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Activating Patient-Centric Health Care Reform



July 1st, 2009

It is often observed wryly that Americans have more interest in the well-being of their automobiles and pets than their own health. The challenges of activating patients to manage diet, lifestyle, and chronic conditions are well documented, and the accompanying costs of chronic illness are even more thoroughly characterized. The threats these pose to health reform, however, are poorly understood.

As we confront the best possibility of health care reform in the last 40+ years, it is important for policymakers to dwell on tools that can address this dilemma and support active, successful collaboration between patients and providers to manage health and health outcomes. We have the tools to achieve this at hand, but public expectations of health care and the incentive structure confronting providers foster apathy and even resistance instead of transformation.

Reform plans circulated to date have emphasized improved access to care for the uninsured and implementation of electronic medical records (EMRs). Both are laudable goals. Neither carries the transformational vision that is required to bring the outcomes achieved in line with the investment made on health care in the U.S. This is because neither of these policy goals has any incentives for improved effectiveness — actually accomplishing the desired results — or efficiency — doing so at less cost — inherent in their implementation.

Many experts believe that investment in information technology (IT) should maximize physicians’ efficiency. Increasingly, some realize that it can also improve the effectiveness of the physician-patient dyad. But there is a further step that IT investment can take, for even greater improvement and savings: enhancement of patients’ self-management. This relies upon a strengthening of the patient relationship with the entire care team, including the physician, but is a very different means of improving clinical outcomes and efficiency.

We propose adding two synergistic goals to the policy conversation:

1.    Support people in taking shared responsibility for their health outcomes, and make tools available to help them.

2.    Pay providers for success in supporting patient self-management, and for preventing the onset or exacerbation of disease, rather than for units of service.

We also advocate for investments in a set of technologies complementary to electronic records that will vastly improve our ability to achieve goal 1 — but only if we are able to move forward simultaneously with goal 2. In fact the technologies, while complementary, can precede or coincide with the adoption of EMRs and still have significant impact.

These technologies exist today as the platform for Care Coordination/Home Telehealth (CCHT). This platform has four essential components: accurately gathered physiologic information (relevant to the chronic illnesses at hand), contextual presentation of that information to the patient, data-driven coaching, and optimized provider involvement. It is this latter component that provides the synergy with EMR usage.

Why should we divert precious resources away from EMR adoption? We agree that it is critically important to improve the quality and efficiency of physician practices. What is called for, however, is a parallel and equally important transformation of the care delivery process itself, so that patients are fully integrated and in many cases manage their care for prolonged periods with little interface with the physician. To achieve our collective goals of improved access, quality, and cost control, then, a new strategy is required.

Why Focus On CCHT?

In short, CCHT addresses chronic care directly, and it is effective. Successful management of chronic illness largely requires lifestyle management and behavior change. Behavior change requires ongoing education and coaching, both of which are natural components of well-designed CCHT interventions. Our physician-centric, acute care-based health care system does not address these challenges well. CCHT services integrate patient coaching into the software that interacts with the patients, and these services are frequently managed by community health workers or non-clinically prepared workers because population analytics and decision support limit the need for physician attention.

CCHT is not, despite widespread misunderstanding, simply a matter of deploying sensors and collecting data for presentation to clinicians. Accurate physiologic information is an effective teaching tool for patients and can lead to insights for providers, but even the most sophisticated analytics and decision support will have limited effect on patients without extensive coaching to support change in health behaviors. The front-line reliance on software that coaches patients, combined with as-needed interventions by community health workers and other community-based coaches, is both economical and effective.

The evidence that CCHT leads to lower utilization of emergency departments, skilled nursing facilities, and hospital admissions, and therefore to decreased net expenditures on care, has been accumulating over the past half-decade. The organization with the most experience, the Veterans Health Administration (VHA), has summarized almost a decade of experience with CCHT in a recent article that reported on their experience with more than 17,000 veterans, including a 25% reduction in bed days of care, 19% reduction in hospital admissions, and mean satisfaction rating of 86%. Similar results have been reported in a handful of private-sector studies, such as four New England hospitals in which in-home monitoring and coaching after hospitalization for congestive heart failure (CHF) reduced rehospitalizations for heart failure by 72%, and all cardiac-related hospitalizations by 63%. Most recently, the Centers for Medicare and Medicaid Services (CMS) has extended and expanded a demonstration that deploys CCHT to private practices serving Medicare fee-for-service beneficiaries.

Why Hasn’t CCHT Gone Further?

The natural question then is, “if CCHT works so well, why hasn’t it gone further?” We cite several reasons.

  • Providers are paid for volume of transactions. CCHT, if well implemented, actually decreases revenue to both hospitals and providers under FFS reimbursement models.
  • Because FFS is so pervasive, support and administrative staff workflow is optimized to this reimbursement model. CCHT changes work flow and thus is often viewed with skepticism by providers.
  • Patients have no incentive to change unhealthy behaviors.

Policy Solutions

What health care policy tools can be plied to help?

Educate physicians on the tools available to manage populations of patients (patient selection tools, patient-provider communications tools, CCHT). Provide tax breaks or other incentives for doctors to adopt these technologies in their offices.

Change the way care for chronic illness is reimbursed. The government should be more aggressive about using such tools as robust pay-for-performance (P4P), case-rate reimbursement, and focused capitation.

Wrap these concepts into the implementation of the patient-centered medical home projects and demonstrations.

There is well-justified excitement in the medical community about the attention the Obama administration is paying to health care reform. This is an unprecedented opportunity to “get it right.” Investments in insurance coverage and EMRs are critical but do not go far enough. Attention to tools that foster population health and patient self-management are critical as well.

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3 Responses to “Activating Patient-Centric Health Care Reform”

  1. Tom_Grinley Says:

    The CCHT platform is missing an essential component- accurately gathering psychological information. It becomes even more important to consider mental health in tandem with physical health when when behavioral change is one of the objectives of the platform.

    Mental health issues need to be an essential component of all the ongoing conversations around medical homes, EMRs, wellness plans, etc. Given the comorbity of mental health issues with both physical disease and substance abuse; not addressing these issues as an essential component of any change model dooms that model to failure.

  2. raymondcarter2 Says:

    Amen! Coincidentally, the Thought Leader segment in this month’s Medical Home News is about the important and growing use of diagnostic and monitoring technologies by mid-level clinicians and consumers. I am convinced that medical homes will lead the way in CCHT, including innovative Medicaid and community health center projects, and share your view that this is a critical piece of meaningful health care reform.
    Raymond Carter, Editor, Medical Home News

  3. SteveBeller Says:

    Excellent post!

    Policy issues aside, from a health IT perspective, I agree that EMR/EHRs alone are grossly insufficient if quality improvement and cost control are our country’s goals. I disagree, however, that the necessary “technologies exist today as the platform for CCHT.” That’s because that has not been enough attention given to patient-centered cognitive support (PCCS), which I contend is essential.

    According to a recent report by the National Research Council of the National Academies, PCCS is a computerized process that improves decision making by fostering profound understanding through use of a “virtual patient” model. The PCCS process employs a computerized model of a “virtual patient” that reflects an actual patient. An HIT tool would use this virtual patient to guide the selection and analysis of data.

    As I discuss at http://curinghealthcare.blogspot.com/2009/06/meaningful-use-clinical-decision.html, the current crop of health IT tools lack a critical element, i.e., they don’t implement the PCCS process.

    Since they do not use the PCCS process, mainstream health IT tools do not (a) help clinicians gain substantially greater understanding of their patients’ situations (i.e., their strengths, weaknesses, risks, needs, and options); nor do they (b) enable patients to understand their own situations better. Decision-making suffers as a consequence.

    Eliminating the health IT-PCCS gap would enhance understanding and promote better shared decision-making about treatment, prevention, health promotion, and self-maintenance. Because both clinicians and patients would be better informed through the PCCS process, the decisions they make would be more likely result in better outcomes (higher quality and safety) at lower cost. This would translate into increased care value (effectiveness and efficiency). In other words, using health IT tools that implement the PCCS process would help realize important benefits to individuals and society.

    As such, PCCS is a necessary ingredient for realizing the benefits of CCHT.

    So, we ought not to be satisfied with EHRs alone since they simply cannot take us where we have to go. They ought to be augmented with PCCS if they are to be truly useful.

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