidney disease, for example—it’s helpful to have that communication between providers as the PCP is looking at the whole patient while the nephrologist is focused primarily on the kidney disease.
It all comes down to understanding from the provider perspective, he says. Patients will run the gamut, with some who are highly engaged, asking questions, staying compliant, to others who will let things happen to them rather than taking an active hand.
“If you can stratify those patients, you’ll know who you have to follow up with more often,” says Carroll. “Whom do I want to follow up with monthly, weekly, daily? Then you get into a scenario where you’ve got relatively empowered folks you check in with less frequently so you can devote time to those polychronic or high-touch cases who are less capable of understanding on their own.”
The right kind of outreach
After stratifying the patients, it’s also important to know how to best provide the education they need to be successful.
“The degree of health knowledge and education the average person has can be challenging at times, so the material needs to be something they can consume on a smart phone, through email, not overly verbose, but able to get folks up to speed,” says Carroll.
The industry has seen more third-party services in the care-navigation space since the start of the pandemic, and areas such as Medicare Advantage have put more of an emphasis on care navigation components.
“We’ve also seen more use of health risk assessments to try to get more information from patients upfront when they get assigned to a panel or cohort so that you get answers back right away from the patient to help assess their ability to self-manage,” says Carroll.
The industry has also made strides getting information into the patient’s hands. Lab results available online through portals with enough information that they can be accurately interpreted have been improving steadily, alongside other digital tools patients can use to engage with their own care.
Some barriers to success with this type of program are those issues that have always been there; for example, who is responsible for which part of the program.
“There have been a lot of assumptions about which side of the equation the payer provides for and which the provider does, and as things have evolved over the last few years, there’s been more attention to detail regarding these contractual formats,” Carroll says. “Who’s responsible for which part of the patient’s care, and things like educational efforts and outreach are a part of that. It all comes down to who is going to pay for what, and if you make an assumption, then it may not get done at all. We’ve encouraged specificity not only about what services are included from a healthcare delivery standpoint, but also what are some of these peripheral components: scoring, outreach, education, and who owns that responsibility.”
There are time pressures to get it right: CMS is pushing to get 90% to 100% of their patients under value-based programs by 2030.
“The question is always: What’s in it for the patient? We could talk about it from a financial or care management viewpoint, but as a patient, what I want to know is that I’ll get something out of it: easier interactions with the system and a better understanding of the costs that are relevant to me for any services I’m going to receive,” says Carroll. “I want a better experience and to know my care is going to be more coordinated across my care team, as well as what I can expect my individual cost to be.”
This is particularly important for polychronic patients dealing with multiple specialists.
“If I’m giving up choice, I should have a better experience, and that ought to have full transparency about cost, better coordination, and improved health,” he says. “That’s what I’d want, as a patient.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.