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Patient, Heal Thyself – Because “Patient Engagement” is Unlikely

Patient Engagement Will Follow The Money

Patient engagement would help patients take more control of their healthcare

“Patient activation” is the new buzzword threatening to replace “patient engagement” – long before many patients have actually been, you know, engaged.

Apparently, we no longer bother to to wait for our terminology to take on meaning before we feel compelled to replace it.

As it stands, neither term has much meaning or basis in reality. The basic idea , however, is that shared decision-making between doctors and their patients yields better treatment compliance and results. This requires a level of health literacy that’s sorely missing today.

It’s a noble goal, but will remain elusive as long as payment schemes fail to incorporate measures of patient engagement that impact how much doctors and hospitals are paid.

Many Americans are still uncomfortable with the idea that their doctors are often more interested in making money than helping their patients. The idea that some are even willing to imperil their patients’ safety by needlessly putting them in dangerous hospitals to protect themselves from potential lawsuits is abhorrent to a public that continues to have a high degree of trust in the medical profession.

This high level of trust is often misplaced, however, as I’ve described in Our Healthcare Sucks and in previous posts (see here, here and here). These posts address hospital billing practices that pad the bills that many patients will have to pay themselves (i.e., they’re not covered by Medicare or private insurers). They also address scurrilous practices by physician oncologists treating cancer patients more aggressively with toxic chemotherapy drugs to fatten their incomes.

Is this really trustworthy behavior?

Or are we truly a nation of suckers?

And will patient engagement or patient activation make any difference in this grand disconnect between our healthcare perceptions and reality?

Not Bloody Likely!

For starters, physician quality measures that impact how much they’re paid don’t assess patient engagement, according to Dr. Grace Lin of UC-San Francisco.

So doctors who aren’t compensated for the extra effort – and time – required to properly educate and engage patients in their healthcare aren’t likely to do so. This means cost-saving patient engagement efforts are likely to continue to be paid lip service while remaining essentially ignored in medical practice.

As an article in MedPage Today, put it:

“In a fee-for-service dominated world, there is little incentive for doctors to spend more time with patients to better explain care plans and lay out the importance of their health decisions.”

I take this a step further in Our Healthcare Sucks by outlining the actual conflicts-of-interest between doctors and their patients under our prevailing fee-for-service payment system. These are summarized in the following graphic from the book: 

Patient engagement is unlikely with conflicts of interest in this table

Putting the “Affordable” in
Affordable Healthcare

According to a study in the February, 2013 issue of Health Affairs, those with the lowest levels of patient engagement in their care cost 21% more in the first half of 2011 than those in the highest range of patient engagement – or “activation”, as we’re now compelled to call it (I’m sure there’s a nuanced distinction between the two, but I suspect it’s a distinction without a difference).

21% is a huge cost-saving opportunity. Indeed, there’s little else available with that kind of cost-saving potential – no new medical device, no breakthrough medication “miracle”, no screening exam…nothing, nada, zilch.

Have I made my point?

Staying Out of Hospitals

Yet another study in the same issue of Health Affairs found that patient engagement reduced hospitalizations by 12.5%. That’s one-in-eight hospitalizations that could be avoided if patients were more actively engaged in – as in better informed about – their healthcare choices.

That’s about the same share of hospitalizations found in a survey I cite in the book. Doctors in that survey admitted that one-in-eight of their hospitalizations were done to protect themselves from feared malpractice lawsuits.

So about one-in-eight hospitalizations occur now for defensive medicine purposes that put doctors’ interests before their patients’ safety, and another one-in-eight (maybe allowing for some overlap) could be avoided if patients were better informed.

That’s an awful lot of healthcare spending that wouldn’t occur if the medical profession could get its act together.

Of course, they’d need some cooperation from policymakers to rationalize medical malpractice (and not by simply capping patient damages) and replace fee-for-service payments that discourage so-called “cognitive services” like taking the time to talk to patients.

President Obama spoke of the latter in his State of the Union speech last night. But talk is cheap – and there may be just too much healthcare exhaustion, and anxiety about implementing Obamacare, to do anything meaningful in the near term.

So these dual impediments to capturing some actual cost-savings – something Obamacare is light on – will be with us for the foreseeable future.

Another Big Disconnect

This disconnect isn’t about the trust awarded and the trust deserved by America’s increasingly unethical medical profession, but about the dollars-and-cents of patient engagement.

Business types – including many employers – subscribe to the simplistic notion that our medical spending will finally be brought under control once patients have more “skin in the game”. This assumes they’ll be more judicious healthcare consumers as they’re forced to pay for more of their healthcare costs out-of-pocket via higher insurance deductibles, co-insurance that more employers are now relying upon, and similar cost-shifting mechanisms.

By this logic – which they believe is self-evident – market forces will then exert their “invisible hand” magic and healthcare costs will finally be reined in. Hallelujah!

If Only It Were That Simple

The disconnect here is that patients bearing more of the financial burden for their healthcare costs won’t actually rein in healthcare costs unless they make better healthcare decisions. Putting them more on the hook for their healthcare costs doesn’t necessarily translate into greater patient engagement. indeed, so far it seems to promote greater patient disengagement (see below).

Simply reducing medical consumption won’t save money in the long run unless they’re smart reductions in consumption.

With an estimated third to half our healthcare spending in America considered by experts to be unnecessary, there’s obviously plenty of room to reduce consumption without harming patients’ real healthcare needs. But that assumes a level of efficiency of execution that’s sorely lacking in our 51% efficient healthcare system.

The odds are far greater that much of the avoided healthcare will be among the half to two-thirds that’s legitimate, needed healthcare. The experience with high-deductible health insurance plans to date bears this out.

Studies show that those with high-deductible health plans defer all elective medical care, not just the marginal stuff they may not actually need.  These include generally advisable services like colonoscopies – one of the few screening exams that pays for itself many times over (read about my own recent experience with colonoscopy here).

To actually achieve the goal of smart reductions in patient demand for marginal and unnecessary care, this cosmic shift in payment responsibility on the demand (patient) side must be balanced with a comparable shift in payments received on the supply (doctor) side. Unless and until it is, we’ll remain consigned to similar penny-wise-and-dollar-foolish decision-making that will save a few shekels in the near-term at the expense of higher spending required to treat the more advanced disease that goes untreated – to say nothing of the human costs.

Knee-Jerk “Solutions” to Complex Problems

In other words, this simplistic “more-skin-in-the-game” approach without more fundamental reforms of how our healthcare is delivered – including a major thrust toward greater patient engagement – is a hatchet solution for a problem requiring a scalpel.

It’s not unlike the knee-jerk answer for malpractice reform of simply capping patient damages. This has been tried now in a majority of states and has failed to subdue healthcare costs in a single one – largely because it fails to correct the continuing ability of doctors to control patient demand in ways that pad their incomes in a fee-for-servcie environment (see “Obamacare 2.0 – Fixing Medical Malpractice“).

This is what the “more-skin-in-the-game” folks – along with most patients and consumers – fail to understand about healthcare. This is an industry like no other – fundamentally different from other industries in ways that render free market theories irrelevant.

The most obvious of these – as noted regarding malpractice reforms that merely cap patient damages – is that, to a very large degree, medical suppliers (doctors) control the demand for their services in ways other industries and professions can only dream about.

Nothing gets done – or paid for – in healthcare without a doctor’s order, plain-and-simple.

And patients are in no position to judge whether they actually need what their doctors prescribe. The knowledge gap is tremendous and not easily closed.

The default thinking by most patients is that of course they need what they’re prescribed. But if that default thinking were always correct, we wouldn’t have a third-to-half of our healthcare that’s not needed, would we?

Closing the Knowledge Gap

So up to half the time, this default mindset of compliance with doctors’ orders serves our doctors’ income objectives more than their patients’ true medical needs.

Increasing patient engagement would mean closing at least some of that gap so patients could assume a greater role in managing and implementing their care.

But expecting doctors to facilitate such patient engagement when it may mean less income for them under current payment schemes – even with Obamacare – is asking them to bite the hand that feeds them.

The only thing that Obamacare changes in this regard is hospital payments that will be penalized for low “patient satisfaction”. And patient satisfaction has very little to do with patient engagement. It usually revolves around things like valet parking and how good the hospital food tastes, rather than meaningful measures of treatment quality and outcomes (see “Medical Uncertainty & Patient Engagement“).

Until that changes and doctors are financially rewarded for taking the time to educate patients  – or have their nurses do so – to involve them more in their own care, you can call it “patient engagement”, “patient activation” or any other new paradigm jargon you can dream up. It doesn’t matter what you call it when it exists only in theory, with no basis in reality.

As the Bee Gees once sang, “It’s only words…and words are all we have” – and words are all we seem able to muster when it comes to meaningful patient engagement in their own healthcare.

For more on why healthcare is immune to normal market forces,
see this free chapter from Obamacare – The Good, the Bad & the Missing

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