The role of patient engagement in value-based reimbursement

Patient engagement is an invitation to participate in shared decision-making, and to "take on" aspects of the management of their own health under the care of their physician or other member of the healthcare team. As a number of studies show, an activated or engaged patient can become a healthier patient.

"Ultimately, better engagement means better value-better outcomes with lower cost," says Brian Eastwood, patient engagement analyst at Chilmark Research, a health IT research and consultancy based in Boston. Knowledge is power and in this new environment, means revenue, he says.

Here's what Eastwood wants clinicians to know about how engagement affects value-based reimbursement.

1. The engagement processes are separated.

A person is a patient, a consumer and may be a member of an insurance provider and an employee, and may receive different information in each category. Typically, a patient receives care in a healthcare setting, while a consumer takes care of themselves outside the care setting, he says.

Given those parameters, here is how Eastwood sees better engagement and better value resulting for the following populations:

a) Patients:

·       Better adherence and compliance

·       Fewer no-shows

·       Improved outcomes

·       Better response to marketing and outreach

"Smaller, independent practices may actually do it better because they've built more of a relationship with their patients, when compared to larger academic medical centers," he says.

b) Consumers:

·       Understanding of conditions and treatments

·       Understanding of what they're paying for

·       Motivation to become part of the care team and process

·       Improved quality of life

Next: How health plan members are affected

c) Health plan members:

·       Better cost management

·       Improved care utilization, or the most appropriate or cost-effective services, such as going to a retail clinic for a sore throat or flu shot vs. the ER. It’s also about “steering” members to preventive services that may cut long-term costs.

·       More data for predictive modeling. This is a matter of using the data they have gathered about members to try to predict who might be at risk of developing preventable conditions and who might as a result benefit from health and wellness services to prevent the onset of that condition, or at the very least would benefit from a health risk assessment or other screening or test.

d) Employees:

·       Better cost management in terms of their health risks

·       Reduced absenteeism

·       Improved benefits offerings

2. Consistency in communications and message alignment from different stakeholders is more effective and increases value for everyone.

Clinicians can develop a strategy that allows them to "skip steps," says Eastwood. "Go directly to employer groups or insurers and work with them. Then everyone can align the message, and together they can broaden the type of engagement offerings and be on the same page about available services and programs patients can enroll in, for example."

If this seems like a big ask, here's how it works, he says. "It's about organizational leaders coming together and putting those services and programs in place. Then communications come down from hospital leaders to individual physicians, versus Anthem or an employer communicating directly with the individual physician."

Put another way, practices can employ a strategy with which they "take the wheel," he says. "Follow the recommendations of the payers that a small practice works with but take the lead on messaging with patients. If there's a particular program or intervention that a payer recommends, and a small practice physician thinks it's a good idea, he or she can be proactive in getting the word out about it."

Eastwood likens it to patient portal messaging of a few years ago. "Practices that were proactive about outreach and education had better adoption rates than the practices that either left it up to the vendor to do automated outreach or didn't do anything at all," Eastwood says.  

Here's another example: Say a patient needs to be in a diabetes prevention program. The payer will cover it, and the employer is willing to pay for it, even as the physician endorses it. If all the stakeholders get together in a continuous information loop, everyone benefits. The idea is to engage before a condition worsens, rather than dealing with the consequences after the fact.

Next: How technology strengthens engagement

3. Technology will strengthen engagement.

Think about the role of patient portals, Eastwood says, the most frequently used patient engagement technology, and about how a practice might improve that service. Smaller IT companies are developing advanced functions such as more user-friendly apps that encourage more personal patient engagement and involvement, including ways to tailor specifics to a patient's particular needs. These companies also provide guidance around interactions that result in direct incentives or penalties. Newer systems also allow engagement around subjects that aren't necessarily covered by billing codes.

"Portals linked to electronic health record (EHR) installation may be designed to capture information primarily for billing, sending that on with data about what happened at the point of care," he says. "A practice may send accurate bills, but those really aren't conducive to collaborative back-and-forth care models desirable under value-based care."

4. Newer case management software engagement solutions are beginning to catch on.

These solutions allow physicians to interact more directly with patients about what was covered during the last visit-eliminating the need for an additional visit. "Video will start to have a larger place in provider-patient communication that involves follow-up," says Eastwood, "so consider how to use it."

Take the chronic care management Current Procedural Terminology code 99490. "Physicians are allowed 20 minutes per month under that code to complete a non-office visit, non face-to-face. It can be an educational video visit, or maybe sending an email with educational resources, logging a 20-minute phone call or two 10-minute email interactions."

Updated software allows providers to track engagements outside typical in-office settings, and to bill Medicare. "That adds value to the care process," he says.

Next: The shifting focus of engagement

5. Focus will shift to engagement tools that conduct outreach and bring new patients to the office.

If a practice doesn't remind patients it's there, they won't remember to connect unless they're sick-completely circumventing preventive care, a foundation of value-based reimbursement.

"It's not about bringing people in for another MRI," says Eastwood. "This could be as simple as a wellness visit reminder, or recommended screenings such as a mammogram or prostate exam-that could catch problems. Remind patients that certain things are recommended based upon their history and records."

Practices can also remind their patient populations about other services available to help the practice hit high quality metrics targets. Notices about flu shots are a great example, he says.

 6. Tow the line: It's OK.

The value-based reimbursement philosophy ensures patients receive screenings, diagnostics and other services that bring them into the practice. "It involves having one foot in the fee-for-service world and another in the value-based reimbursement world," says Eastwood. "Providing these services means a practice delivers higher-value care. Services that do this can hit achievable quality metrics and bring more business into the practice."