There's general agreement in health policy circles that over the next five years the growing emphasis on patients understanding our health care system and taking an active role in it will continue to gain in importance. Yet our ability to detail the responsibilities that “patient engagement” implies remains elusive.
In part that's a reflection of the quality of debate on the future of health care—whether it, and we, are mature enough to overcome ideological differences and grapple with pressing challenges. And in part it's a reluctance to let go of some of the givens of an earlier health care age, like the need for “skin in the game.”
Those underlying assumptions still hold power, but the changing structure of health care is making them less meaningful, even as we call for patients to be active, informed consumers. If we are to truly embrace patient engagement as a worthy goal, we need to understand how entwined the concept is with four of the major challenges of health care today.
NEW STRUCTURES, NEW DEMANDS
The first challenge is maintaining the momentum we've gained—some 20 million people's worth—toward health insurance coverage for all. This means continuing to strengthen the public programs, Medicaid particularly, that in many states have created almost universal coverage for the economically disadvantaged. It also means continuing support for employer-based health insurance, through tax incentives and regulatory standards. Equally important, we must maintain large health insurance pools in which risk is not segmented, recognizing that most people's health status and health care costs vary over time. All three of these elements are at the core of the Affordable Care Act, and critical to the effective operation of health care. Simultaneously, we must weigh and balance patients' cost-sharing and their ability to utilize covered services, to ensure that an economic stake in the system doesn't lead to self-rationing of needed care or unsustainable debt.
A second essential is virtually unlimited information flow. We've tended, traditionally, to prioritize privacy, and surely any of our modern information transfer systems needs to ensure adequate security. But enabling the highest-quality care requires that information be effectively communicated: electronic health records are a vital tool but the actual sharing of the information they contain is the essential, and trickier, element—one to which both patients and providers must be committed.
Third, expanded primary care is a basic building block of a successfully operating health care system. The traditional doctor's visit, 15 minutes of one-on-one time, is giving way to a relationship with a team-based practice supported by electronic records and open communication. Instead of relying on patients to make an appointment, these practices are taking responsibility for reaching out to patients who will benefit from a checkup or test or intervention; additionally, the historical chasm between physical and mental health care is being bridged, as behavioral health diagnosis and interventions are being offered in the primary care setting.
Fourth, primary care practices are increasingly being linked with other organizations in integrated networks buoyed not by fee-for-service payments based on type and volume of care provided but by value-based payments grounded in the quality of care and outcomes achieved. Integral to this evolution is patients' understanding of how quality is judged, and that individual performance—“the best doctor”—is subsidiary to how complex parts of an organization work together. Providers, for their part, need to understand what is most meaningful to patients. For both of those goals, reducing the huge volume of current quality assessments and focusing on “measures that matter” is urgent.
RETHINKING OLD MYTHS
It wasn't long ago that “patient engagement” was often little more than “consumer-directed health care,” essentially the idea that increased out-of-pocket costs yielded better consumers. Today, we are more likely to see that as last-generation mythology, less relevant as new policies and practices reshape health care. The four issues above are among the most serious we face, yet with the exception of insurance coverage they are not, largely, within the scope of serious public debate. It is vital that we make certain they are, to propel a vision of individuals interacting with the health care system in working relationships based on open communication and informed judgment.