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Beware of Claims That Patient Engagement Cuts Costs

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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.

More Blog Posts by Jessie Gruman

author bio

Jessie C. Gruman, PhD, was founder and president of the Center for Advancing Health from 1992 until her death in July 2014. Her experiences as a patient — having been diagnosed with five life-threatening illnesses — informed her perspective as an author, advocate and lead contributor to the Prepared Patient Blog. Her book, AfterShock, helps patients and caregivers navigate their way through the health care system following a serious or life-threatening diagnosis. The free app, AfterShock: Facing a Serious Diagnosis, offers a pocket guide based on the book. | More about Jessie Gruman


Tags for this article:
Patient Engagement   Health Care Cost   Pay for your Health Care   Inside Healthcare  


Comments on this post
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Cathie Currie says
October 9, 2013 at 8:30 PM

Nailed it, Jess, as you always do. Einstein advised that we should make a problem simple, but not too simple.

Healthcare cost management is not Madison Avenue advertizing, where glib extravagant claims are highly valued.

We need careful investigations of each contribution to our healthcare system's cost escalation without corresponding increases in quality of care and beneficial outcomes.

Michael Millenson says
October 9, 2013 at 10:27 PM

Nicely said, as always, Jessie.

This reminds me of the claim that "quality is free," based on the industrial model pioneered by Deming. That's true if you are a company doing warranty work; not true with traditional, piecework fee-for-service care. In fact, the "cheapest" hospital care would be to kill or cure each patient quickly. It's that lingering illness that's costly financially.

Of course, as with patient engagement and empowerment, while you might spend more on medical expenses, the payoff in terms of productivity and plain old-fashioned happiness could be worth it.

In other words, rather than bending the cost curve, you may either be getting a greater return on your money or be providing more ethical care. Those, too, are good things.

Shoshanna Sofaer says
October 10, 2013 at 12:03 AM

The folks with the most power in health care, including the power to lower costs, haven't done it. So they ask patients and caregivers, who arguably have the least power to make substantive changes in health care, to do it for them (not even with them).

Some folks fall for this. I suppose it makes them feel "empowered," my least favorite word in the English language. I agree that we should beware of "overselling" patient engagement as a cost cutting mechanism -- this reveals our belief that clinicians, health care executives and policy makers won't support it unless it is cost cutting.

We should do, and promote, patient engagement because of its potential to improve the patient's health and their experience of care. I even worry about the latter, saying it will improve their experience of care, because it often requires patients and caregivers to work harder at getting the care they want and need, and have difficult conversations with clinicians and others.

We should also keep in mind that there may not really be much of a true constituency for cutting health care costs. Every dollar we spend is income/revenue for some person or organization in health care. Has anyone noticed a lot of health care providers raising their hands to volunteer to get less money?

I agree that we have to promote patient engagement because it is good for patients

Marilyn Mann says
October 10, 2013 at 7:25 PM

Victor Montori, Glyn Elwyn, and Jon Tilburt make similar points with respect to shared decision making here:

http://www.bjll.org/index.php/ejpch/article/view/645

Matthias Schablowski (InterComponentWare AG) says
October 11, 2013 at 6:39 AM

Within all the hype regarding cost cutting by patient engagement, I have been wondering for all while - where is the evidence?

It's intriguing to see that while from a clinical perspective, everyone agrees that we need more evidence-based assessment of treatment options, the same thing seems not to be required for the economical view on healthcare..

Jonathan says
October 11, 2013 at 4:25 PM

I agree with you about how it in most cases (and when I mean most, I mean all) is more expensive and most care givers and patients alike do not want to bother.

I wrote an article that I think you and your readers will enjoy.

Please let me know your thoughts.

Failure of the Patient Portal, Poor Doctor-Patient Engagement

- See more at: http://getreferralmd.com/2013/10/patient-engagement-patient-portal/

Austin Brandt says
October 16, 2013 at 5:08 PM

Like the others here, I completely agree with you on the dangers of overselling the benefits of patient engagement. If its advertised as the holy grail to achieving the Triple Aim, but then that steak doesn't sizzle, we'll lose all credibility in the industry as a whole.

I would argue, however, that there certainly can be a cost saving component to certain engaging activities. The most obvious to me is a reduction in redundant testing as a result of the patient managing their own medical records. An unengaged patient won't think twice about going through another screening, which their physician is financially incentivized to providing. Whereas the engaged patient with their medical records in hand can stop that cost from occurring. This is what Dave Chase is referring to as a "negaclaim", a term I quite like.

Earnest Carlton Ph.D says
September 8, 2014 at 12:40 PM

Not every patient is engaged or compliant. However, those patients
who are "engaged" by definition are more likely to be compliant, better record keepers, communicate more accurately to all health care providers, and thereby reduce medical errors and unnecessary readmissions and from an actuarial perspective, reduce health care costs.