Improving outcomes and lowering costs

Lupus Foundation of America

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The goal of improving health outcomes is not new. Neither is the desire to cut health care costs. Two studies published this year in Health Affairs showed that both health care costs and patient satisfaction are affected by the “patient activation level,” defined as “the skills and confidence that equip patients to become actively engaged in their health care.”

Past and present

“A traditional model of health care was that the provider told patients what to do [and] they didn’t question anything,” says one of the study’s authors, Valerie Overton, vice president for quality and innovation at Fairview Medical Group in Minneapolis. “These days, there is too much complexity to be that passive. Both patients and providers need to know how to interact in new ways that allow the patients to have the knowledge, skills, and confidence to manage their own health.”

The term Overton coined for this is “evidence-based interaction.”

“A few decades ago, we had a whole movement in health care called ‘evidence-based medicine’—the provider chose a medication or a treatment for a patient based on the best available research information,” she explains. “What we know now is that you can choose the best medication based on the evidence, but if the interaction you have with the patient, in describing what they’re supposed to do with that medicine, is not evidence-based, you’re still going to get poorer outcomes. You need to prescribe the right medication with the right interaction in order to maximize patient outcomes.”

In other words, the health care provider should sit down with the patient and say, ‘I can give you my expert opinion about the evidence-based medicine, but you are the expert on who you are and what is best for your life. Let’s talk about that and share in decision-making,’ Overton says.

“This is a whole new way of learning,” she says, “one that providers need to embrace in order to really get to better outcomes.”

“I need to know this about my patients”

Using a 13-item “Patient Activation Measure,” or PAM, the researchers gathered information on health management topics from 33,163 adults enrolled with Fairview Medical Group, which oversees 44 primary care clinics. Scores that fell into one of four patient activation levels—ranging from least activated to most activated—were then assigned to participants.

Fairview has been using PAM since 2009. Overton says the individual providers took some convincing before incorporating the measure into the office visit. “We figured [health practitioners] would just take it and run with it. It turns out that is not the case. People really need you to take the conceptual elements of patient activation and break it down for the day-to-day workflows that they need. We’re doing that now.”

The developer of PAM is Judith H. Hibbard, a senior researcher at the Health Policy Research Group, Institute for Sustainable Environments, and a professor emerita in the Department of Planning, Public Policy, and Management, all at the University of Oregon in Eugene. She agrees that it’s not always clear at the beginning that measuring patient activation is the way to go. Doctors “may feel this is one more thing that’s being imposed on them. They don’t necessarily see the value at first,” she says. “But when they do [see it], then they really embrace it, and they say things like, ‘This is like a vital sign. I need to know this about the patient.’”

The patients like it, too, she says. “And if people start to experience success, they become more motivated.”

Overton adds, “One of the key questions in the surveys is: ‘When all is said and done, I’m the person who’s responsible for taking care of my health.’ What you’ll find is that the highly active patients will strongly endorse that type of question.”

The future

The researchers believe that strategies to improve the patient experience “should focus not only on providers but also on improving patients’ ability to elicit what they need from their providers.” Such strategies include health coaches and peer groups who help patients understand medical information, set goals, and form and ask questions at the office visit. Improving people’s ability to solve health problems at home, instead of going to the hospital emergency department, is a cost-saving measure that especially appeals to health care delivery managers.

Most of all, the studies found that patients involved in their health care decisions not only have a better overall experience—but actually do better medically.

Hibbard says, “In the coming years, I think patient activation is going to become even more important, as the evidence emerges that when patients do have confidence and skills and knowledge, they do so much better. We can’t afford to ignore that. We need to help patients gain the skills and confidence that they need.”


Health Affairs 32, no. 2 (2013): 216–222
Health Affairs 32, no. 7 (2013): 1299–1305