Some Thoughts on Patient Engagement

There is currently a strong belief among health care thinkers that if they can just get patients “engaged” in their health and their health care services, cost and quality outcomes will improve.  While there certainly is some evidence that engaged patients have better outcomes and a little evidence that as patients become more engaged, outcomes may improve; closer examination reveals that particularly in regard to costs, patient engagement may not be able to make that much difference.  It is valuable to always start by segmenting patients according to the level of health spending associated with cohorts.   Recall that a small percent of patients account for a great deal of spending and that half the population has almost no annual health spending.  Now imagine a graph with health engagement on the vertical (lets say we are ranking that from zero to 10) and health spending on the horizontal dimension.  If we imagine a cloud representing the points where all Americans are on that graph, we will see a very oddly shaped figure, boomerang-like, with the arms hugging each measuring line closely except near the intersection.

Almost all the people with strong engagement will have low spending and a large number of the people with low engagement will have high spending.  In part this is due to a very large number of high spenders not really being in a position to be engaged–many have dementias, a large number are in nursing homes and basically debilitated.  Now a surrogate decision-maker may be able to be engaged on behalf of these patients, but that is a difficult proposition and research shows that surrogates are likely to want more and more expensive care on behalf of the patient.  So for a significant portion of health spending, patient engagement is just irrelevant.  Another large chunk of high spenders got there with an acute episode that engagement is unlikely to have deterred–car and other accidents, and most cancers and some other illnesses are largely not amenable to prevention through engagement.

And then there is my favorite group of high spenders, the churlish very sick, who are determined not to give a damn about their health or health care.  People with emphysema who keep smoking, people with high blood pressure who keep eating a lot, etc., etc.  These people aren’t likely to be engaged by anything, even severe financial penalties or telling them that they won’t get care at all if they don’t change behavior.  So unless we are prepared to carry out that last threat, we are stuck paying for these people, and I mean “we” because most of them are on taxpayer-funded health care programs.  So its great that there are more and better ways to engage patients, but the most-engaged people tend to be the healthiest already.  And I suspect that the cohort of engaged but unhealthy people may actually incur higher costs as their engagement increases, because they will want more and more services.  So engagement sounds great but is likely to be less filling.