A BED'S EYE VIEW OF HEALTH REFORM

What Patients See When They Look at the New Landscape of Health Care Delivery
Presentation to VHQC April 9, 2013

Chuck Alston
Senior Vice President/Director of Public Affairs MSL Washington DC

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Todays 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

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WE MEAN WELL, BUT SOUND SCARY

Take Care With How You Talk About Health Care

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The Way We Talk About Health Care

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Do They Hear What You (Think You) Say?

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

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Come Again?
What You Say
Medical home Medical decision support Guidelines or treatment guidelines Integrated health care delivery system Integrated care Multispecialty medical group

What They Hear

Nursing home, home health, end of life End-of-life decisions Restrictive, rigid, limited, driven by cost Bureaucratic, industry language, meaning unclear Bureaucratic, industry language, meaning unclear Bureaucratic, industry language, meaning unclear, trying to do too much, low quality, limited choice of specialists to choose from Bureaucratic, meaning unclear, insincere, cookie-cutter care, not tailored to the individual Impersonal, one size fits all

Best practices

Evidence-based medicine

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.
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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.
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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

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Reform Fatigue
Improvements, sure Changes, maybe But please, no more reform

REFORM

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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):816. 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.
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Whos 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):816. 2009. Talking About Health Care Payment Reform with U.S. Consumers. Princeton, N.J.: Robert Wood Johnson Foundation, 2011. (No authors given.)
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THE JOURNEY FROM VOLUME TO VALUE

You Want to Go Where with My Health Care?

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From Volume to Value

This mantra works for:

What could be wrong with that?

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Just Ask Them

They think

Valu
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is a four letter word

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What Value Looks Like

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

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Health Care: I Dont 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.
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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.
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Summary: Barriers to Communicating Value

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, skys the limit

Third-party payment system patients only see their portion of the costs* *
Lets talk more about this later!

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Park Your ACO in a Medical Home Garage

Takeaways: Consumers resist being consumers when it comes to their health care
Consumers dont want to talk about delivery system typology, or how doctors and hospitals are paid
They dont know volume from value, and dont want to The get mad that money influences the way care is delivered

Conclusion: Put the Were Your New Hometown ACO Campaign on hold

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SO WHAT, WHO CARES, WHATS IN IT FOR ME?

The Path to Patient-centered Messaging

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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.)
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The Conversation About Care Starts Here

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What Do Patients Want?

More time with their physicians

Better coordinated care

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

More time with their physicians

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

More time with their physicians

Better coordinated care To not pay more

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

An ACO wrapped around a medical home. (Just dont call it that.)

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ENOUGH ABOUT WHAT NOT TO SAY

The ABCs of Delivery Reform Communications

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Its All About Me

Patients want to hear whats 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.
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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: DONT focus messaging on keeping people out of the hospital DO focus messaging on the solutionimproving care for patients when they return homebecause it will be seen as a benefit

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

Source: Talking About Health Care Payment Reform with U.S. Consumers. Princeton, N.J.: Robert Wood Johnson Foundation, 2011.
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If You Have to Talk About Reimbursement

Dont Talk about
How doctors are paid MDs giving too many tests because of system incentives

Instead
How insurance companies pay for care 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 right tests Getting same test twice or tests you dont need

Getting the wrong tests Getting unnecessary tests

Source: Talking About Health Care Payment Reform with U.S. Consumers. Princeton, N.J.: Robert Wood Johnson Foundation, 2011.
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PATIENT ENGAGEMENT
The Blockbuster Drug of the Century

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Framing question

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The RIO on Better Patient Engagement

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 individuals level of activation

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
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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
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Even the Doctors Dont Mind

Weeks after my visit, I thought, wasnt 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 didnt 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
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Engagement: More Than You May Think

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

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

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
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COMMUNICATING ABOUT MEDICAL EVIDENCE

Put Evidence in the Context of Shared Decision-making

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Nothing About Me Without Me

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.

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

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The Care They Want v. The Care They Get

Source: Alston C, et al. Communicating with Patients on Health Care Evidence. Washington, D.C.: Institute of Medicine. September 2012
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Put Evidence Under an Umbrella Concept

Making an informed decision about the care thats right for you

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Elements of an Informed Medical Decision

Medical Evidence

Informed Medical Decision

Clinician Expertise

Patient Goals & Concerns

Source: Alston C, et al. Communicating with Patients on Health Care Evidence. Washington, D.C.: Institute of Medicine. September 2012
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People Value All 3 Elements Strongly

Source: Alston C, et al. Communicating with Patients on Health Care Evidence. Washington, D.C.: Institute of Medicine. September 2012
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What Patients Want to Hear

When discussing treatment options, patients want their doctor to use clear language and listen to the patient Patients want to hear:
The truth about the diagnosis no sugar-coating All options for treatments Risks and side effects of treatment options What the diagnosis and treatment mean for future quality of life Recommendations for a website or literature where the patient can learn more Next steps

And for some:

How the illness or condition developed A willingness for the patient to get a second opinion

Source: Alston C, et al. Communicating with Patients on Health Care Evidence. Washington, D.C.: Institute of Medicine. September 2012
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Shared Decision-making Messaging

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.

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

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Satisfaction Linked to Shared Decisions

Source: Alston C, et al. Communicating with Patients on Health Care Evidence. Washington, D.C.: Institute of Medicine. September 2012
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Finding Language that Resonates

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Why Certain Language Resonates

meaning one of the discs number of options Participants appreciate the explanation of what is wrong describing what a herniated disc means. 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. Many like that the physician reports on the scientific evidencethey 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. Risks are a key component of treatment options that consumers want to hear. 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. 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. The doctors 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. Again, participants want to be integrally involved in making decisions, so many like hearing this from their doctor 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?
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scientific evidence

carries risk no guarantees outcomeswill be better if you lose a bit of weight my opinion is the decision needs to be yours is there information I can give you

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

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 doctors 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.

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PATIENTS AS CONSUMERS
Spending My Money is Another Matter

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High Deductibles Will Drive Consumerism

Health plans increasingly have high deductibles

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Price Seekers

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

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Growing Demand for Price Transparency

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Get Your Story Ready about Quality

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RESOURCES
The Research Behind Todays Presentation

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To Learn More
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 EngagementWhat 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): 816. 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.)
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Health care communications and public affairs

We are part of the MSLGROUP Americas, the PR arm of the Publicis Groupe, one of the worlds largest communications firms. Our team offers clients the personal touch and category expertise of a boutique, with access to national and global resources should they require them. Our health care and health care policy work is holistic: We design and execute programs that seek to change minds, policy and behavior with audiences running the gamut from the chronically ill to the chronically wonky. We specialize in health, health care and medical issues, working on the cutting edge of patient and provider communications, quality improvement, delivery and payment reform, and public affairs and reputation management. Whether your business is delivering care to patients or messages to Capitol Hill, find out why trade associations, non-profit foundations, health plans, hospitals and health systems have turned to us to take care of them.

Chuck Alston senior vice president/director chuck.alston@mslgroup.com

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To Follow Up

Chuck Alston chuck.alston@mslgroup.com

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