Patient Activation Changes as a Potential Signal for Changes in Health Care Costs: Cohort Study of US High-Cost Patients.

BACKGROUND: Programs to improve quality of care and lower costs for the highest utilizers of health services are proliferating, yet such programs have difficulty demonstrating cost savings. OBJECTIVE: In this study, we explore the degree to which changes in Patient Activation Measure (PAM) levels predict health care costs among high-risk patients. PARTICIPANTS: De-identified claims, demographic data, and serial PAM scores were analyzed on 2155 patients from multiple medical groups engaged in an existing Center for Medicare and Medicaid Innovation-funded intervention over 3 years designed to activate and improve care coordination for high-risk patients. DESIGN: In this prospective cohort study, four levels of PAM (from low to high) were used as the main predictor variable. We fit mixed linear models for log10 of allowed charges in follow-up periods in relation to change in PAM, controlling for baseline PAM, baseline costs, age, sex, income, and baseline risk score. MAIN MEASURES: Total allowed charges were derived from claims data for the cohort. PAM scores were from a separate database managed by the local practices. KEY RESULTS: A single PAM level increase was associated with 8.3% lower follow-up costs (95% confidence interval 2.5-13.2%). CONCLUSIONS: These findings contribute to a growing evidence base that the change in PAM score could serve as an early signal indicating the impact of interventions designed for high-cost, high-needs patients.

Costs of an ostomy self-management training program for cancer survivors.

OBJECTIVE: To measure incremental expenses to an oncologic surgical practice for delivering a community-based, ostomy nurse-led, small-group, behavior skills-training intervention to help bladder and colorectal cancer survivors understand and adjust to their ostomies and improve their health-related quality of life, as well as assist family caregivers to understand survivors' needs and provide appropriate supportive care. METHODS: The intervention was a 5-session group behavior skills training in ostomy self-management following the principles of the Chronic Care Model. Faculty included Wound, Ostomy, and Continence Nurses (WOCNs) using an ostomy care curriculum. A gender-matched peer-in-time buddy was assigned to each ostomy survivor. The 4-session survivor curriculum included the following: self-management practice and solving immediate ostomy concerns; social well-being; healthy lifestyle; and a booster session. The single family caregiver session was coled by a WOCN and an ostomy peer staff member and covered relevant caregiver and ostomate support issues. Each cohort required 8 weeks to complete the intervention. Nonlabor inputs included ostomy supplies, teaching materials, automobile mileage for WOCNs, mailing, and meeting space rental. Intervention personnel were employed by the University of Arizona. Labor expenses included salaries and fringe benefits. RESULTS: The total incremental expense per intervention cohort of 4 survivors was $7246 or $1812 per patient. CONCLUSIONS: A WOCN-led group self-help ostomy survivorship intervention provided affordable, effective, care to cancer survivors with ostomies.

Improving Population Health Management Strategies: Identifying Patients Who Are More Likely to Be Users of Avoidable Costly Care and Those More Likely to Develop a New Chronic Disease.

OBJECTIVE: To explore using the Patient Activation Measure (PAM) for identifying patients more likely to have ambulatory care-sensitive (ACS) utilization and future increases in chronic disease. DATA SOURCES: Secondary data are extracted from the electronic health record of a large accountable care organization. STUDY DESIGN: This is a retrospective cohort design. The key predictor variable, PAM score, is measured in 2011, and is used to predict outcomes in 2012-2014. Outcomes include ACS utilization and the likelihood of a new chronic disease. DATA: Our sample of 98,142 adult patients was drawn from primary care clinic users. To be included, patients had to have a PAM score in 2011 and at least one clinic visit in each of the three subsequent years. PRINCIPAL FINDINGS: PAM level is a significant predictor of ACS utilization. Less activated patients had significantly higher odds of ACS utilization compared to those with high PAM scores. Similarly, patients with low PAM scores were more likely to have a new chronic disease diagnosis over each of the years of observation. CONCLUSIONS: Assessing patient activation may help to identify patients who could benefit from greater support. Such an approach may help ACOs reach population health management goals.

Summarized Costs, Placement Of Quality Stars, And Other Online Displays Can Help Consumers Select High-Value Health Plans.

Starting in 2017, all state and federal health insurance exchanges will present quality data on health plans in addition to cost information. We analyzed variations in the current design of information on state exchanges to identify presentation approaches that encourage consumers to take quality as well as cost into account when selecting a health plan. Using an online sample of 1,025 adults, we randomly assigned participants to view the same comparative information on health plans, displayed in different ways. We found that consumers were much more likely to select a high-value plan when cost information was summarized instead of detailed, when quality stars were displayed adjacent to cost information, when consumers understood that quality stars signified the quality of medical care, and when high-value plans were highlighted with a check mark or blue ribbon. These approaches, which were equally effective for participants with higher and lower numeracy, can inform the development of future displays of plan information in the exchanges.

Adding A Measure Of Patient Self-Management Capability To Risk Assessment Can Improve Prediction Of High Costs.

We explored whether supplementing a clinical risk score with a behavioral measure could improve targeting of the patients most in need of supports that reduce their risk of costly service utilization. Using data from a large health system that determines patient self-management capability using the Patient Activation Measure, we examined utilization of hospital and emergency department care by the 15 percent of patients with the highest clinical risk scores. After controlling for risk scores and placing patients within segments based on their level of activation in 2011, we found that the lower the activation level, the higher the utilization and cost of hospital services in each of the following three years. These findings demonstrate that adding a measure of patient self-management capability to a risk assessment can improve prediction of high care costs and inform actions to better meet patient needs.

Making comparative performance information more comprehensible: an experimental evaluation of the impact of formats on consumer understanding.

STUDY OBJECTIVES: We aimed to investigate how different presentation formats influence comprehension and use of comparative performance information (CPI) among consumers. METHODS: An experimental between-subjects and within-subjects design with manipulations of CPI presentation formats. We enrolled both consumers with lower socioeconomic status (SES)/cognitive skills and consumers with higher SES/cognitive skills, recruited through an online access panel. Respondents received fictitious CPI and completed questions about interpretation and information use. Between subjects, we tested (1) displaying an overall performance score (yes/no); (2) displaying a small number of quality indicators (5 vs 9); and (3) displaying different types of evaluative symbols (star ratings, coloured dots and word icons vs numbers and bar graphs). Within subjects, we tested the effect of a reduced number of healthcare providers (5 vs 20). Data were analysed using descriptive analysis, analyses of variance and paired-sampled t tests. RESULTS: A total of 902 (43%) respondents participated. Displaying an overall performance score and the use of coloured dots and word icons particularly enhanced consumer understanding. Importantly, respondents provided with coloured dots most often correctly selected the top three healthcare providers (84.3%), compared with word icons (76.6% correct), star ratings (70.6% correct), numbers (62.0%) and bars (54.2%) when viewing performance scores of 20 providers. Furthermore, a reduced number of healthcare providers appeared to support consumers, for example, when provided with 20 providers, 69.5% correctly selected the top three, compared with 80.2% with five providers. DISCUSSION: Particular presentation formats enhanced consumer understanding of CPI, most importantly the use of overall performance scores, word icons and coloured dots, and a reduced number of providers displayed. Public report efforts should use these formats to maximise impact on consumers.

Working under a clinic-level quality incentive: primary care clinicians' perceptions.

BACKGROUND: A key consideration in designing pay-for-performance programs is determining what entity the incentive should be awarded to-individual clinicians or to groups of clinicians working in teams. Some argue that team-level incentives, in which clinicians who are part of a team receive the same incentive based on the team's performance, are most effective; others argue for the efficacy of clinician-level incentives. This study examines primary care clinicians' perceptions of a team-based quality incentive awarded at the clinic level. METHODS: This research was conducted with Fairview Health Services, where 40% of the primary care compensation model was based on clinic-level quality performance. We conducted 48 in-depth interviews to explore clinicians' perceptions of the clinic-level incentive, as well as an online survey of 150 clinicians (response rate 56%) to investigate which entity the clinicians would consider optimal to target for quality incentives. RESULTS: Clinicians reported the strengths of the clinic-based quality incentive were quality improvement for the team and less patient "dumping," or shifting patients with poor outcomes to other clinicians. The weaknesses were clinicians' lack of control and colleagues riding the coattails of higher performers. There were mixed reports on the model's impact on team dynamics. Although clinicians reported greater interaction with colleagues, some described an increase in tension. Most clinicians surveyed (73%) believed that there should be a mix of clinic and individual-level incentives to maintain collaboration and recognize individual performance. CONCLUSION: The study highlights the important advantages and disadvantages of using incentives based upon clinic-level performance. Future research should test whether hybrid incentives that mix group and individual incentives can maintain some of the best elements of each design while mitigating the negative impacts.

Sources of traffic and visitors' preferences regarding online public reports of quality: web analytics and online survey results.

BACKGROUND: In the context of the Affordable Care Act, there is extensive emphasis on making provider quality transparent and publicly available. Online public reports of quality exist, but little is known about how visitors find reports or about their purpose in visiting. OBJECTIVE: To address this gap, we gathered website analytics data from a national group of online public reports of hospital or physician quality and surveyed real-time visitors to those websites. METHODS: Websites were recruited from a national group of online public reports of hospital or physician quality. Analytics data were gathered from each website: number of unique visitors, method of arrival for each unique visitor, and search terms resulting in visits. Depending on the website, a survey invitation was launched for unique visitors on landing pages or on pages with quality information. Survey topics included type of respondent (eg, consumer, health care professional), purpose of visit, areas of interest, website experience, and demographics. RESULTS: There were 116,657 unique visitors to the 18 participating websites (1440 unique visitors/month per website), with most unique visitors arriving through search (63.95%, 74,606/116,657). Websites with a higher percent of traffic from search engines garnered more unique visitors (P=.001). The most common search terms were for individual hospitals (23.25%, 27,122/74,606) and website names (19.43%, 22,672/74,606); medical condition terms were uncommon (0.81%, 605/74,606). Survey view rate was 42.48% (49,560/116,657 invited) resulting in 1755 respondents (participation rate=3.6%). There were substantial proportions of consumer (48.43%, 850/1755) and health care professional respondents (31.39%, 551/1755). Across websites, proportions of consumer (21%-71%) and health care professional respondents (16%-48%) varied. Consumers were frequently interested in using the information to choose providers or assess the quality of their provider (52.7%, 225/427); the majority of those choosing a provider reported that they had used the information to do so (78%, 40/51). Health care professional (26.6%, 115/443) and consumer (20.8%, 92/442) respondents wanted cost information and consumers wanted patient narrative comments (31.5%, 139/442) on the public reports. Health care professional respondents rated the experience on the reports higher than consumers did (mean 7.2, SD 2.2 vs mean 6.2, SD 2.7; scale 0-10; P<.001). CONCLUSIONS: Report sponsors interested in increasing the influence of their reports could consider using techniques to improve search engine traffic, providing cost information and patient comments, and improving the website experience for both consumers and health care professionals.

Large performance incentives had the greatest impact on providers whose quality metrics were lowest at baseline.

This study examined the impact of Fairview Health Services' primary care provider compensation model, in which 40 percent of compensation was based on clinic-level quality outcomes. Fairview Health Services is a Pioneer accountable care organization in Minnesota. Using publicly reported performance data from 2010 and 2012, we found that Fairview's improvement in quality metrics was not greater than the improvement in other comparable Minnesota medical groups. An analysis of Fairview's administrative data found that the largest predictor of improvement over the first two years of the compensation model was primary care providers' baseline quality performance. Providers whose baseline performance was in the lowest tertile improved three times more, on average, across the three quality metrics studied than those in the middle tertile, and almost six times more than those in the top tertile. As a result, there was a narrowing of variation in performance across all primary care providers at Fairview and a narrowing of the gap in quality between providers who treated the highest-income patient panels and those who treated the lowest-income panels. The large quality incentive fell short of its overall quality improvement aim. However, the results suggest that payment reform may help narrow variation in primary care provider performance, which can translate into narrowing socioeconomic disparities.

When patient activation levels change, health outcomes and costs change, too.

Patient engagement has become a major focus of health reform. However, there is limited evidence showing that increases in patient engagement are associated with improved health outcomes or lower costs. We examined the extent to which a single assessment of engagement, the Patient Activation Measure, was associated with health outcomes and costs over time, and whether changes in assessed activation were related to expected changes in outcomes and costs. We used data on adult primary care patients from a single large health care system where the Patient Activation Measure is routinely used. We found that results indicating higher activation in 2010 were associated with nine out of thirteen better health outcomes-including better clinical indicators, more healthy behaviors, and greater use of women's preventive screening tests-as well as with lower costs two years later. Changes in activation level were associated with changes in over half of the health outcomes examined, as well as costs, in the expected directions. These findings suggest that efforts to increase patient activation may help achieve key goals of health reform and that further research is warranted to examine whether the observed associations are causal.

The impact of an incentive on the use of an online self-directed wellness and self-management program.

BACKGROUND: Those who pay for health care are increasingly looking for strategies to influence individuals to take a more active role in managing their health. Incenting health plan members and/or employees to participate in wellness programs is a widely used approach. OBJECTIVE: In this study, we examine financial incentives to health plan members to participate in an online self-management/wellness program-US $20 for completing the patient activation measure (PAM) and an additional US $40 for completing 8 learning modules. We examined whether the characteristics of plan members differed by the degree to which they responded to the incentives. Further, we examined whether participation in the wellness program was associated with improvements in PAM scores and changes in health care utilization. METHODS: This retrospective study compared demographic characteristics and change in PAM scores and health utilization for 144,625 health plan members in 2011. Four groups were compared: (1) those who were offered the incentives but chose not to participate (n=128,634), (2) those who received the initial incentive (PAM only) but did not complete 8 topics (n=7099), (3) those who received both incentives (completing 8 topics but no more) (n=2693), and (4) those who received both incentives and continued using the online program beyond what was required by the incentives (n=6249). RESULTS: The vast majority of health plan members did not participate in the program (88.91%, 128,634/144,675). Of those who participated, only 7099 of 16,041 (44.25%) completed the PAM for the first incentive, 2693 (16.79%) completed 8 topics for the second incentive, and 6249 (38.96%) received both incentives and continued using the program beyond the incentive requirements. Nonparticipants were more likely to be men and to have lower health risk scores on average than the other three groups of participants (P<.001). In multivariate regression models, those who used the online program (8 topics or beyond) increased their PAM score by approximately 1 point more than those who only took the PAM and did not use the wellness program (P<.03). In addition, emergency department visits were lower for all groups who responded to any level of the incentive as compared to those who did not (P<.01). No differences were found in other types of utilization. CONCLUSIONS: The incentive was not sufficient to spark most health plan members to use the wellness program. However, the fact that many program participants went beyond the incentive in their use of the online wellness program suggests that the users of the online program found value in using it, and it was their own internal motivation that stimulated this additional use. Providing an incentive for program participation may be an effective pathway for working with less activated patients, particularly if the program is tailored to the needs of the less activated.

A case study of a team-based, quality-focused compensation model for primary care providers.

In 2011, Fairview Health Services began replacing their fee-for-service compensation model for primary care providers (PCPs), which included an annual pay-for-performance bonus, with a team-based model designed to improve quality of care, patient experience, and (eventually) cost containment. In-depth interviews and an online survey of PCPs early after implementation of the new model suggest that it quickly changed the way many PCPs practiced. Most PCPs reported a shift in orientation toward quality of care, working more collaboratively with their colleagues and focusing on their full panel of patients. The majority reported that their quality of care had improved because of the model and that their colleagues' quality had to. The comprehensive change did, however, result in lower fee-for-service billing and reductions in PCP satisfaction. While Fairview's compensation model is still a work in progress, their early experiences can provide lessons for other delivery systems seeking to reform PCP compensation.

When seeing the same physician, highly activated patients have better care experiences than less activated patients.

Measures of the patient care experience are now routinely used in public reports and increasingly influence health provider payment. We examined data from 5,002 patients of forty-nine primary care providers to explore the relationship between patient activation-a term referring to the knowledge, skills, and confidence a patient has for managing his or her health care-and the patient care experience. We found that patients at higher levels of activation had more positive experiences than patients at lower levels seeing the same clinician. The observed differential was maintained when we controlled for demographic characteristics and health status. We did not find evidence that patients at higher levels of activation selected providers who were more patient-centric. The findings suggest that the care experience is transactional, shaped by both providers and patients. Strategies to improve the patient experience, therefore, should focus not only on providers but also on improving patients' ability to elicit what they need from their providers.

What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs.

Patient engagement is an increasingly important component of strategies to reform health care. In this article we review the available evidence of the contribution that patient activation-the skills and confidence that equip patients to become actively engaged in their health care-makes to health outcomes, costs, and patient experience. There is a growing body of evidence showing that patients who are more activated have better health outcomes and care experiences, but there is limited evidence to date about the impact on costs. Emerging evidence indicates that interventions that tailor support to the individual's level of activation, and that build skills and confidence, are effective in increasing patient activation. Furthermore, patients who start at the lowest activation levels tend to increase the most. We conclude that policies and interventions aimed at strengthening patients' role in managing their health care can contribute to improved outcomes and that patient activation can-and should-be measured as an intermediate outcome of care that is linked to improved outcomes.

Patients with lower activation associated with higher costs; delivery systems should know their patients' 'scores'.

Patient activation is a term that describes the skills and confidence that equip patients to become actively engaged in their health care. Health care delivery systems are turning to patient activation as yet another tool to help them and their patients improve outcomes and influence costs. In this article we examine the relationship between patient activation levels and billed care costs. In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences. What's more, patient activation was a significant predictor of cost even after adjustment for a commonly used "risk score" specifically designed to predict future costs. As health care delivery systems move toward assuming greater accountability for costs and outcomes for defined patient populations, knowing patients' ability and willingness to manage their health will be a relevant piece of information integral to health care providers' ability to improve outcomes and lower costs.

An experiment shows that a well-designed report on costs and quality can help consumers choose high-value health care.

Advocates of health reform continue to pursue policies and tools that will make information about comparative costs and resource use available to consumers. Reformers expect that consumers will use the data to choose high-value providers-those who offer higher quality and lower prices-and thus contribute to the broader goal of controlling national health care spending. However, communicating this information effectively is more challenging than it might first appear. For example, consumers are more interested in the quality of health care than in its cost, and many perceive a low-cost provider to be substandard. In this study of 1,421 employees, we examined how different presentations of information affect the likelihood that consumers will make high-value choices. We found that a substantial minority of the respondents shied away from low-cost providers, and even consumers who pay a larger share of their health care costs themselves were likely to equate high cost with high quality. At the same time, we found that presenting cost data alongside easy-to-interpret quality information and highlighting high-value options improved the likelihood that consumers would choose those options. Reporting strategies that follow such a format will help consumers understand that a doctor who provides higher-quality care than other doctors does not necessarily cost more.

Consumers' and providers' responses to public cost reports, and how to raise the likelihood of achieving desired results.

There is tremendous interest in different approaches to slowing the rise in US per capita health spending. One approach is to publicly report on a provider's costs--also called efficiency, resource use, or value measures--with the hope that consumers will select lower-cost providers and providers will be encouraged to decrease spending. In this paper we explain why we believe that many current cost-profiling efforts are unlikely to have this intended effect. One of the reasons is that many consumers believe that more care is better and that higher-cost providers are higher-quality providers, so giving them information that some providers are lower cost may have the perverse effect of deterring them from accessing these providers. We suggest changes that can be made to content and design of public cost reports to increase the intended consumer and provider response.

Development of the Patient Activation Measure for mental health.

Our objective was to adapt the physical health Patient Activation Measure (PAM) for use among people with mental health conditions (PAM-MH). Data came from three studies among people with chronic mental health conditions and were combined in Rasch analyses. The PAM-MH's psychometric properties equal those of the original 13-item PAM. Test-retest reliability and concurrent validity were good, and the PAM-MH showed sensitivity to change. The PAM-MH appears to be a reliable and valid measure of patient activation among individuals with mental health problems. It appears to have potential for use in assessing change in activation.

Bringing meaning to numbers: the impact of evaluative categories on decisions.

Decision makers are often quite poor at using numeric information in decisions. The results of 4 experiments demonstrate that a manipulation of evaluative meaning (i.e., the extent to which an attribute can be mapped onto a good/bad scale; this manipulation is accomplished through the addition of visual boundary lines and evaluative labels to a graphical format) has a robust influence in health judgments and choices and across diverse adult populations. The manipulation resulted in greater use of numeric quality-of-care information in judgments and less reliance on an irrelevant affective state among the less numerate. Recall results for provided quality-of-care numbers suggested that the manipulation did not influence depth of number processing with the exception of cost information that was not remembered as well. Results of a reaction-time paradigm revealed that feelings were more accessible than thoughts in the presence of the manipulation, suggesting that the effect may be due, at least in part, to an affective mechanism. Numeric information is often provided in decisions, but may not be usable by consumers without assistance from information providers. Implications for consumer decision making and the functions of affect are discussed.

Plan design and active involvement of consumers in their own health and healthcare.

OBJECTIVE: Underlying consumer-driven health plans (CDHPs) is the belief that the financial incentives, enhanced choices, and increased information will stimulate consumers to become active, informed managers of their own health and healthcare (ie, activated consumers). To examine this assumption, we assessed whether enrollees became more activated after enrolling in a CDHP and the degree to which those who were more activated adopted productive health behaviors. METHODS: This was a longitudinal study of employees of a large manufacturing company where a CDHP was offered along with a preferred provider organization in 2004. Two waves of survey data were collected with a final sample size of 1616 employees. RESULTS: The hypothesis that enrollees in a CDHP become more activated over time was not supported. However, the data suggest that those who were more activated were more likely to engage in the behaviors that CDHPs seek to encourage and to newly adopt these behaviors over time. This appeared to be true regardless of plan type. CONCLUSION: Even though CDHPs do not appear to foster activation, they may provide a supportive environment for those who are more activated to manage their health. Encouraging enrollment based on enrollee readiness to take advantage of the CDHP environment may be more productive than relying on plan designs alone to activate enrollees once they are enrolled.