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Patient Motivation a Must for Accountable Care

By HCPro Staff  
   October 05, 2011

This article was originally published in the September issue of Managed Care Contracting & Reimbursement Advisor.

Accountable care is not a new concept to ­physicians, but the Patient Protection and Affordable Care Act of 2010 (PPACA) is creating new pressure to get ­patients more ­actively involved in their care, says Erica ­Drazen, managing partner for emerging practices with the healthcare consulting firm CSC in Waltham, MA. Not only will patients' health improve, but the practice's ­revenue also can benefit.

PPACA includes several provisions that will tie ­reimbursement to performance, including:

  • Value-based purchasing program: Beginning in ­October 2012, CMS will provide hospitals that meet established performance or improvement standards with value-based incentive payments.
  • Excessive hospital readmissions penalty: ­Also b­eginning in October 2012, CMS will reduce ­reimbursement to hospitals with excess readmissions for pneumonia, heart failure, and acute myocardial infarction.
  • Shared savings program: Groups of providers will be able to establish accountable care organizations by January 2012 for the care of Medicare FFS beneficiaries.

"Clearly, change is afoot. As healthcare organizations become more accountable for the care they provide, engaging patients in their health, wellness, and ­medical decisions will be ­increasingly ­important," ­Drazen says. "However, the biggest challenge lies in how to successfully motivate patients to take an active role in their health and medical decisions."

Along with CSC research analyst Caitlin Lorincz, Drazen recently authored a report, Preparing for Accountable Care, which details the four dimensions of health IT tools needed to successfully engage patients and how healthcare organizations can move ahead in implementing these tools. (The full report can be found online.)

These were their key recommendations:

  • Enable patient identification and tracking. The implementation of an electronic medical record (EMR) is a big part of achieving this goal.
  • Promote patient and provider interaction and communication. Utilize secure messaging, e-visits, tele-visits, and social media.
  •  Increase patients' access to personal information and self-service capabilities. Patient portals,patient-maintained health records, and personal health records are good strategies.
  • Encourage and support patient self-care ­activities. Examples are greater use of telemedicine, telemonitoring, and mobile health activities.

Patients should be accountable

"Healthcare organizations need to work on engaging patients to be accountable for their own care," Drazen says. "When you think about all the things happening with accountable care, we are holding the payer and provider accountable, but there is nothing holding the patient accountable."

A physician can recommend the right things for a ­patient to improve his or her health and provide the ­necessary tools, but unless the patient engages and uses those tools, the provider cannot achieve the quality scores that will result in improved revenue, Drazen says.

"We have a pretty poor record of engaging patients in their care. Engaging them really is the only way we can be sure we're providing the highest quality of care," she says. "We're moving to the era of outcome measures, where the number of patients with their blood pressure out of control is your number for blood pressure control. You probably have patients who just aren't taking their meds, or patients who don't show up for appointments, and you're still accountable for them."

Stage 2 of meaningful use also includes motivation for patient engagement. In Stage 2, physicians will be judged on how many patients participate in a health improvement effort, rather than how many you offer the tool to, Drazen explains.

One of the most important steps to getting patients involved is to establish a patient portal, which also is ­required for meaningful use, she says.

This portal-a user-friendly way for patients to access your practice online for resources, tools, and information about their care-can encourage patients to more actively engage in their care, Lorincz says.

Portals encourage participation

Lorincz compares physician practice portals to online banking websites, which are increasingly popular ways for customers to access and manage their bank accounts and related services.

"Portals can do the same thing for patients, making it much easier for them to be informed and involved in their care," she says. "Research indicates that providing patients with greater access to their medical information can increase their knowledge and provide a greater sense of control. When that information is available electronically, it can prompt people to take a more active interest in their healthcare."

Other than the largest physician practices, few physician groups are very far along in this effort, Drazen says. One obstacle is that until you have an EMR, you don't have much information you can send the patient electronically or make available through the patient portal, she says.

Drazen advises doctors to begin their efforts to improve accountable care as soon as possible, partly so there is time to make mistakes and correct them before the results are used to determine reimbursement or penalties.

"In terms of Stage 2 meaningful use, 2013 is when you're really going to have to have the portals and other infrastructure in place," Drazen says. "A lot of commercial payers have already put quality standards in place for physician practices that include measures for accountable care and patient engagement, and if you don't meet them, you don't get your part of the bonus pool. So the time to do this is right now."

Getting your patients more involved in their care: Where to start?

Considering the complexity of the programs estab­lished under the Patient Protection and Affordable Care Act of 2010, physician practices may wonder where to ­begin in coordinating their patient engagement activities.

Erica Drazen, managing partner for emerging practices with the healthcare consulting firm CSC in Waltham, MA, and CSC research analyst Caitlin Lorincz recommend these ­initial steps:

Establish a foundation. Financing health IT investments can be challenging. Healthcare organizations with limited resources may wish to begin by ­focusing their efforts on the first two dimensions of health IT tools, namely establishing tools to enable patient identification and tracking and to promote interaction between patients and their care teams.

"With these two capabilities in place, healthcare organizations will be able to identify at-risk patient populations, such as chronic care patients who are behind in their recommended care procedures, and proactively reach out and engage them," Drazen and Lorincz write in their recent report from CSC, Preparing for Accountable Care. "These two tactics would establish a foundation that could be built from to provide patients with ­self-service and self-care tools at a later date. ­Healthcare ­organizations with the former capabilities already in place should concentrate on the latter two dimensions and implement tools to increase patients' access to personal information and self-service capabilities, as well as tools to encourage and support patient self-care activities."

Align your efforts with other incentive ­programs. Healthcare organizations should take steps to ­complement their infrastructure investments with ­other ­incentive programs, such as the meaningful use program.

Many meaningful use "criteria closely parallel necessary patient engagement activities," Drazen and Lorincz write. "For instance, stage one criteria measures include gener­ating condition-specific patient lists for quality improvement and outreach activities, providing patients with electronic ­access to, or electronic copies of, their medical information, sending patient reminders for ­follow up orpreventative care ­visits, and sharing patient-specific edu­cational resources."

Proposed Stage 2 meaningful use criteria seek to ­expand upon these measures and add new measures that are relevant to patient engagement activities, such as providing and ensuring usage of both patient portals and ­secure messaging.

Target efforts to ensure high impact. Healthcare organizations will want to initiate their patient engagement activities-getting patients more ­involved in their own healthcare-in a manner that will ensure the greatest impact. For instance, avoidable hospital readmissions are one area worthy of attention since they are costly and, in the near future, will expose hospitals and healthcare organizations to financial penalties.

Rehospitalization is common among Medicare beneficiaries. Drazen notes that one study found roughly ­one-fifth of Medicare beneficiaries were rehospitalized within 30 days and cost Medicare $17.4 billion in 2004. Pneumonia, heart failure, and acute myocardial infarction are some of the most frequent reasons for readmission.

Starting October 1, 2012, CMS will begin reducing reimbursement for excess readmissions for these conditions and will begin targeting additional conditions in 2014. Hospitals and healthcare organizations stand to lose up to 1% of Medicare payments in the first year and up to 3% by the third year.

"By identifying and engaging hospitalized ­patients with these conditions first, healthcare organizations can establish contact and provide patients with the ­information and tools that they need to successfully manage their care at home and potentially avoid rehospitalization," Drazen and Lorincz write.

Consider logistical components. Physician practices should consider how best to initiate patient engagement activities and deploy ­available health IT tools. One method of launching patient ­engagement activities is to concentrate on point-of-care settings, beginning with the most ­costly setting and ­incrementally expanding to other areas, Drazen says.

Through the use of patient identification tools, ­healthcare organizations can identify hospitalized ­patients and establish contact with them prior to discharge.

Similarly, healthcare organizations can also ­establish contact with other "seen" patients as they attend scheduled office appointments, Drazen says. "­Healthcare organizations can then reach out to ­other ?unseen' patients by sending out educational ­information, reminder notices to schedule wellness visits, and other information."

"This would aid in reestablishing contact ­between ­patients and providers and help better engage ­patients," Drazen and Lorincz write. "Once ­connectivity is ­established with patients, healthcare organizations can then equip them with self-service and self-care tools over time."

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