Editor’s note: For more on engaging patients to be active participants in their own care, see the February issue of Health Affairs, “New Era Of Patient Engagement.”

Currently, most hospitals and health systems focus on patient engagement because of their mission to deliver patient-centric care. These efforts are pursued despite the neutral or even negative economic consequences to these organizations, which operate within the fragmented, fee-for-service payment system. For example, care coordination attendant to patient engagement efforts will, at times, reduce demand for services and, thereby, reduce fee-for-service payments to providers.

As public and private sector health care purchasers shift payment models towards value and as demographic changes result in more chronically ill patients entering the health care system, patient engagement efforts will become increasingly important to the financial sustainability and clinical success of these hospitals and health systems.

New patient engagement efforts shift focus from the inpatient core of hospitals to ambulatory care settings and to the integration of care into the homes and communities of patients. To succeed at these efforts, organizations must build longitudinal partnerships with patients to drive ongoing management of chronic conditions and utilization of preventive care services to drive long-term quality and cost outcomes.

Why Patient Engagement Now?

In response to increasing growth in health care spending, public and private health care purchasers are introducing new payment models to promote higher-value care in the U.S. health care system. Traditional fee-for-service payment methodologies pay providers for each health care service delivered, regardless of efficiency. The fee-for-service system encourages higher-acuity specialty utilization to the exclusion of other critical health system activities such as care coordination or care collaboration. Thus, the fee-for-service payment model contributes to a fragmented health care delivery system resulting in duplicative care, preventable utilization, escalation of care to higher-acuity settings, and ultimately, poorer patient outcomes.

To curb health care spending and improve outcomes, purchasers are shifting performance risk to providers by requiring organizations to achieve specific quality or cost goals. (See Figure 1, click to enlarge.)



For example, the Medicare Hospital Readmission Reduction Program increases health system accountability for the quality of care episodes, including both the acute care stay and 30 days after discharge. Hospitals and health systems are, therefore, accountable for patient outcomes spanning a longer segment of the care continuum.

Payers also are promoting higher-value care by introducing population health management incentives. Private sector accountable care contracts and public programs such as the Medicare Pioneer and Shared Savings Programs (MSSP) hold providers at risk for the utilization of care for an attributed population of patients across a set period of time. Providers who succeed under these programs must reduce unnecessary utilization and shift care from less efficient, higher-acuity setting to more appropriate, lower-acuity settings.

Across the next several years, the increased prevalence of chronic conditions and contributing factors such as obesity threaten to push health care spending even higher. Reducing high-cost utilization of health care services among individuals with chronic conditions vis-à-vis accountable payment systems requires a more coordinated care management system that prioritizes the management of patients in lower-acuity, primary care settings with diverse access points – a kind of “medical perimeter.” (See Figure 2, click to enlarge.)


Furthermore, such a shift in acuity settings is critical to ensure that hospitals and health systems preserve inpatient capacity for the most acute patient. In fact, our research indicates that hospitals and health systems that do not invest in developing such a “medical perimeter” to provide more appropriate, lower acuity care to chronically ill patients are at risk for being over-capacity within 10 years, swamped by non-surgical cases. Patient engagement is a critical focus of these new primary care access points to support ongoing management and avoid more costly inpatient admissions.

The Challenge of Patient Engagement for Hospitals and Health Systems

Traditionally, hospitals and health systems have little influence over patient behavior after a patient is discharged.  As new payment innovations and changing demographics encourage migration of health care delivery to lower acuity settings, the challenge for hospitals and health systems will be to create mechanisms for interacting with patients in the outpatient setting and in patients’ homes to ensure successful outcomes and management of utilization risk

Moreover, today’s delivery system includes numerous clinical and non-clinical barriers to patient engagement. Providers may not devote enough time educating patients about treatment plans and condition management. For example, interviews between the Advisory Board Company and its member hospitals and health systems (N= 61) indicate that over one-third of surveyed institutions spend 20 minutes or less on discharge education. (See The Advisory Board Company’s 2010 report, Preventing Unnecessary Readmissions: Transcending the Hospital’s Four Walls to Achieve Collaborative Care Coordination.)

In addition, providers overestimate the health literacy levels of some patients. In one recent study, while 77 percent of physicians believed patients understood their diagnosis, only 57 percent of patients could correctly state their diagnosis. Limited or poor communication channels between patients and providers also can inhibit full plan adherence and prevent timely identification of preventable complications.

Interviews with Advisory Board membership (N= 19) suggest that patient engagement activities currently are prioritized behind other, more pressing transformational activities such as adoption of electronic medical records, general care management workflow improvements, and integration of physicians — activities which many health system leaders see as foundational to the success of patient engagement efforts and their organizations more broadly.  Furthermore, organizations report that patient engagement responsibilities within hospitals and health systems are diffuse across the organizations and may be difficult to organize and scale.

Under value-based payment systems, providers must address these barriers by partnering with patients to ensure adherence to recommended care plans, even as patients transition to post-acute care settings or return home. This requires not only redesigning current approaches to spend more time on patient education, but also working with patients to identify ways to integrate care management into daily routines and activities. To offer additional support to patients, organizations also are expanding the reach of the health system through community partnerships and affiliations to help reinforce effective chronic care management.

Hospitals And Health Systems’ Innovative Approaches To Patient Engagement

Though comprehensive patient engagement across the care continuum presents a challenging task for hospitals and health systems, some organizations have designed innovative strategies that provide evidence of the potential for success of these efforts. These institutions have focused on prioritizing the time and attention of care team members to drive improved patient outcomes across large patient populations. The initiatives generally are designed for three types of patient groups.  (See Figure 3, click to enlarge.)  For the smallest group, the highest-risk patients, innovative patient engagement strategies focus efforts on building the appropriate care teams to partner with patients, and their caregivers, on complex condition management.  A larger group of medium-risk patients require more targeted attention to encourage ongoing self-management.  Finally, low-risk patients need easy primary care access points for lower-acuity health care problems.


Implications For Policy Makers To Advance Patient Engagement

As purchaser demands and demographic shifts require hospitals and health systems to significantly strengthen patient engagement efforts, providers face unresolved questions that will impact these efforts.

Financial Incentives or Penalties for Patients. Many policy makers are examining the degree to which financial incentives should be utilized to encourage engagement on the part of individual patients. Indeed this question relates to a larger question policy makers are struggling with: how much financial reward or penalty should be tied to individual health behaviors and utilization of health care services (i.e., how much “skin-in-the-game” should patients have)? Recently, policy makers have expanded the ability to leverage skin-in-the-game strategies. For example, the Affordable Care Act codifies the ability of health insurance premiums to vary based on participation in wellness programs or in relation to tobacco use. In addition, the Medicare Payment Advisory Commission (MedPAC) recently recommended changing cost-sharing requirement for patients to incentivize the use of higher-value providers.

The Medicare program, however, restricts the ability of providers to offer most financial incentives to patients even within shared-savings arrangements. (See 42 CFR 425.304(a)(2).) As payment models have already moved to reward or penalize organizations for cost and quality across longer episodes of care, this creates unilateral financial implications for providers. For example, organizations are preparing for Medicare’s Readmission Reduction Program, which links financial incentives to treatment and recovery outcomes across 30-days after discharge.3 Although patients share much of the responsibility for key strategies to prevent readmissions such as following recommended care plans, making appropriate lifestyle changes, and communicating with the care team in the event of unexpected symptoms, there are no direct financial implications for patients who chose not to engage their care.

The private sector has moved more quickly in this regard, and employers and purchasers are piloting programs where patients either receive financial incentives for participation in care plan activities or increased cost exposure for a lack of participation in care plans. As the imperative for providers to engage patients grows, policy makers will have to consider the appropriate level of financial incentives to facilitate these efforts.

Patient Privacy and Autonomy in Care Plan Adherence. On the other hand, as providers increase patient engagement efforts, patient concerns about privacy and autonomy also emerge. For example, as the locus of care expands beyond the traditional four walls of a hospital, more and more providers and non-providers will request access to patient health care information. Examples of this increased data sharing include home monitoring technology, enterprise-wide medical records, passive data monitoring tools, and partnerships with other community stakeholders involved in patient’s day-to-day activities.

Not all patients will be receptive to the sharing of data or increased oversight on the part of providers. What is the best way to ensure data may be shared appropriately and still respect patients’ privacy and autonomy over health decisions?  Policy makers must identify the appropriate use of data and oversight that balances patient privacy and autonomy but also permits organizations to partner with patients to transform care delivery.