The role of patient engagement in the effectiveness of the ACA

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The Affordable Care Act (ACA) was passed in 2010 with three broad objectives: provide access to care for all Americans, improve population health outcomes, and decrease healthcare costs across the board.

The interconnection of these objectives is such that any one goal can only be successful with the success of all three. With the ACA in its second year of implemented existence, there is an opportunity to see how the United States measures up to meeting these goals and pivot as necessary to ensure the legislation's success.

Taking Measure: Where are we today?

How is the country doing? Have we seen progress or success with the legislation's goals? The answer to these questions is "yes, but we still have a long way to go."

In recent years, the growth of healthcare related spending has slowed, but it is not yet clear if this is a direct result of the ACA, as the slowdown began before the legislation's passage. Early data is promising for improved healthcare outcomes, including more frequent primary care visits and increased treatment of mental health problems; however, to definitively report on trends, additional data is needed over a longer time period. Further, millions of Americans have been able to obtain health insurance coverage due to the ACA. As of Q1 2015, the uninsured rate for adults over age 18 dropped below 12%, the lowest the index has been since Gallup and Healthways began tracking in 2008. However, health insurance coverage does not equal access to care for many of the newly insured, mainly due to the increased demand on providers.

Despite the push for the newly insured to identify a primary care physician, many doctors' offices do not have the staff needed to take on new patients. As a result, patients are finding wait times for doctors' visits to be as long as a month, and patients are left with no option but to go to a hospital's Emergency Department. This is especially prevalent among the Medicaid population, which accounts for approximately 16% of the Nation's total population. More than half of Medicaid enrollees prefer the 'one-stop-shop' of a hospital Emergency Department over a primary care physician's office. This has led to a significant increase in the number of patients that visit the Emergency Department, which is often the most expensive place to treat minor injuries and illness. The nation's 24 busiest Emergency Departments reported an 18.7% increase in visits from 2012 to 2013 and admissions in 2014 and 2015 have continued to rise at a constant rate.

With the lack of accessible care today, there are many challenges our country has to face in order to improve population health outcomes and decrease healthcare costs. Reality must be faced, and we must recognize that the supply of physicians may never be in balance with patient demand, nor would it be feasible to reduce costs with a physician-only model. Due to these pressures, alternative care delivery models must be assessed and implemented to move our healthcare system towards meeting the goals of the ACA.

Vynamic's Perspective: Where do we go from here?

Access to care remains an issue for the population at large, but by focusing efforts on specific populations, the greatest impact can be made to the issue. Over 16 million Americans have taken the first step toward access to care by obtaining health insurance coverage under the ACA through exchanges and expanded Medicaid coverage; however, most of this newly insured population have had little-to-no prior experience with care options. For many of these patients, their health is managed through episodic care in an Emergency Department instead of preventative, more coordinated care. While this adds to the challenge of improving population health outcomes that will in turn drive down health cost, it presents an opportunity to educate and engage patients regarding how to navigate through the healthcare system to improve their health and prevent unnecessary costs. It is imperative that patients are educated on the benefits of preventative care, when to use specific avenues of care, and the importance of owning the responsibility for their own care. Targeting the newly insured population will be the difference between the success and failure of the ACA.

With an understanding of this new population's behavior when it comes to seeking care, there are two key opportunities that can support effective engagement:

  1. Influence patient behavior when seeking care: A focus must be placed on influencing care-seeking behavior so that patients can obtain the right care when needed and in a less costly setting.
  2. Promote access to preventative care: With limited access to primary care resources for the newly insured population, alternative healthcare resources and targeted care management services should be identified and promoted to ensure patients are receiving more coordinated, prevention-focused care. Given that hospital Emergency Departments serve as the current gatekeeper of patient care for the newly insured, Emergency Departments are well positioned to help patients gain access to the information and resources they need beyond their episode of care and prevent costly hospital readmissions.

With these two key points in mind, the right controls should be put in place to appropriately intervene and create continuity in patient care. Patient engagement strategies can serve as tactics to help drive success in years to come.

Taking Aim: Tactics for Success

Success will not be achieved based on the efforts of patients and consumers learning how to navigate the healthcare system alone. Providers, insurers and many others will need to enact patient engagement strategies in order to support the education of patients and team members. A collaborative approach will be needed between state and local government, payers, and hospitals to develop strategies such as:

  1. Patient Education. A number of strategies can be used to help enhance Patient Education. It's important to start at the source where the concentration of patients is highest – the Emergency Department – to educate patients, their families, and caregivers on utilizing the appropriate place for receiving care. In addition, patient education should be delivered by staff other than the care team to ensure both the patient and providers are focused on the patient's current condition. Patient education should also be timed to occur at a point when the patient can give the appropriate level of attention to the information being presented to them, most commonly at discharge. It is also critical to develop educational materials and train hospital staff to actively display and leverage materials as a starting point for conversations with patients, when appropriate. In doing so, it's necessary to consider your audience and tailor educational materials and posters that are easy to understand and available in different languages. Lastly, it's critical to assess opportunities to use technology and social media campaigns for disseminating and reinforcing information.
  2. Care Transition Support. To help patients successfully transition from a hospital or emergency room setting back to their primary care physician, processes should be developed to encourage hospital- or state-employed case managers to follow-up with patients who are identified as requiring additional care upon discharge or who are at a high risk of returning to the Emergency Department. Case Managers should work to ensure the patient has identified a primary care physician they can see for any required follow ups. When primary care appointments are unavailable, alternative sources of care should be arranged by Case Managers, such as scheduling an appointment at a community clinic or having a community nurse come into a patient's home. These case management services should be available to accommodate patients after normal business hours, as emergencies do not follow a 9-to-5 schedule. Case management services should work to identify flexible care options that extend outside normal working hours to accommodate Emergency Department utilizers who simply cannot use other care options due to work schedules, travel restrictions, etc. It is also important to account for unique social situations that a patient may have, whether it be mental illness, homelessness, or poverty; as part of the care transition support, these situations should be evaluated to ensure the patient receives the best care possible which may include outreach and scheduling with additional services or providers such as social services. In doing so, case management services should place emphasis on the development of controls to reduce the risk of alternative care sources resulting in an unnecessary referral back to the Emergency Department due to lack of testing equipment, appropriate patient history information, or other easily addressed items.
  3. Closing the Gap on Frequent Emergency Department Users. Medicaid patients utilize the emergency room twice as much as those privately insured and could benefit from personalized support through targeted case management services. It is common for hospitals to have a mechanism for identifying frequent Emergency Department utilizers, either through claims data, providers' referrals, and/or patient condition data. In order to support hospitals and providers in using this information to reduce unnecessary admissions and readmissions, states should provide case managers who can work with high-utilizers to overcome socioeconomic barriers and close gaps in care.
  4. Appropriate Emergency Department Redirection. On average, the wait time in Pennsylvania to be seen by a doctor in the Emergency Room is approximately 24 minutes, but can vary widely based on time of day, the severity of the patient's current condition (such as chest pain versus a broken finger), and other factors outside the patient's control. To alleviate the stress and inconvenience of waiting, most hospitals have processes to appropriately re-direct patients to a more appropriate level of care who have non-emergency needs through triage activities based on their symptoms. Collaborative and simplified processes such as this should be developed and implemented in all Emergency Departments to appropriately triage patients, identify alternative and available providers, and assist patients in reaching these alternatives (e.g., scheduling assistance, travel assistance) to reduce wait times further for non-emergent conditions.

Beyond developing interventions primarily focused in the Emergency Department, health plans that serve the newly insured population, including Medicaid and CHIP patients, should consider opportunities to move patient education and engagement upstream. These tactics should be implemented in parallel to and in collaboration with Emergency Department tactics to increase positive outcomes. These tactics include:

  1. On-Call Nurse Support. Provide patients with telephone access to nurses 24/7, or leverage Mobile-Health (which circulates information through mobile technology), who can offer clinical advice and guide patients to the most appropriate clinical setting based on the nature of their symptoms or concerns. Other types of telehealth, such as home-video conferencing and remote-patient monitoring, can serve as innovative solutions for providing consultative, diagnostic and treatment services and helping individuals stay healthy in their home without needing to come into a physician's office.
  2. Patient Education Services. Establish services to contact and have meaningful conversations with prospective and new plan members about the primary care and alternative care options available through their selected plan, enabling them to make more informed decisions about their health care. Much like inpatient discharge follow-ups, health plans should follow up with newly insured individuals once they purchase coverage to offer no-cost educational services to them such as eLearning tools.

In support of these tactics, primary and alternative care providers should look to implement patient engagement strategies of their own to provide opportunities to educate patients at all points of the care continuum. Further, these providers should consider new operating models to shift patient hours to improve access for populations that traditionally cannot travel to an appointment during normal working hours. These changes will allow for patients to be engaged in new and more appropriate settings. Payers should also consider supporting changes to new payment models, such as value-based payments, that incentivize providers to implement these tactics as patient redirection can result in lost revenue and present a barrier to adoption.

By pursuing and executing on these tactics, providers and payers can begin to move education and health foresight of patients upstream, allowing patients to make smarter decisions sooner that have the best return for their health and their wallets. When patients make informed decisions about their own health, it results in easier access to care and better health outcomes which will, in turn, help to drive costs down. This is how the ACA succeeds – turning the current vicious cycle of care in the most expensive locations into a virtuous cycle of care, focused on preventative care and utilizing targeted patient engagement initiatives to improve outcomes at a lower cost.

Contact Vynamic to learn more about these tactics and how to implement them in your organization or across partnerships.

Dylan Casey is a healthcare industry management consultant with a focus on health policy, public health and life sciences. He comes from a background in Engineering, having graduated from Villanova University with a B.S. in Chemical Engineering.

Ashley Michel is a healthcare industry management consultant with a focus in health plans and public health. She comes from a background in Finance, having graduated from Drexel University with a B.S. in Finance.

Kaylee Tully is a healthcare industry management consultant with diverse experience across the provider, public health and health plan sectors. She received her B.S. in Supply Chain and Information Systems at The Pennsylvania State University.

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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