CFAH recently interviewed the following employers and purchaser representatives for our Here to Stay: What Health Care Leaders Say About Patient Engagement report:
- Larry Boress, President and CEO, and Cheryl Larson, Vice President, Midwest Business Group on Health, Chicago, IL
- Laurel Pickering, MPH, President and CEO, Northeast Business Group on Health, New York, NY
- Michael Vittoria, Vice President, Corporate Benefits, MaineHealth, Portland, ME
Over the past 18 months, CFAH, with support from the Robert Wood Johnson Foundation, interviewed over 35 health care stakeholders to gather their perspectives on patient engagement. Our informants represented seven key groups: patients, clinicians, employers, health plans, community health programs, governments, and health care consultants and contractors. We asked each participant eight questions about defining patient engagement, identifying engagement behaviors, measuring its impact, exploring its barriers and what is needed for it to thrive.
Six overarching themes emerged from our discussions:
- Engagement is active.
- The health care system doesn't make engagement easy.
- Everyone benefits from engagement.
- Engagement is demanding, and many are unprepared.
- Partnerships are required.
- It's like the Wild West.
Here are some highlights from our interviews with employer representatives:
CFAH: Here is the CFAH definition of patient engagement: "Actions people take to support their health and benefit from their health care." What's missing from this definition? What would you add, subtract, or word differently?
BORESS & LARSON: "Patient engagement" means different things to different people. For employers, sometimes "engagement" means that a worker participates in a wellness program, but participation doesn't usually change behavior. From our research, we know there's a need to help employees with both navigating the health care system and addressing the issue of benefits literacy – not understanding what benefits are available or how to use them (this includes available wellness and disease management programs). Also, not everyone knows that they can take steps to improve their health. Others do know, but don't care – it's a key challenge in engagement and why the vast majority of people don't engage.
So, in terms of the CFAH definition, we'd expand it to include "benefits literacy": people not understanding what their health benefits are and how to effectively navigate the health care system
s. Also, it should convey the need to understand the value of my own health, the value of engagement, and the role I need to play in managing my health. Engagement should lead to positive changes in health behaviors, use of health benefits, and interactions with providers.
PICKERING: This seems like a good definition to me. One question I would ask is why you chose the word "support" vs. "improve" their health. While it makes sense that health status might not always improve, at first glance "support" seems passive. I am struck by the fact that this definition is from a consumer's perspective, whereas an employer or provider would be looking to "improve" health.
VITTORIA: The definition seems somewhat passive; it should be more active. People can do things to support their health and benefit from their health care that don't require much active engagement. For example, they can make a doctor's appointment, but not actually be engaged during and after the appointment or follow through on their doctor's advice. So, they may be passively present and go through the motions, but not be actively participating, such as thinking critically about the doctor's recommendation, asking about alternatives, and working with their care team to make the best decisions and get the best outcomes.
Many of our employee initiatives aim to get them actively involved in making better treatment decisions and in managing their health and health risks. When people are engaged, they feel in control even if they're relying on health care providers for technical expertise. They understand what is happening in their situation, understand their risks, and can participate in making decisions and managing their care. This is a different picture than what's in the CFAH definition.
CFAH: What are some interventions that you've heard of that show promise in helping people to engage in their health and health care?
PICKERING: Two areas that I have been hearing more about are tools and products that use theories from behavioral science, like gaming and Prochaska's Stages of Change theory, to assess a person's readiness to change. Both of these fields rely on engaging users in very small, doable steps, with little points of progress, and either try to meet the person where they are or make the process of change more enjoyable/fun…
A higher touch approach that works directly with health care providers and builds on the patient/clinician relationship is needed. People trust health care providers more than health plans. For example, I heard about a company that is actually paying for additional nursing staff in some primary care offices. They are so invested in primary care as the front line of health that they are willing to invest in the extra care.
VITTORIA: Health coaching and disease management programs work well if done in person. I don't know of any employers that are truly happy with engagement results and participation rates from telephonic support. In-person support lets coaches discuss changes in diet and other areas needed. Face-to-face seems to have the greatest impact in terms of health outcomes and costs.
CFAH: What do you see as the greatest barriers to patients being more effectively engaged in their health?
BORESS & LARSON: From employee focus groups and employer benchmarking surveys, we know the greatest barriers are time, access to health services, cost, conflict with lifestyle, and trust and confidence in the people/organizations providing programs. Also, family and loved ones have a huge influence, especially when the employee has a chronic disease and needs to exercise or eat properly. If the meals and opportunities for exercise are supported at home, there's a greater chance the person will be able to manage their conditions. Convenience is a big driver of why people eat fast food; they feel eating healthy food takes more time than getting takeout and is more expensive. Finally, stress has a huge role. People multi-task all of the time and feel they can't take on anything else.
VITTORIA: The biggest ones are time and resources. People are too busy, so they put off doing the things they know they should do. In health care, part of the problem is that it's hard to get quality information about treatment options, costs, and quality – hard even for doctors and well-educated people. Cost-quality-outcomes transparency is an ongoing challenge for all of us. But technology, such as smartphone applications, has great promise to help us get better information and be more engaged. If your doctor says you need a lab test, people can punch up on their phone which labs do high quality work and cost less. The key is to help people with the time crunch.
CFAH: To what extent do you think that efforts by employers can reduce these barriers/increase the capacity of people to engage?
BORESS & LARSON: There are a lot of opportunities to reduce barriers. Employers can motivate employees with incentives, educate them, and offer programs. People spend only seven to 10 minutes with their doctors, but spend over 2,000 hours at work each year, so our members are making their worksite culture and environments healthier. To promote healthy eating, they're updating policies about foods at meetings, in vending machines, and in the cafeteria. Worksites are smoke-free. Wellness programs offer peer support. Employers are creating walking trails and opening stairwells. Beyond that, they're educating employees about available benefits and services.
VITTORIA: Employers have an opportunity to reduce barriers and support engagement because they sponsor health plans and can provide access to information, tools, technologies, incentives, and more. Employers have more ability to influence engagement than they often believe they have. Or they just rely on negative ways to shape people's behavior, such as creating financial barriers to discourage unnecessary or low-value care, such as excessive emergency department visits. Instead, employers need to develop better strategies to encourage engagement, especially in creating incentives and offering tools to help people navigate health care systems. Technology is now creating new opportunities for employers to get involved in positive ways.
When employees make good decisions, both employees and employers benefit from better outcomes. Employers have to do more to engage their employees in their health and health care, especially by aligning incentives to create these win-win situations.
Full interviews and the results of our study are available in our report: Here to Stay: What Health Care Leaders Say About Patient Engagement.