Thursday, January 8, 2009

Getting Patients More Involved with Health and Health Care

U.S. health policy leaders are desperate. Despite innumerable studies, policy proposals and conferences, population health statistics continue to decline while health care costs continue to rise. Not an impressive result for all of that analysis!

One of the leading magic bullets proposed for the health system has been "consumer directed health care." The core idea is that if high deductibles put patients at risk for more of the cost of their care they will become (a) more active in promoting their own health and (b) more discerning "consumers" of health care. These are clearly desirable outcomes.

We know that "consumer directed health care" achieves two desirable outcomes. The cost to employers is reduced and the premium cost to individual enrollees is less than their cost would be for insurance without the deductibles. But what about the impact of deductibles on patients. Do they become more active in promoting their own health and sizing up the value of proposed health interventions?

A study from the University of Oregon published in American Journal of Managed Care suggests that the answer is - no.

The researchers surveyed 1616 employees at the start of their enrollment in plans with and without high deductibles and a year later. The key finding was that patients who were higher on a measure of "activation" (knowledge, skill, and confidence in managing one's own health and health care) became more active over the course of a year regardless of whether they were or were not in a "consumer directed health plan." Enrollment in a high deductible plan, however, did not prod patients to become more active.

In other words, in this group of insurees, the magic bullet of "skin in the game" did not transform otherwise passive patients into active "consumers" and self-managers.

Another article in the same issue studied a different approach to change. Instead of prodding patients with financial risk, on the assumption that they lacked "skin in the game," patients were treated as partners, and given the same information about clinical guidelines that their physicians received. Simply providing patients with clinically relevant information increased adherence to evidence based guidelines by 12/5%.

Wise clinicians will not be surprised by these findings. Health has intrinsic worth. It isn't a consumer item that requires financial penalties to make us care about it. Providing patients and clinicians with the same information at the same time is like well-timed therapy for a couple. It points in directions both want to go in.

Two studies aren't definitive, but they suggest a direction that builds on the core values of physicians and their patients. That seems promising!


Anonymous said...

eve is in the conflation of the terms and associated roles of consumers and patients.

Patients don't direct their healthcare. when they seek the services of a professional provider, they are at best participants and partners in their care.

They do, however, direct health seeking behaviors to the extent that they have the resources to do so - the education, guidance and coaching that you referenced in the study.

Patients have some perceived dependency and so must trust a physician or nurse with their vulnerabilities in order to achieve a desired outcome. this is quite different than a commercial transaction which does not require a trusted party in which one delivers his most personal story, may consent to painful and life threatening treatment and procedures, and in which one cannot usually easily compare cost, quality and therapeutic relationship effectiveness.

One factor not included (as the norm) is how professional nursing impacted the interventions and patient outcomes. I would hypothesize that when patients are adequately cared for by nurses with a minimum of a baccalaureate education, that their health seeking and self health management behaviors would be significantly improved, as previous research demonstrates lower morbidity and mortality of surgical patients in post-operative recovery. (Aiken, IOM)

Jim Sabin said...

Hi Annie -

Thank you for the very thoughtful comment.

I share your dislike of using consumer concepts for conceptualizing the clinician patient relationship. The historical view of health care as a calling is a better vehicle for thinking about and planning for the relationships you describe so well in the fourth paragraph of your note.

I also share your belief that the nursing profession is especially attuned to help patients with health information seeking and self management activities. That's certainly what I've seen happen with my nurse practitioner colleagues throughout my career.