It's a widely accepted truism that increasing patient engagement in health care leads to lower costs and better outcomes.
It appears in government documents and in promotional, commercial and advocacy material. I've heard it again and again as I've interviewed professionals about what engagement means: doctors, nurses, and representatives of health plans, employers and vendors. When I ask why they think people's active participation in their health care is important, almost everyone replies along the lines that "the greater patients' participation in their care, the lower its cost and better the outcomes."
This perspective might be accurate if you assume that engagement is equivalent to compliance with evidence-based health advice. Let's say a person who is engaged in his health and health care by definition walks 10,000 steps per day, maintains a moderate weight, avoids cigarettes, sleeps eight hours per day, adheres to all screening and testing guidelines, takes medications as directed by his clinician and follows directions to care for acute and chronic conditions. It's probably true, then, that this person's health care will cost less than someone who does only a few (or none) of these. Healthy is cheaper than sick. And really, it shouldn't be a problem to convince us to act on our own behalf and engage in the behaviors that support health, right?
I see two problems with this viewpoint and with the assertion that patient engagement will lower the cost of health care:
First: From the perspective of patients, our engagement in our care is not defined by adherence to evidence-based standards but rather by our ability and willingness to make informed choices about every aspect of our health care. Sometimes – often, in fact – our choices are inconsistent with our doctors' recommendations or guidelines. Further, many of us believe that more care is better than less, that expensive care is better than cheap and that our local doctor and hospital deliver high quality care. There are few reasons to believe that we are attracted to lower price service and technology options for ourselves and for those we love.
Second: Interventions to substantially change and maintain our health habits and self-care behaviors to better conform to medical recommendations and guidelines have been only marginally effective to date, leading to incremental shifts in individual behaviors. Further, while those changes may reduce our need for health care in the aggregate, at an individual level such behaviors have little to no impact on reducing the cost of care when we seek it.
When Don Berwick, former director of the Centers for Medicare and Medicaid Services, describes how to achieve the Triple Aim of improving the experience of care, improving population health and reducing the cost of care, he notes that these three aims are not independent. Accomplishing any of them can only take place if the other two shift as well. Thus, it is probably unrealistic to claim that individuals will, by making different choices and acting in different ways for the rest of their lives, be able to lower the costs of their health care and, by doing so, accomplish something that the powerful forces of policy and professional practice have been unable to do so far.
Now I sympathize with the desire of professional advocates to stack the deck for an economic argument in support of patient engagement. God knows, it is not clear that anyone would pay any attention to our experiences, needs and preferences at all these days if there wasn't some way we could be enjoined in the epic struggle to "bend the cost curve."
But I am concerned that in time, the patient engagement agenda will be undermined by these overstatements. As evidence and critical thinking are brought to bear, you can see the wheels starting to come off. See the arguments of Al Lewis and Vik Khanna about the exaggerated return on investment claims of workplace wellness/health promotion, for example, or the recent critique in the Journal of the American Medical Association that questions the ambitious claims of cost savings due to shared decision making.
It is likely that the well-intentioned interventions inviting us to share decisions with our clinicians, view our health records, self-manage our chronic conditions and generally behave ourselves will simply not be strong enough to deliver the cost savings professional advocates lead us all to expect. We have seen this before: big claims for a new approach that will save money but that doesn't deliver and so withers away to some vague shadow, a cautionary tale or a bad joke. (Think managed care and disease management.)
I worry that when efforts to support patient engagement fall short of their rhetoric, only faint vestiges will remain of the current grand efforts to establish our rightful place alongside those determining our care and our future.