The future of healthcare: Patient engagement as a success strategy for ACOs

More than 40% of Americans live in areas with at least one Accountable Care Organization (ACO) and they are quickly becoming an integral part of the next generation of healthcare.

ACOs role are to maintain responsibility for the cost and quality of healthcare offered to a population that is managed by a group of providers. The ACO takes on a degree of accountability for this entire population for their long-term health outcomes. And while the term "Accountable Care Organization" was coined in 2006, the entities were not formed until 2009 with the (Patient Protection and) Affordable Care Act.

In that same year, several leading researchers defined the three main principles of ACOs1:

- Providers must have accountability for the quality and cost of care which cannot be obtained in the current fee-for-service environment.
- The income of providers should be removed from the volume of services provided. Spending should be reduced along with improvements in quality and reduced waste.
- Transparent performance measures are essential for cost and quality of care.

Within each principle, patient engagement is a core part of achieving positive results. Engagement improves various metrics that ACOs need to reach in regards to quality of care and communication. Engagement also assists cost-saving efficiencies and allows ACOs to be more transparent with their reporting. However, when it comes to patient engagement, ACOs often place minimal priority on its execution despite the established connections between patient engagement and positive long-term outcomes and satisfaction. Many ACOs realize engagement is important, but it is not typically given as much weight as other strategic priorities such as clinical integration.

There also is not a clear understanding within ACOs as to why patient engagement can be a vital piece of achieving business objectives. ACOs must meet several requirements for engagement, for example, those set by Meaningful Use Stage 2 guidelines in order to enjoy shared savings. Some of these measures include receiving timely care, health promotion and education as well as shared decision making—all of which engagement can improve. Knowledge of the hard costs that can be lowered and the efficiencies gained should prompt ACOs to look deeper at engagement as a business imperative.

And while reducing cost is a key goal of ACOs, it must be balanced with improving outcomes and performance metrics. As a group, ACOs do have lofty cost-savings targets, with the Centers for Medicare & Medicaid Services' report "Lower Costs, Better Care: Reforming our Health Care Delivery System" stating ACOs can save up to an estimated $940 million in the first 4 years of development.2 Yet, by not understanding how patient engagement is vital to achieving business objectives, many ACOs will fall behind in performance.

The Case for a Complete Engagement Strategy

Why does patient engagement matter? Well, as several studies such as the "Health Policy Brief" from the Robert Wood Johnson Foundation specify, engagement plays an essential role in improving outcomes and lowering costs. The Robert Wood Johnson Foundation report specifically notes a correlation between patients with the lowest activation scores (defined as the least confidence engaging in their care) and 21% higher incurred costs.3

And despite patients being the most important part of the healthcare system, they are an underutilized resource in achieving business outcomes. For example, it's common for engagement to be thought of only as satisfaction. As a Healthcare Intelligence Network survey states, 88% of administrators are using "patient satisfaction" as a metric to measure performance. This is followed closely by 85% noting "clinical outcomes" and then 64% stating "health utilization" as usable metrics.4

Metrics Used to Measure Performance

However, a core goal of healthcare practitioners is to encourage patients to either begin or cease an action or series of actions, and this almost entirely depends on truly engaged and empowered patients, not just those that are satisfied. And while relaying the need for the change is easy (lose 40 pounds for a better resting heart rate), motivating patients to achieve their goals is difficult. ACOs need to work collaboratively to aid patients over many touch points, not only within an acute care setting. Handing a discharged patient a flier on weight loss strategies is not enough to meet the definition of a complete patient engagement strategy. Patient engagement is a much broader strategy of understanding patient goals, providing education, competence and confidence, teach back, follow-up care and personalized information.

Benefits of well-planned engagement strategies for patients, according to the Bipartisan Policy Center's Health Information Technology Initiative, include5:

- Increased levels of satisfaction and health literacy
- Higher levels of positive behavior changes affecting health
- Stricter adherence to prescribed medicines

Engagement also delivers positive results for both the ACO healthcare provider and individual physicians. A RAND Corporation and American Medical Association study correlates high-quality care with physicians' job satisfaction, and notes any obstacles to providing quality care are stressors for doctors.6

The Bipartisan Policy Center's report further describes how patient engagement benefits both the patient and the ACO as both enjoy:

- Reduced testing and related expenditures
- Fewer referrals and elective surgeries
- Improved health literacy and the empowerment that comes with greater understanding of one's condition and care

Additionally, according to the Health Information Technology Initiative, engagement can change longer-term patient behaviors, with well-informed patients carrying out more changes such as exercise, modification of diet, and quitting smoking. This creates a positive feedback loop where engagement, through quality care, drives change and better outcomes.7

Patient Engagement Pays Business Dividends

Patient engagement initiatives make good business sense for ACOs. Patients are consumers, and consumers that are treated poorly by a business are more likely to complain. High engagement can result in more positive patient feedback, referrals and high levels of overall satisfaction.

There is also the financial incentive for achievement of outcome and satisfaction measures that can be attained largely by engaging patients in their own care. For the entire healthcare system, engagement can lower costs such as any penalties and lowered reimbursements, thereby reducing the pressure for ACOs as a whole.

According to researchers writing for the journal Medical Economics, the proportion of a provider organization's cost that is utilized by human resources is 56%, a burdensome number that needs to be reduced through engaging patients in order to lead to improved efficiencies and outcomes.

Additional benefits of patient engagement that help the ACOs bottom line include:

- More engaged patients result in better adherence to prescribed care and less time spent with each patient, allowing time and resources to be more efficiently spread through the population.
- Improved patient engagement and the resulting positive outcomes drives higher physician job satisfaction.6 More satisfied ACO doctors offer better and more thoughtful care, resulting in more satisfied patients, better outcomes, etc.8
- Improved communication between patients and physicians can reduce complications and other issues. Doctors need to relearn how to speak to patients in non-medical terms, especially given the National Institute for Literacy assesses 50% of the adult U.S. population has basic or "below basic" literacy levels. Improved communication can reduce the need for follow-up visits and the possibility of medical errors (and possible malpractice suits) due to misunderstandings.9
- Readmissions are a significant cost for ACOs, especially in cases where they are avoidable and could be prevented through better communication. Patients are often readmitted for several reasons, such as lack of understanding as to their ailment(s), confused about medicine usage, patients do not schedule follow-up appointments with primary care, and hospital staff not informing patients about test results. All of these issues can be addressed with technology-focused engagement strategies.10

Engagement Through Technology and Associated Outcomes

Several areas of the ACO healthcare experience act to thwart patient engagement, such as long wait times in offices, the complexities of insurance and medical terminology and no clear picture of the costs of the provided services. Thankfully, technology tools and mobile devices are altering this picture to give patients more information about their own care and allowing them to operate more efficiently.

Ultimately, patient engagement through technology aids the most important metric of all – patient outcomes. There is a strong relationship between engagement and improved patient outcomes due to better adherence to prescriptions and care, being informed about follow up procedures and a deeper understanding of conditions and treatment options. Various studies illustrate the benefits of engagement as it results to ultimate patient outcomes:

The Journal of Internal Medicine links readmission rates to the degree of patient activation, meaning the use of their knowledge and confidence of their care regimens post-discharge. Of 700 patients discharged from Boston Medical Center, those with the lowest levels of activation had "1.75 times the risk of 30-day readmissions, more ED visits, and greater utilization of health services, even after adjusting for severity of illness and demographics". The study did adjust for the degree of the patient's illness and demographic factors (age, ethnicity) which are known to influence activation rates.11

- Patients with the lowest levels of activation had 1.75 times the risk of readmissions, ED visits and greater use of utilization.
- Physicians and staff spend as much as 11% of their time answering patients on the phone.12 Reducing this time through technology tools such as automated scheduled calls and better engagement benefit the patients by empowering them to find information on their own. It also means phone calls are answered more quickly and given more attention when patients really do need person-to-person information.
- The Bipartisan Policy Center notes many benefits arising from engagement including; fewer referrals, improved health literacy, positive behavioral changes for improved health and faster recovery times.

Pushing Engagement to the Forefront

ACOs are part of larger healthcare reform goals to move the industry from a fee-per-service to a model where payments are massed together and determined by both the value and quality of care.

Despite "patient engagement" becoming a popular phrase among senior leaders, there is still a shortage of ACOs that are actually putting engagement initiatives in place. As ACOs are evaluated on performance, leadership needs to view patient engagement as a main driver of positive outcomes and reduced costs. ACOs face many challenges including:

- An odd payment structure that requires them to move to a prepaid model quickly
- Questions over the size of the patient population that is necessary to produce meaningful data
- Not all ACOs have the right cultural attitudes of improvement and reflection that are necessary for the implementation of sweeping changes
- Concerns about having enough staff and monetary resources to change the business to one focused on accountability13

In order to overcome these challenges, ACOs will need to view engagement as the cornerstone of an approach that results in better outcomes and positive measurable benchmarks.


1- "Fostering Accountable Health Care: Moving Forward In Medicare." Health Affairs, January 2009.

2- "LOWER COSTS, BETTER CARE: REFORMING OUR HEALTH CARE DELIVERY SYSTEM." Report from the Centers for Medicare and Medicaid Services, March 2013 -

3- "Health Policy Brief." Robert Wood Johnson Foundation, February 2013

4- "Health Information Technology Initiative." Bipartisan Policy Center, December 2012

5- "Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy." RAND Corporation and the American Medical Association, 2013.

6- Alexandra B. Kimball MD MPH, Kristen C. Corey MD, Joseph C. Kvedar MD, "Engaging patients to decrease costs and improve outcomes.", Medical Economics, January 2015.

7- Haas, Jennifer S. MD, MSPH, Cook, Francis E., ScD, Puopolo, Ann Louise, RN, BSN, Burstin, Helen R., MD, MPH, Cleary, Paul D., PhD, Brennan, Troyen A., MD, JD. "Is the Professional Satisfaction of General Internists Associated with Patient Satisfaction?" American Board of Internal Medicine.

8- "When Health Care is Lost in Translation." Tufts Journal, May 2015.

9- "Care About Your Care." The Dartmouth Institute for Health Policy & Clinical Practice.

10- "Patient Activation Measure Tool Helps Patients Avoid Hospital Readmissions." The Hospitalist, March 2014.

11- Liederman, E. "The impact of patient-physician web messaging on provider productivity." Journal of Healthcare Information Management, 2005.

12- "What are the barriers and challenges such organizations might face?" Council of Accountable Physician Practices.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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