As patients have demanded a larger say in their care, they are also expected to play a larger role in selecting their providers and health plans. With increasing amounts of information available to them, but also a growing number of financial considerations when making care choices, this month’s issue of Health Affairs analyzes the ups and downs of expecting patients to act as consumers.
Engaging In Care
In the opening overview paper, Karandeep Singh and coauthors describe a variety of new tools that patients have to manage their care, including patient portals, data extracted from their own electronic health records, and mobile apps. Yet the authors conclude, “While access to digital consumer resources is steadily growing, a culture shift will be required—particularly among health professionals—before consumers and patients fully realize the benefits.”
Analyzing survey data over a twenty-year period, Mark Schlesinger and coauthors find a more than doubling of people seeing comparative quality data on physicians. The growth occurred in the past decade, with the rate 12 percent in 2008 and 26 percent in 2015.
Ming Tai-Seale and coauthors describe how four health care delivery organizations use technology to increase consumer engagement. One example: Ochsner Health System in Louisiana combined patient home monitoring, expanded tools in the electronic health record, and reporting through the patient portal to support team-based care for people with hypertension. At six months, patients recorded more blood pressure readings and showed greater medication adherence compared to those not in the program.
Engaging In Research
A critical element of patient and consumer engagement is participation in the research enterprise that creates the evidence base for care. Laura Forsythe and colleagues at the Patient-Centered Outcomes Research Institute (PCORI) analyze the published literature and catalogue a range of mechanisms for consumer engagement in research from the project design phase, through the conduct of research itself, and culminating in the dissemination of results.
Jonathan Delman and coauthors describe an undertaking to conduct community-based participatory research that engages people with serious mental illnesses who are members of racial and ethnic minority groups. The authors point out, “Even when people of these communities are provided with resources to participate in a research collaborative, their consistent participation can be difficult to achieve if values of freedom, empowerment, and justice are not upheld.”
What information do research participants want to receive? Reporting results of a survey they conducted, Consuelo Wilkins and colleagues find that in addition to results that might guide their care, research participants are also interested in gaining access to clinical trials and in learning how those conducting the research will use the results.
Financial Incentives
As more Americans are enrolled in health plans with high deductibles, concerns have grown regarding postponing or forgoing needed care. J. Frank Wharam and coauthors find delays in initiation of breast cancer care—imaging, biopsy, diagnosis, and treatment—among women in high-deductible plans. Low-income women delayed chemotherapy by more than eight months, while high-income women delayed care by more than five months.
Benjamin Chartock and colleagues explore how consumers respond to receiving a surprise medical bill from an out-of-network provider during an in-network hospital stay. Looking at data for women with two nonemergency childbirths, the authors find that 11 percent of the women experienced a surprise medical bill with the first birth, and they were 13 percent more likely to switch to a different hospital for their second birth.
What happens when an insurer gives its enrollees a cash rebate when they select a low-price provider? Christopher Whaley and coauthors report results from a program adopted by the fourth-largest health plan in the United States. Program participants increased their use of a price-shopping tool by more than fivefold, and about one-quarter of those who used the tool received a reward for using a lower-price provider.
Value-based insurance design (VBID) lowers out-of-pocket spending for high-value services and has been shown to increase their use. Analyzing data from one state’s program, Betsy Cliff and colleagues find concomitant increases in low-value services, suggesting that VBID’s emphasis on prevention may lead people to obtain preventive services they do not need.
Susan Perez and coauthors find modest support among consumers for value-based approaches, such as VBID and reference pricing. However, the authors report, “Consumers are interested in provider quality, but their definition of that quality [which focuses on relationships and experiences] differs dramatically from what clinical experts use to measure quality.”
Acknowledgments
Health Affairs thanks Dominick L. Frosch of the Palo Alto Medical Foundation for serving as theme issue adviser. We also thank PCORI and the New York State Health Foundation for their financial support.
