A Bed's Eye View of Health Reform

© 2011 MSLGROUP SLIDE 1

Chuck AlstonSenior Vice President/Director of Public AffairsMSL Washington DC

What Patients See When They Look at the New Landscape of Health Care Delivery

Presentation to VHQCApril 9, 2013

A BED'S EYE VIEW OF HEALTH REFORM


Today’s Takeaways

• How to talk about the changes in health care delivery and not scare people

• The rewards of genuine patient engagement

• Communicating medical evidence with shared decision-making

• Why patients may start acting like consumers


Take Care With How You Talk About Health Care

WE MEAN WELL, BUT SOUND SCARY


The Way “We” Talk About Health Care


Do They Hear What You (Think You) Say?

The new landscape of delivery and payment reform is covered with language landmines


Come Again?

What You Say What They Hear

Medical home Nursing home, home health, end of life

Medical decision support End-of-life decisions

Guidelines or treatment guidelines Restrictive, rigid, limited, driven by cost

Integrated health care delivery system Bureaucratic, industry language, meaning unclear

Integrated care Bureaucratic, industry language, meaning unclear

Multispecialty medical group Bureaucratic, industry language, meaning unclear, trying to do too much, low quality, limited choice of specialists to choose from

Best practices Bureaucratic, meaning unclear, insincere, cookie-cutter care, not tailored to the individual

Evidence-based medicine Impersonal, one size fits all

Accountable Something will go wrong, minimal care, buzz word

Source: Ross M, Igus T and Gomez S. “From Our Lips to Whose Ears? Consumer Reaction to Our Current Health Care Dialect.” The Permanente Journal.13(1):8-16. 2009.


A Few Choice Words About Medical Homes

“It just sounds like a nursing home.”-- Boston focus group

participant

“First you go to a medical home, and then you go to the funeral home.”

-- Edina, MN focus group participant

“It just gives me the creeps.”-- Edina, MN focus group

participant

Source: Ross M, Igus T, Gomez S. “From Our Lips to Whose Ears? Consumer Reaction to Our Current Health Care Dialect.” The Permanente Journal. 2009;13(1):8-16.


Lost in Translation

“Of course the system is integrated. There are black and white patients.”

-- Participant in focus group conducted for MSL client

“I know my doctor is high-quality. He has Town & Country in the waiting room.”

-- Participant in 2007 focus group for the Robert Wood Johnson Foundation


REFORM

Reform Fatigue

• Improvements, sure

• Changes, maybe

• But please, no more reform


Beware of the “Team Trap”

Messages about “teams” can create more concern than comfort

Sources:Ross M, Igus T and Gomez S. “From Our Lips to Whose Ears? Consumer Reaction to Our Current Health Care Dialect.” The

Permanente Journal.13(1):8–16. 2009.Talking About Health Care Payment Reform with U.S. Consumers. Princeton, N.J.: Robert Wood Johnson Foundation, 2011. (No

authors given.)Photo: The Medical Group, Beverly, MA.


Who’s in Charge?

Concerns recede when it is clear the doctor is calling the signals

Sources:Ross M, Igus T and Gomez S. “From Our Lips to Whose Ears? Consumer Reaction to Our Current Health Care Dialect.” The

Permanente Journal.13(1):8–16. 2009.Talking About Health Care Payment Reform with U.S. Consumers. Princeton, N.J.: Robert Wood Johnson Foundation, 2011. (No

authors given.)


You Want to Go Where with My Health Care?

THE JOURNEY FROM VOLUME TO VALUE


From Volume to Value

This mantra works for:

What could be wrong with that?


Just Ask Them

They think

Valuis a four letter word


People equate value with “bargain-basement pricing” not high-quality care

What Value Looks Like


Health Care: I Don’t Want to Buy in Bulk

Tested statement:

“Here in our community, we are looking at ways to improve the health care that we all receive, so that we get more for the money we spend. That includes making sure that doctors understand that we want to pay for the right care, not tests that we do not need or other unnecessary procedures.”

Charlotte, N.C., woman:

“More for the money, I don't know, it sounds like you are buying bulk.”

Source: Focus group held in Charlotte, N.C. for the Robert Wood Johnson Foundation, 1 March 2011.


VALU = Rationing, Poor Quality

• “Eliminating waste,” “increasing efficiency” or even “saving money” sparks fear of rationing care that they want – and feel they need – but that may be expensive

• Feelings that care will be cheapened, or that time

with physician will be cut or – worst of all – that the care that they want could be curtailed is threatening. It shuts down the conversation.

• The premise of VBID programs — the use of high quality providers or evidenced-based procedures leading to lower costs — is counterintuitive to employees’ perceptions that lower cost equals lower quality

Sources: Talking About Health Care Payment Reform with U.S. Consumers. Princeton, N.J.: Robert Wood Johnson Foundation, 2011. (No authors given.)Employee Health Engagement: Identifying the Triggers and Barriers to Engaging Employees in Their Health Benefits and Wellness Programs. Chicago, Ill: Midwest Business Group on Health, 2011.


• Consumer beliefs:

Quality tracks cost -- higher priced care must be better

More care must be better

Agency theory – doctors have my interests at heart

When it comes to my health care, sky’s the limit

• Third-party payment system – patients only see their portion of the costs*

* Let’s talk more about this later!

Summary: Barriers to Communicating Value


Park Your ACO in a Medical Home Garage

Takeaways: Consumers resist being consumers when it comes to their health care

• Consumers don’t want to talk about delivery system typology, or how doctors and hospitals are paid

• They don’t know volume from value, and don’t want to

• The get mad that money influences the way care is delivered

Conclusion: Put the “We’re Your New Hometown ACO Campaign” on hold


The Path to Patient-centered Messaging

SO WHAT, WHO CARES, WHAT’S IN IT FOR ME?


The Problem with My Health Care is…

• Uneasy relationship with my doctor

• Doctor is pressed, encounter feels rushed, questions go unanswered

• Lack of clear,

trustworthy information

• Too many mistakes, too much miscommunication that can make things go wrong

Source: Talking About Health Care Payment Reform with U.S. Consumers. Princeton, N.J.: Robert Wood Johnson Foundation, 2011. (No authors given.)


The Conversation About Care Starts Here

The doctor-patient relationship is the foundation for messaging about quality improvement or delivery and payment reform. Start here and build out.


What Do Patients Want?

• More time with their physicians





• Better coordinated care





• Better coordinated care

• To not pay more




An ACO wrapped around a medical home.

(Just don’t call it that.)


The ABCs of Delivery Reform Communications

ENOUGH ABOUT WHAT NOT TO SAY


“It’s All About Me”

• Patients want to hear what’s in it for them

• Messaging about payment or delivery should focus on patient benefits

• Position the benefits as “improving care coordination,” “increasing preventive care,” “improving the doctor-patient relationship” and "improving communication across doctors”

• Offer “solutions” to problems they see

• If you must talk about money, talk about spending health care dollars wisely, not saving money

Source: “Talking About Health Care Payment Reform with U.S. Consumers.” Princeton, N.J.: Robert Wood Johnson Foundation, 2011.


Example: Red Flag over the Revolving Door

• Hospitals are on red alert to reduce readmissions to avoid Medicare penalties

• Do not make these efforts sound like you want to ration or take away care

So:• DON’T focus messaging on keeping people out of the

hospital

• DO focus messaging on the solution—improving care for patients when they return home—because it will be seen as a benefit


How to Say It

We want to find better ways to care for you to improve your care and make sure you get the best care possible

• Improving communication, coordination among doctors, nurses, others

• Getting you all the preventive care you need• Making sure you get right

medications and tests

• Helping you make appointments easily, fill out forms once, take tests once, so you do not have to repeat yourself over and over

• Providing high-quality care, tailored just for you, based on best medical evidence and your doctor’s recommendationSource: “Talking About Health Care Payment Reform with U.S. Consumers.” Princeton, N.J.: Robert Wood Johnson Foundation,

2011.


How to Say It

We want you to have:

• A stronger relationship with your doctor

• More time with your doctor

• All your concerns addressed

• No decision made about you without you – patient involvement

• An understanding of your follow-up care

• After-hours help, alternatives to the emergency room



If You Have to Talk About Reimbursement

Don’t Talk about… Instead…How doctors are paid How insurance companies pay for care

MDs giving too many tests because of system incentives

Right now, insurance companies pay doctors based on how many patients they can squeeze in a day or how many different procedures they do

“Reward” or “incentivize” Make sure the way insurance pays for health care is consistent with way you want to receive it; High-quality care, tailored for you

Getting the “wrong” tests Getting the right tests

Getting “unnecessary” tests Getting same test “twice” or tests you don’t need



The Blockbuster Drug of the Century

PATIENT ENGAGEMENT


When it comes to your patients, are you better off if you do things:

TO THEM?

FOR THEM?

OR WITH THEM?

Framing question


WITH THEM


• Better health outcomes• Better experience of care• Lower health care costs

Characteristics of Effective Interventions

• Utilized peer support• Changed the social environment• Increased patient skills• Tailored support to the individual’s level of

activation

The RIO on Better Patient Engagement

Source: Greene J and Hibbard J. “What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs.” Health Affairs. 32(2): 207-214. February 2013


Engaging Patients with Visit Notes

By reading their notes, patients:

• Better remember what is discussed during visits• Feel more in control of their care• Are more likely to take medications as prescribed• Can share notes with their caregivers, better equipping

them to stay up to date with visit events and help enact the recommended treatment plan

Source: Delbanco T, et al. “Inviting Patients To Read Their Doctors’ Notes: A Quasi-Experimental Study And A Look Ahead.” Annals of Internal Medicine. 157(7): 461-470. October 2012


Even the Doctors Don’t Mind

“Weeks after my visit, I thought, wasn’t I supposed to look into something? I went online immediately. Good thing! It was a precancerous skin lesion my doctor wanted removed (I did).” -- Patient

“I felt like my care was safer, as I knew that patients would be able to update me if I didn’t get it right. I also felt great about partnering with my patients, and the increased openness.” -- Doctor

Source: http://www.myopennotes.org/wp-content/uploads/2012/10/OpenNotes-Results-Fact-Sheet.pdf


A Multidimensional Framework For Patient And Family Engagement In Health And Health Care.

Carman K L et al. Health Aff 2013;32:223-231

Engagement: More Than You May Think

Source: Carmen K, et al. “Patient And Family Engagement: A Framework For Understanding The Elements And Developing Interventions And Policies.” Health Affairs. 32(2): 223-231. February 2013


Put Evidence in the Context of Shared Decision-making

COMMUNICATING ABOUT MEDICAL EVIDENCE


People want to be involved in decision-making• Especially about surgery or medications

Patients want doctors to communicate options• People trust their doctors and want more time to

talk/listen

People value results of comparative effectiveness research• Regardless of politics, patients see deep value in CER

• Their fear, however, is that money will ultimately drive decisions and/or their preferred treatment will be off limits.

Nothing About Me Without Me

Source: Alston C, et al. “Communicating with Patients on Health Care Evidence.” Washington, D.C.: Institute of Medicine. September 2012


What Patients Want from Doctors



The Care They Want v. The Care They Get



Making an informed decision about the care that’s right for you

Put Evidence Under an Umbrella Concept


Elements of an Informed Medical Decision

Medical Evidence

Clinician Expertise

Patient Goals & Concerns

Informed Medical Decision



People Value All 3 Elements Strongly



Tap into motivations:• Getting the best care possible• You know yourself best• Improving the MD/patient relationship• Increasing knowledge about health and treatments

Part of getting the best possible care is having a doctor who listens to you, answers your questions, and includes you in decisions about what treatments are best for you.

Shared Decision-making Messaging



Satisfaction Linked to Shared Decisions



Finding Language that Resonates


“meaning one of the discs…” Participants appreciate the explanation of what is wrong—describing what a herniated disc means.

“number of options” Participants like options, particularly when it comes to surgery. If there are options for treatment, they want to hear about them. A few crossed out “a number of” because only two options were presented.

“scientific evidence” Many like that the physician reports on the scientific evidence—they want to know what evidence exists. “Medical evidence” tends to work better than “scientific evidence”, however. Also, adding “recent” or “up-to-date” modifiers may help for some who wonder how recent the evidence is.

“carries risk” Risks are a key component of treatment options that consumers want to hear.

“no guarantees” Knowing that there is “no guarantee” is a key factor that would weigh in the decision process. Additionally, the phrase resonates with participants who appreciate the honesty in a discussion.

“outcomes…will be better if you lose a bit of weight”

Some participants like this because it is truthful, while others like it because they prefer to take steps on their own prior to medical intervention.

“my opinion is…” The doctor’s recommendation is key, although a few do not like the word “opinion”, which feels uncertain. “My experience’ or “my recommendation” may be a better word choice.

“the decision needs to be yours” Again, participants want to be integrally involved in making decisions, so many like hearing this from their doctor

“is there information I can give you”

Participants like this gesture, and feel it is an opening to ask questions. An improvement might be asking directly: “Do you have any questions right now that I can help answer?” “How do you feel about all of this?” “What are your thoughts and concerns?”

Why Certain Language Resonates



Making sure you get the best possible care starts with you and your doctor making the best decision for you.

Your doctor can help you understand what types of care work best for your condition, based on medical evidence.

Because there are always new treatments, doctors use this evidence to keep up with which work best.

Your doctor’s experience helps him/her evaluate and apply the evidence to your situation.

The doctor also needs to listen to you so he/she understands your values, preferences and goals.

This is important because every patient is different, and when there are options, it is important for the doctor to know what is important to you.

Best Framing Language


Spending My Money is Another Matter

PATIENTS AS CONSUMERS


High Deductibles Will Drive Consumerism

Health plans increasingly have high deductibles


Price Seekers

Altarum Institute Spring/Summer 2012 Altarum Survey of Consumer Health Care Opinion

• Who is most likely to ask about the price of care? Younger age, Lower income, Higher insurance deductible, Recent hospitalization, More experience using computers and smartphones, and Not being an impulse shopper in other aspects of life.

• Neither health status nor gender was predictive of asking about price.


Growing Demand for Price Transparency


The Research Behind Today’s Presentation

RESOURCES


• Alston C, et al. “Communicating with Patients on Health Care Evidence.” Washington, D.C.: Institute of Medicine. September 2012.

• Bechtel C and Ness D. “If You Build It, Will They Come? Designing Truly Patient-Centered Health Care.” Health Affairs. 29(5): 914-920. May 2010.

• Carmen K, et al. “Evidence That Consumers are Skeptical about Evidence-based Health Care.” Health Affairs. 29(7): 1400-1406. July 2010.

• Carmen K, et al. “Patient And Family Engagement: A Framework For Understanding The Elements And Developing Interventions And Policies.” Health Affairs. 32(2): 223-231. February 2013.

• Coulter A. “Patient Engagement—What Works?” Journal of Ambulatory Care Management. 35(2): 80-89. April-June 2012.

• Delbanco T, et al. “Inviting Patients To Read Their Doctors’ Notes: A Quasi-Experimental Study And A Look Ahead.” Annals of Internal Medicine. 157(7): 461-470. October 2012.

• Gerber A, et al. “A National Survey Reveals Public Skepticism About Research-Based Treatment Guidelines.” Health Affairs. 29(10): 1882-1884. October 2010.

• Greene J and Hibbard J. “What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs.” Health Affairs. 32(2): 207-214. February 2013.

• Ross M, Igus T and Gomez S. “From Our Lips to Whose Ears? Consumer Reaction to Our Current Health Care Dialect.” The Permanente Journal.13(1): 8–16. 2009.

• “Talking About Health Care Payment Reform with U.S. Consumers.” Princeton, N.J.: Robert Wood Johnson Foundation, 2011. (No authors given.)

• “Talking with Physicians about Improving Payment and Reimbursement.” Princeton, N.J.: Robert Wood Johnson Foundation, 2011. (No authors given.)

To Learn More


To Follow Up

Chuck [email protected]

A Bed's Eye View of Health Reform

Health & Medicine

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