The following is a guest blog post by Peter Edelstein, MD, is the Chief Medical Officer at Elsevier.
Today’s healthcare reform world is filled with buzzwords. “Population Health Management.” “Value-Based Care.” “Patient Engagement.” I am in no way suggesting that these topics do not play critical roles if we are to realize the enormous potential of healthcare reform. However, if you ask ten people to define any one of these buzzwords, you’ll receive twelve different definitions. And in a world of threatening reimbursement penalties and expanding healthcare legislation, the sooner that we come to some consensus on the basic meaning of these terms, the sooner we can understand the associated myths and realities.
Relative to the patient population (that is, the general population), the population of providers (doctors, nurses, and other clinicians) represents a fairly homogeneous and small group to target with initial reform efforts. In addition, we are all painfully aware of the unacceptable number of preventable deaths and complications which occur at the hands of providers each and every day. Thus reform legislation has first focused on reducing variability, elevating quality, and controlling the cost of care delivery through programs focused on providers (hospitals and healthcare systems, as well as the physicians, nurses, other clinicians who work in such institutions).
Again, this makes sense as a starting point. That said, to believe that we will achieve our ultimate goals of evolving into a system dominated by preventative care and outpatient and home health maintenance (leaving hospitals to serve only those whose chronic conditions can no longer be controlled in the outpatient setting) solely by changing how providers deliver care is a myth of epic proportions. Far-and-away our greatest opportunity to shift our population’s health from reactive, acute, and expensive to proactive, preventative, and cost-efficient is by directly engaging and educating and empowering the general population of patients and future patients themselves.
This perspective is based on two major realities. First, studies (as well as our own experience) confirms that even individuals with chronic conditions spend on average only a handful of hours annually in front of a professional care provider. (How many hours did you or your spouse spend under the direct care of a provider in the previous twelve months? For the overwhelming majority of you, the answer is less than a couple.) Second, patients who demonstrate interest in and ownership of their health have better clinical outcomes and reduced costs of care. In a nutshell, people spend virtually all of their lives away from doctors, nurses, and hospitals, and as with virtually any complex processes, those who are more involved and knowledgeable have better outcomes.
Now we come up against another reality: limited resources. Hospitals and healthcare systems have limited staff and finances, and Patient Engagement often draws the short straw when competing with electronic health records, computerized order sets, and other provider-specific support solutions. But, as I’ve suggested, de-prioritizing Patient Engagement as “less important” or “less impactful” is a myth which greatly limits our potential to increase the value (elevate quality/reduce costs) of healthcare delivery. Thus, the most important first step for healthcare stakeholders to accept is the reality that assigning resources to Patient Engagement must be as great a priority (if not greater) as allocating staff and money to products and solutions which target only traditional providers.
Once healthcare leaders accept the critical importance of Patient Engagement, they again have to consider their limited resources. It is another common and perilous myth when trying to allocate resources and develop and implement Patient Engagement strategies to consider all patients within a healthcare system’s catchment area as a homogeneous population. The reality here is that not all individuals have the same potential for or barriers to becoming engaged patients. And understanding with which patient subpopulations you can get “the most bang for your buck” is a necessity which is often overlooked.
For example, any of us who have directly cared for a large cohort of patients knows that there are some individuals (comprising a patient subpopulation) who simply have no intention of ever lifting a finger to care for themselves. I think about the roughly 50% of Americans with chronic conditions who fail to take their medications as prescribed. Or the diabetics who simply cannot be troubled with checking their blood sugars. Every provider can immediately call to mind dozens of patients who, understanding how to better their own health, simply refuse to do so. The reality is that as in all areas of life, there are simply some people who just will not engage, be accountable, take ownership. To waste valuable resources trying to engage this patient subpopulation is foolish, disillusioning for staff, and wasteful, and it is best to quickly identify these individuals and accept that all you can do is provide reactive care when they become ill.
A second and large patient subpopulation is well worth the resources and efforts to engage. These are the folks with limited literacy and numeracy skills. Multiple studies have demonstrated the inverse relationship between literacy and healthcare outcomes. Thus, assigning resources to clearly engage and educate these individuals so that they have the knowledge and understanding necessary to engage is worthwhile.
The third large patient subpopulation worth targeting is comprised of people whose upbringing or culture serves as a barrier to engagement. Perhaps the largest of these cohorts is elderly Americans, many of whom were raised never to question a physician or ask for clarification. Such patients are unable to engage because they refuse to address their lack of understanding of recommendations for their self care. Another large faction are those who were raised in cultures (often outside of the United States) where, as with elderly Americans, the provider is God, never to be questioned. Thus, these folks don’t really understand what they can do to improve their health, and they refuse to ask for further clarification.
The reality for these two large patient subpopulations is that the appropriate use of resources to understand and directly address the obstacles to true engagement and education can result in great successes.
In the end, our ability to achieve truly dramatic and impactful healthcare reform depends to a great extent on engaging and educating the patients of today and tomorrow. Appreciating this reality, and understanding the realities related to identifying patient subpopulations which can truly be engaged and educated is the best approach to achieving successful reform.
About Peter Edelstein, MD
Peter Edelstein, MD, is the Chief Medical Officer at Elsevier. Edelstein is board certified by the American College of Surgeons and the American Society of Colon and Rectal Surgery. He has more than 35 years of experience practicing medicine and in healthcare administration. Edelstein was in private practice for several years before serving on the surgical faculty at Stanford University, where he focused on gastrointestinal, oncologic and trauma surgery. He then spent more than a decade as an executive in the Silicon Valley medical device industry. Edelstein’s most recent role was as Chief Medical Officer for the healthcare business at LexisNexis Risk Solutions, a Reed Elsevier company. He is also the author of the recently published book, ‘Own Your Cancer: A Take-Charge Guide for the Recently Diagnosed & Those Who Love Them’.