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Getting Healthy

By Cyndy Nayer, April 1, 2013

In January 2013, US News published a report on why Americans aren’t healthier and gave us the concept of a health lag.  In fact, the gap between America’s health status and that of other industrialized nations is a 30-year trajectory of lower outcomes.

Last week, Modern Healthcare published a review of Kaiser Family Foundation findings in which the highest hospital readmissions were directly correlated to the unhealthiest counties in the US.

On the same day as the MH-KFF release, I was privileged to receive a tweet on patient engagement that highlighted the blog of Gilles Frydman  on, which highlights the real engagement and outcomes of patients who seek to understand their conditions and treatment by conversing with others.  The point here is in the definition of engagement, per the blog, “An engaged patient is someone deeply involved in the scientific understanding of their disease, fully aware at all times of the entire spectrum of available therapeutic options. It requires a set of learning, cognitive and psycho-social tools that can only be acquired by conversing often with a real network of peers who are similarly involved in this complex endeavor. 

This, says the author, is exactly opposite of the current definition of patient engagement as used by HIT, care professionals, benefits personnel, and service providers:  “the engagement flows from the various professional stakeholders of the health care system to the patients. It is a direct extension of the concept of consumer engagement.”

It’s exactly the discussion I am most involved in, most of the time, in which the (choose one) doctor/ IT developer/ hospital administrator/ national thought leader talks about patient engagement as the patient behaving according to the “guidance” he/she is provided.  But what if the guidance reaches the patient at the same time she is dealing with her teenager who had a car accident, or her husband who may lose his job? What if the “guidance” is a follow-up visit or test, but the office isn’t open late when she is off work? What if the “guidance” is the purchase of a pharmaceutical that she either can’t afford or that may cause side effects for her?  What if she simply didn’t understand the instructions or, three months later, is feeling better and stops the medication or falls off her nutrition plan?

Unfortunately, the problem here is that the engagement and persistence (which, by definition is part of engagement) did not occur because people have other parts to their lives than the body parts with issues.  They have financial needs, emotional needs, social needs, even transportation needs that interfere with engagement. While the most-influential people in the patient’s life, according to surveys, is the clinical “face” (doctors, pharmacists, nurses, etc.), these people do not follow the patient everywhere, and others in her sphere of influence take precedence.

Emergency department visits drop when medical practices extend hours. There are examples of patient engagement strategies that work and that translate directly to saved dollars.  In surveying more than 9,500 people with steady sources of care, the Center for Studying Health System Change focused its results on 1,470 individuals who had tried to contact their primary care practices after normal business hours in the past year. The study, published online in Health Affairs on Dec. 12, found that nearly 21% had difficulties reaching their physicians after hours, and those who reported more difficulty accessing after hours had higher rates of emergency department use (37.7%  and higher rates of unmet medical needs (13.7%).

As I’m on my relentless pursuit of solutions that deliver better health outcomes, I have to  emphasize this, re-emphasize it, and then state it many times more.  Those who doubted the power of value-based benefit design or outcomes-based clauses did not fully understand the suite of services and, what I call surround-sound messaging, that is necessary for patient engagement in health.

We cannot be paternalistic, nor maternalistic, in making health the end goal.  We have to meet people where they are and stop treating body parts separately (you know, hypertension over there and depression over here and diabetes…).  We have not only organize in patient-centric efforts but, perhaps more importantly, in patient-driven circles.  This is the success of the senior-citizen breakfasts that promote Medicare health plans, of the breast-health discussions that occur in churches and hair salons, and of the Dr. Oz and Dr. Phils of the world who reach through social media (including TV) to their audiences.

Transparency will only matter if the patient is seeking healthcare.  If, instead, she is seeking a carpool for her kids or the money for rent, then transparency of treatments may not be as meaningful, if it’s on the radar at all.  ”Entitlement programs,” as Medicare and Medicaid are increasing called, cause splits in peer groups and often in the same family, pitting seniors against young working adults in the “subsidy” allotment.

These are not directly related to the delivery of treatment from the health system, but they are distractions to the patient decisions.  If the incentives to the prescriber are different than the incentives to the patient, the patient will more often seek the treatment recommended by the doctor, as this is the trusted relationship.  In survey after survey for many years, the clinician advice trumps the insurance benefit advice, yes, but it also relieves the patient of asking price or quality or convenience questions of the physician.  To this point, in my March 15 2013 I sent out the Health Affairs link to the Kaiser study showing that consumers do not want to be responsible for their healthcare costs, and they don’t want their doctors to be responsible, either.  

If we want to close the health valley that we are in, if we want to use the amazing healthcare resources in our country wisely and widely for all of us, then we have to stop this narrow focus of hospital v doctor v benefit plan v pharmaceutical manager v insurance and get back to the basics:  making healthcare understandable, actionable, and most of all, relevant WITH the patient not TO the patient.  Patient engagement IS the holy grail for healthcare and health improvement.  But it can’t be done around the patient, it must be done with the patient fully present and asking questions and envisioning the future of his or her health.  If he or she can’t see it, he or she can’t achieve it.

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