COSTS AND OUTCOMES: Does patient engagement work?

Paul Wasserstein, MD

Four new federal programs (value-based purchasing, meaningful use of electronic records, monitoring hospital readmissions, and creating accountable care organizations) will significantly impact hospitals and physicians through the use of Medicare penalties and incentives. In order to qualify for the incentives and avoid penalties, hospitals and physicians will have to employ new “patient engagement” strategies that actually work to decrease costs and improve outcomes and the overall patient experience. But no one seems to agree on the definition of patient engagement. Maybe it’s this (from a recent healthcare blog):

“Patient engagement is shared responsibility between patients, healthcare practitioners, and healthcare administrators to co-develop pathways to optimal individual, community and population health. Patient engagement brought to life means involving patients and caregivers in every step of the process, providing training or financial support if necessary to their participation.”[1]

But does patient engagement work? The evidence to date is mixed. A few patient-engagement projects appear to have generated some savings and better quality scores, but the reduction in per-capita costs pales in comparison to the estimated 35% of U.S. healthcare dollars spent on care that is inefficiently delivered or doesn’t improve health.[2]

Patient-engagement projects that have demonstrated success include several in Boston, Miami, Los Angeles and Seattle. On average, the risk-adjusted per-capita health spending at these projects was around 15-20% below the regional average. Of interest is that most of the projects accomplished these savings without significant health information system support!

The Seattle project, called an Intensive Outpatient Care Program (IOCP), has been described in detail by Dr. Arnold Milstein, professor of medicine at Stanford University, director of the Stanford Clinical Excellence Research Center, and medical director of The Pacific Business Group on Health. He writes:

“The pilot enrolled 740 eligible non-Medicare Boeing patients being treated by physicians at the Everett Clinic, Valley Medical Center IPA, and Virginia Mason Medical Center clinics. Patients who accepted were connected to a care team that included a dedicated RN care manager and an IOCP-participating MD. … Each IOCP-enrolled patient received a comprehensive intake interview, physical exam, and diagnostic testing. A care plan was developed in partnership with the patient. The plan was executed through intensive in-person, telephonic and email contacts--including frequent proactive outreach by an RN, education in self-management of chronic conditions, rapid access to and care coordination by the IOCP team, daily team planning huddles to plan patient interactions, and direct involvement of specialists in primary care contacts, including behavioral health when feasible.”[2]

Dr. Milstein goes on to describe the many difficulties encountered while implementing the IOCP project, including the lack of incentives, problems with recruiting patients, shortcomings of the existing electronic health record system,  and limiting specialty care to the highest-performing specialists. Nonetheless, the results were impressive:

“Evaluation of results occurred … after 276 patients had both participated in the program for at least 12 months and could be matched based on health spending risk factors to a non-participating Boeing-insured patient in the predicted high-cost quintile. Functional status scores, HEDIS intermediate outcomes scores, depression scores, patients’ experience of care scores, and employees’ absenteeism scores improved compared to baseline. Compared to a matched control group of Boeing’s enrollees in Puget Sound that did not receive their primary care from one of the three physician groups, unit price-standardized per capita spending dropped by an estimated 20%, primarily due to lower spending for ER visits and hospitalizations.”[2]

What does patient engagement look like in Marin County? A good place to start is with the county’s three main coordinated care organizations: Meritage Medical Network ACO, Kaiser Permanente, and Sutter Health.

Recently approved as a Medicare ACO, Meritage (formerly known as the Marin-Sonoma IPA) is using a format relatively similar to the Seattle project. “We are starting with four high-risk conditions: diabetes, congestive heart failure, asthma and COPD,” says Andrea Kmetz, RN, Meritage’s director of care management. “We’ve hired four new RNs to assist with outreach to patients. We want to identify the patients early, educate them, and monitor them closely. We’ll dedicate RN case managers to specific medical practices and place these case managers in the physician offices. The goal is to have the patients seen by the MD and the RN at the same time and have the patients see them as a trusted team.”

Kmetz adds, “We’ve outlined a system with a lead physician in every practice. This lead will review care for any patient that is outside established goals identified through online evaluation of the patient’s lab, pharmacy and hospital admission data. That MD will report to the ACO case management committee for further review.”

What’s the biggest obstacle? “Connecting with the primary care physicians in order to enroll patients,” says Kmetz. What works? “Well, we have a great information system that lets us maintain the patient care plan, coordinate care with the physicians, and monitor the patients closely.”

Cardiovascular disease (CVD) is the leading cause of death and disability in the United States. Dr. Dan Smith, a family physician at Kaiser San Rafael Medical Center, has been the local champion of the Kaiser PHASE program (Preventing Heart Attack and Stroke Every day) for the past four years; the program has been in existence for eight years. He explains that patients enter PHASE as part of secondary prevention for myocardial infarction, coronary artery disease, diabetes, peripheral vascular disease, or stroke, or if they are referred as a new patient by a primary care physician. The PHASE program assists with the management of 10,000 patients in Petaluma, Novato and San Rafael.

PHASE patients, according to Dr. Smith, are co-managed by specially trained pharmacist care managers. These pharmacists are in the doctor’s office, working directly with the patient’s doctor and the patient. A database allows the pharmacists to enroll all appropriate patients. The pharmacists develop customized care plans in coordination with the patient’s physician. The pharmacists also outreach to patients to educate them about their chronic disease and teach them the skills needed to improve their health.

Patients’ labs and tests are under regular review by their pharmacist care manager. Intervention occurs if the patient’s LDL is greater than 99 mg/dL, blood pressure is greater than 139/89, or the hemoglobin A1c is greater than 6.9. The patient receives a phone call from the pharmacist to discuss their test results and next steps. Patients are reminded regularly of labs that are due or appointments with their care team. If patients are noncompliant or not engaging in their care, an escalating reminder system of robo-calls and letters is used, up to and including an outreach phone call from their primary care physician.

As Dr. Smith says, “The program works. It has lowered the likelihood of death due to heart disease by 30%. If you are a Northern California Kaiser member, your risk of dying from heart disease is lower than your risk of dying from cancer.”

In contrast to Kaiser, Sutter Health is relatively new to the patient-engagement arena. Three Sutter affiliates, including the local Sutter Pacific Medical Foundation, have partnered with the Pacific Business Group on Health (PBGH) in an intensive outpatient care project. The project targets a high-risk chronic disease population with specialized education classes, patient visits, and close contact with the patient population. Patients are identified using predictive modeling software.

“This high-risk chronically ill population represents about five to eight percent of the total population,” says Don Ransom, PhD, Sutter’s local director of clinical integration. “We think the ratio is about 100 of these patients to one RN.”

How to pay for all the extra nurses and support staff? “We’re funding this project internally for now,” says Dr. Ransom, “but the larger PBGH demonstration grant is intended to provide results that encourage CMS [Medicare] to modify its payment model for primary and population-based care. We have begun to make these kinds of structural changes in the way we provide care to keep people healthier and out of the hospital. As Sutter Health takes on increasing risk for the total health care dollar, these kinds of initiatives to reduce the total cost of care will make sense financially”.

Money is a significant problem for these new patient-engagement programs. As Dr. Toni Brayer, chief medical officer of the Sutter West Bay region, points out, “Nobody’s paying for this stuff!”

Starting up patient-engagement programs is expensive, and the payoff down the road is uncertain. “And we’re at a disadvantage in Northern California”, says Dr. Ransom. “We already have a low readmission rate to hospitals and, overall, provide Medicare services much more efficiently and at lower cost, in terms of the total cost per beneficiary per year, than the rest of the country. There may not be much excess money to squeeze out in the care of traditional Medicare patients.”

Whether or not these programs will save enough money to pay for themselves is yet to be determined. Nonetheless, it’s becoming clear that once patients understand they are being cared for by a team, they seem to like it. Some form of “hypermanagement” of chronically ill patients seems to be here to stay.

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Dr. Wasserstein, who serves on the MMS Board of Directors, is a pathologist with offices in Novato and Greenbrae.

Email: pwasserstein@pathgroup.com

References

1. Cryer D, “Defining patient engagement,” Center for Advancing Health, cfah.org (Feb. 18, 2011).

2. Milstein A, Kothari P, “Are higher-value care models replicable?” Health Affairs Blog, healthaffairs.org (Oct. 20, 2009).