Plain Talk with US Consumers and Patients:

Achieving the Triple Aim

Presentation by Susan Dentzer

Senior Policy Adviser to the Robert Wood Johnson Foundation

To Maximus Plain Talk Conference – March 12, 2015

This Presentation at a Glance

Achieving the Triple Aim: Needed now more than ever

How do we talk with patients/consumers about

Changes in insurance coverage, delivery and payment

Appropriateness of care

Cost and quality of care

Being proactive about their health and care

“Plain Talk” is necessary but not sufficient; other strategies

to improve communication also important

Case Examples

Some conclusions

The Triple Aim

Better health

Better health care

Lower cost

Core principle at heart of

Affordable Care Act and major

U.S. payment and delivery

system reform efforts that

have followed

Better communication central

to achieving these goals

Donald Berwick, MD

Former Administrator

Centers for Medicare

and Medicaid Services

Scope of the Communications

Problem

Nearly 9 in 10 adults have

difficulty using everyday

health information broadly

available in health care

facilities, communities,

media

Source: Health Literacy: A Prescription

to End Confusion. Institute of

Medicine, 2004

“Universal Precautions” Approach

Adopted from infectious

disease field

Notion that clear

communication should be

basis for all exchanges of

health information

Source: National Action Plan to Improve

Health Literacy, 2010

But the Problem Cuts Two Ways

75 percent of orthopedic

surgeons surveyed believed

that they communicated

satisfactorily with patients

Only 21% of their patients

reported satisfactory

communication with their

doctors

Source: JR Tongue et al, Journal of Bone Joint

Surgery Am. 2005; 87:652-658

Patient Engagement

First-ever

National

Quality

Strategy,

mandated

by the

ACA

Confusion over health insurance

Explaining health insurance coverage

Many enrolling in coverage under ACA have obtained it for

first time

When explaining health coverage to consumers, critical to

confirm that they understood what was said – e.g.,

“deductible,” “co-pay”

Ideally should explain back concepts in their own words

(teach-back method)

If they still don’t understand, use other concepts to convey

meaning

Source: IOM Discussion Paper, K Patel et al, “Helping Consumers Understand and

Use Health Insurance in 2014.”

HealthCare.gov gets better – and clearer

Communicating with patients

about their care

Realities of Patient-Physician

Communication

Source: The Decisions Study: Medical Decision Making, 2010,

30 Supplement I

Patient Satisfaction on Physicians, University

of Utah

© 2014 Press Ganey

Associates, Inc.

Shared Decision Making

“A collaborative process that

allows patients and their

providers to make health

care decisions together…

“..taking into account the

best available scientific

evidence …

“..as well as the patient’s

values and preferences.”

Incorporated into Affordable

Care Act, but as yet not

widespread

Source: informedmedicaldecisions.org

Patients Want Shared Decision Making But

Are Afraid

Focus groups run by Dominick Frosch and colleagues at

Palo Alto Medical Foundation

Patients strongly embraced shared decision making but felt

trapped in “socially sanctioned roles” – e.g., deference to

physicians

Found many physicians authoritarian

Feared being categorized as “difficult” patients

Source: DL Frosch et al, Health Aff, May 2012, vol. 31 no. 5, pp. 1030-1038

Shared Decision Making:

Process and Tools

Shared Decision Making at Group Health

Over six months, use of decision aids associated with

26 percent fewer hip replacement surgeries

38 percent fewer knee replacements

12-21 percent lower costs

Source: D Arterburn et al, Health Affairs, September 2012

Angelo Volandes & Aretha Davis,

Harvard Medical School

Advance Care Planning Decisions

Videos at acpdecisions.org

Shared Decision Making at Mayo Clinic

Communicating with patients about

inappropriate care

“Choosing Wisely” Survey,

2014 73 percent of physicians said the

frequency of unnecessary tests and

procedures is a “very or somewhat

serious problem.”

53 percent say that even if they

know a medical test is

unnecessary, they order it if a

patient insists.

72 percent of physicians say the

average medical doctor prescribes

an unnecessary test or procedure

at least once a week.

(PS: They blame malpractice)

“Choosing Wisely” Campaign

Launched by American Board of Internal Medicine

Foundation

More than 35 specialty societies participating

Developed lists: Five Things Physicians and Patients

Should Question – for each

Examples: colonoscopy; imaging for a headache; pre-term

induction of labor; white blood cell growth factors or

colony-stimulating factors (CSFs) to boost white blood cells

during cancer chemotherapy

www.choosingwisely.org

Activating patients about their health

and heath care

Patient Engagement and Activation

Engagement = actions that

people take for their health or

health care

Activation = understanding

own role in care process and

having knowledge, skills and

confidence to take it on

Increasingly understood as a

distinguishable factor in

achieving Triple Aim

Patient Activation Measure

Gauges the knowledge, skills and confidence essential to

managing one’s own health and healthcare

13-item questionnaire; patients rate selves on a scale

Statements include

“When all is said and done, I am the person who is responsible

for managing my health condition.

“I am confident that I can take actions that will help prevent

or minimize some symptoms or problems associated with my

health condition.

“I know what each of my prescribed medications do.”

Measure segments consumers into one of four progressively

higher activation levels

Patient Activation Measure

Patient activation and the “3 M’s”

It can be measured

It can be moved – patients’ low scores can be improved via

engagement over time

It matters – the degree to which patients are activated

predicts their factors such as their success in medication

adherence, use of emergency department, and their

likelihood of having avoidable readmissions

Source: JH Hibbard, J Greene, Health Aff, Feb. 2013 vol 32 no. 2, 207-214

Engaging the Seriously Disabled

Minnesota-based Courage

Kenney Rehabilitation

Institute serves disabled

and injured

Has substantially raised

Patients’ Activation

Measure scores

Reducing hospital stays

for this population by 71%

Technology to Support Communication and

Patient Engagement

Disruptive Technologies

Digital health, mhealth

(mobile), apps

Pushing care out of

institutions and into homes

and offices

Enabling more self care

Engaging patients and

enhancing sense of

knowledge, confidence,

activation

Physicians and founders Tom Delbanco and Jan Walker,

Beth Israel Deaconess Medical Center, Boston

Started giving patients access to physicians’ notes through EHRs

12-month pilot of patients at Beth Israel Deaconess,

Geisinger, and Harborview Medical Center, Seattle WA

77-87 percent of patients who opened at least one note

reported feeling more in control of their care

Source: Annals of Internal Medicine, Oct. 2012

New entrants into health care: Apple

Apple Health dashboard allows

consumers to compile and view health

care information

Apple’s HealthKit: new platform for

health apps

Apple Watch has heart rate sensors;

annual sales of 485 million predicted

Link with Epic EHR

Exploring incorporation of blood pressure

and glucose monitoring into iPhone

“Symple” Symptom Tracker and

Health Diary

Natasha

Gajewski,

Founder,

Symple Health

Ease of communication

with doctors

Mobile Health: Text4Baby – free mobile text

messages

Big White Wall

• Safe online community

• Professionally led support groups

• Ability to speak to clinician in real time

• Affiliations with National Health Service in England; Kaiser Permanente• See video at http://www.bigwhitewall.com/landing-pages/landingV3.aspx#.VPiBKLPF-yw

Some conclusions

Context Matters

“Think like a wise man but communicate in

the language of the people.”

--William Butler Yeats

“The good physician treats the disease; the great

physician treats the patient who has the disease.”

--William Osler, one of four founding professors of

Johns Hopkins Hospital

The End