Patient-Centered Care: Health Literacy, HIT and Shared Decision-making

By Nalini K Pande, JD

“When we want your opinion…”

When we talk about patient engagement, a cartoon comes to mind that I often used when I was teaching at Georgetown.  The cartoon depicts a group of doctors conferring amongst themselves while they lean over a patient who is sick in a hospital bed.  The patient is trying to speak and a doctor interrupts and says, “When we want your opinion, we’ll let you know!”

That, in a nutshell, depicts how many patients feel when it comes to interacting with the healthcare system.  Ironically, on the flip side, many healthcare delivery executives are trying to determine how they can increase the value of the care they provide, and as a result, produce better outcomes for their patients.  Increasingly, organizations are recognizing that meaningfully engaging patients and families is the answer to this question. In fact, these organizations are focusing on more than engaging patients in making choices about their care. Health systems are focusing on engaging and supporting patients in self-care for chronic disease management, and asking for patient input on how healthcare organizations can better engage patients.

Payment Reform and Patient Engagement Go Hand-in-Hand

With payment reform leaving providers with increased risk-sharing and accountability, patient engagement may be seen as the Holy Grail to tap into improved patient outcomes and contain costs.  Yet, many patients lack the health literacy to effectively navigate what is now an increasingly complex and confusing health system.  Koh et al propose a Health Literate Care Model that would “weave” health literacy strategies into the widely adopted Care Model (formerly known as the Chronic Care Model).  In this way, health literacy would become an “organizational value infused into all aspects of planning and operations, including self-management support, delivery system design, shared decision-making support, clinical information systems to track and plan patient care, and helping patients access community resources.” [1] 

Further, the HIT infrastructure can help providers keep patients and caregivers informed, educated and literate about their personal health and medical conditions. It can support on-going self-care and wellness management, including coaching from healthcare providers and ongoing dialogue between those providers and patients.  Additionally, patient portals (available online and via kiosks)  can be effective tools in providing access to electronic health records, appointment scheduling as well as clinical support such as secure provider messaging, patient reminders, alerts, test result views and prescription refill requests. 

Perhaps, most importantly, taking a population health approach to patient engagement is essential.  Bending the cost curve and improving quality requires the management of patients in lower-acuity, primary care settings with diverse access points, education of treatment plans and adherence through clinical care and community partnerships as well as strong patient activation.

Policy makers, payors, providers, patients and caregivers should work together to develop strategies to implement:

 • The health literate care model
 • Provider, patient and system competencies needed for patient-centered care
 • HIT infrastructure & population health approaches to patient/family engagement.

Changing the healthcare culture and allowing for stronger shared-decision-making may not be the top agenda item for many health system executives.  However, given the costs of maintaining the current status quo, health system executives would do well to re-think their priorities.



Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, prevention, population health, patient engagement, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  She previously taught a graduate health quality course at Georgetown University as an Adjunct Professor. Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.

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[1] Koh et al. “Analysis and Commentary: A Proposed ‘Health Literate Care Model’ Would Constitute A Systems Approach To Improving Patients’ Engagement In Care.” Health Aff. February 2013, 32:357-367. 

Prevention, Incentives and Medicare Costs

By Nalini K Pande, JD

A little over a year ago at my previous consulting job, I served as the project director for a very interesting prevention project.   The project was for the Bipartisan Policy Center’s (BPC) Health Care Cost Containment Initiative¹.   BPC had asked us to develop a financial model of the costs and benefits of a diabetes Type 2 prevention program.  Our report illustrated how the financial incentives for three different payors  (commercial plans, Medicare, and ACOs) vary given different assumptions of who would pay for these prevention services and the age at which individuals would first receive prevention services. We chose to model Type 2 diabetes prevention services given that Type 2 diabetes is reversible and given the tremendous amount that the US spends on Type 2 diabetes² .   What we learned was fascinating.

Prevention Efforts Can Yield Cost Savings

The key finding from our report was that a diabetes prevention program “can produce overall cost savings which increase over time for an individual.” Given this, why wouldn’t we roll out these prevention programs on a widespread basis?  Well, the answer may surprise you.  To delve into this, you will need to understand three key issues:

• - First, who pays for the diabetes prevention program? 
• - Second, who benefits?
• - Third, when do the savings kick in?

Our report showed that if private commercial plans bear the cost of the diabetes prevention program, they may not reap all the benefits.  This is because of two reasons.  First, if individuals switch health plans over time, another plan would reap the benefits – allowing for only small benefits for the plan that implemented the prevention program.  Second, if you’re 55 or older, there is no incentive for a private commercial plan to cover your participation in a diabetes prevention program.  Simply put, by the time the cost savings would kick in (10 years), you would be on Medicare and Medicare, not the plan, would reap the benefits. 

So, what if Medicare paid private plans to cover these diabetes prevention programs?  Perhaps, then, we would all win.  Those with private commercial plans would benefit from diabetes prevention services and Medicare would benefit from healthier beneficiaries who save the program money. Our report found that while the Government does recoup savings when it pays for the program, it only did so for those who are near 60.  In fact, the Government receives very little savings from a younger population who would stay with the private sector and continue to be with a commercial plan during the timeframe when most of the savings would be realized over a 25-year period.

Where does this leave us?

In essence, what we have is a scenario where payors are reluctant to pay for prevention services since they won’t benefit completely.  Has our patchwork system of health care created disincentives around prevention?  Not quite.  Our study found that if patients could join an ACO when they are under 65 (as a commercial ACO) and then stay in the same ACO when they are over 65 (as a Medicare ACO with shared savings between the ACO and Medicare), perhaps the ACO would get the best of both worlds.  In this scenario, an ACO could invest in its patients through prevention programs and recoup the benefits, assuming limited plan switching.

Investing in prevention appears to be a game of “what’s in it for me?” How do we change it to a “win-win” scenario? The answer is simple.  We do so by utilizing new systems like ACOs that allow payors to reap long-term savings. 

Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, prevention, population health, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.


Follow @nalinipande

                                           

¹ Under the leadership of former Senate Majority Leaders Tom Daschle (D-SD) and Bill Frist (R-TN), former Senator Pete Domenici (R-NM), and former White House and Congressional Budget Office Director Dr. Alice Rivlin, BPC’s Health Care Cost Containment Initiative  “explored and evaluated strategies to contain health care cost growth on a system-wide basis, while enhancing health care quality and value.” 
 ² In Appendix D of our report, we noted a study by Dall and colleagues that estimated the costs associated with Type 2 diabetes as $105 billion for medical costs (along with $54 billion for non-medical costs such as lost work days).