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How the Affordable Care Act Impacts Patient Engagement

The signing of the Affordable Care Act brought the healthcare industry full-throttle into the age of patient-centered care and patient engagement.

The 2010 passage of the Affordable Care Act began a thorough overhaul of the healthcare system. Some states expanded Medicaid, consumers began to buy health insurance on federal and state health insurance exchanges, and healthcare professionals started to emphasize patient engagement.

Alongside these changes, the push for patient-centered healthcare and engagement gained significant traction. Between the expansion of healthcare coverage for previously uninsured patients, the implementation of patient engagement requirements, and providers’ own strategies for patient engagement, the ACA has served as a tipping point for healthcare.

The ACA made it easier for people to get health insurance

One of the direct results of the ACA’s passage was the opening of health insurance exchanges through which low-income individuals could purchase health plans for an affordable price. Because of this, the ACA enabled those who previously could not afford health insurance to gain coverage.

According to a 2015 report from the Hospital Corporation of America (HCA), the Affordable Care Act made it so previously uninsured individuals now were more responsible for their own healthcare.

Congress designed the ACA so that individuals who previously did not pay for care would take personal financial responsibility for that care. HCA’s data reveals that patients on the federally-facilitated Exchanges, unlike uninsured patients, make significant contributions to the cost of their treatment.  The ACA embodied a carefully-constructed ‘shared responsibility’ framework under which healthcare providers would shoulder some of the costs but also share in some of the benefits.  HCA’s data show that hospitals have taken significant cuts in federal reimbursements under the ACA, but that these cuts are beginning to be offset by new revenues from expanded Exchange insurance.

In theory, requiring patients to shoulder some of the burden of paying for their care will cause those patients to make smarter decisions about their health.

These patients will ideally stay on top of their treatment plans for chronic illnesses, take preventative actions, and make more cost-conscious decisions about utilizing services.

HCA’s data shows that enhancing patient responsibility had a positive effect on spending in the healthcare industry.

“In 2014, uninsured patients visited the ER approximately ten times for every inpatient admission,” the brief says.  “By contrast, individuals insured through the federally-facilitated Exchanges are visiting the EHR approximately three times for every inpatient admission.  Thus, HCA’s data indicate that uninsured patients are about 300% more likely than Exchange patients to rely on ER care.”

When uninsured patients rely on the emergency department for care, rather than selecting a more cost-effective and appropriate treatment option, it costs the hospital and the healthcare system more money. It also puts a high traffic burden on the ED.

When patients bear some of the responsibility, however, they are more likely to seek the appropriate method of treatment, putting less strain on the ED and making healthcare more cost effective for all parties involved.

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The ACA catalyzed the EHR Incentive Programs

Within the ACA were smaller initiatives supporting patient-centered healthcare, including the EHR Incentive Programs, also known as meaningful use.

The EHR Incentive Programs, a part of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, created a set of incentives for providers to adopt EHRs and use them in an effective manner. Patient engagement measures were included as part of the incentive requirements.  

As of present, the patient engagement provisions in Stage 2 meaningful use include the following:

  • One patient seen by an eligible provider during an EHR Incentive Program reporting period must view, download, or transmit their electronic health data.

  • One patient seen in an eligible hospital or critical access hospital during an EHR Incentive Program reporting period must view, download, or transmit their electronic health data.

Stage 3 meaningful use, which is optional for participants in 2017 and required by 2018, will consolidate patient engagement requirements into one overarching rule:

In the Stage 3 Patient Electronic Access Objective, we proposed to incorporate certain measures and objectives from Stage 2 into a single objective focused on providing patients with timely access to information related to their care. We also proposed to no longer require or allow paper-based methods to be included in the measures (80 FR 16753) and to expand the options through which providers may engage with patients under the EHR Incentive Programs. Specifically, we proposed an additional functionality, known as application programming interfaces (APIs), which would allow providers to enable new functionalities to support data access and patient exchange.

In order for providers to be successful with the patient engagement portion of meaningful use, they need to adopt a patient portal, which both allows  patients access to their health data and facilitates secure messaging between patient and provider.

However, simply possessing the portal is not enough. Providers need to get the patients to participate on the other side of the portal screen. Part of this involves adopting a patient portal which patients feel will serve their specific health needs.

“A patient portal that mostly provides administrative functions, such as scheduling appointments and getting lab results, will not be as interesting or useful to patients,” the agency says in an educational document aimed at helping with meaningful use attestation. “Patients will be more likely to use a portal that is designed and configured to address their personal interests and needs.”

Provider testimony is likewise critical for patient portal adoption. If the patient sees that their provider – whom they presumably trust – advocates for the technology, they will be more likely to adopt it.

“To simplify the portal registration process, have staff assist patients with the process, and consider providing a registration kiosk in the office,” ONC explained. “Staff can educate patients about how to use the portal’s features, and can offer guidance about the kinds of communication that are appropriate between providers and patients.”

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Providers adopted additional patient engagement strategies

Because the ACA and its related federal incentive programs, the push for value-based reimbursement, and population health management put a high emphasis on patient-centered care, healthcare providers have been forging their own individual patient engagement strategies because they have a financial incentive for doing so.

At DC-based MedStar Health, for example, hospital leaders are looking at how patients – or health consumers – have new needs when it comes to their healthcare.

“Consumer expectations have really increased,” said Michael Ruiz, vice president and chief digital officer for MedStar Health.

“Your expectation when you go to a healthcare system is that I should be able to find the doctor I need, get the appointment that I require, be able to get my way to that office in the most effective way possible, see that doctor with the smallest amount of wait, and be able to have an exceptional experience where I walk away from it having my issue resolved.”

As a response, MedStar began a program where they properly match a patient with a provider based upon a patient’s reported ailments. This means that a patient with shoulder pain will see an orthopedist who specializes in shoulders, not one who is an expert on knee replacements. This boosts patient satisfaction, allows the patient to engage properly with his or her provider, and makes good use of all parties’ time.

VCU Health has also been promoting patient engagement by taking advantage of their EHR-tethered patient portal. This has allowed its physicians, like Susan Wolver, MD, to help treat patients outside of the doctor’s office.

“[The patient portal] has absolutely changed the paradigm and the dialogue from episodic care to care in between those points,” said Wolver, an associate professor of internal medicine at VCU Medical Center. “Different providers take advantage of it in different ways, but for me it really has completely changed the way that I practice medicine.”

Because Wolver is able to directly message her patients about issues such as their blood sugar levels, she can adjust their insulin dosages accordingly, keeping them healthy between visits.

Patient portal use has also helped VCU Health patients stay on top of their own care. Because the portal allows them to gain access to their health data, the patients are able to stake a larger claim in their treatment.

“[The patients] feel that they are more participant in their care,” Wolver said. “They bring things to their providers that they may not have understood or known about before. I know all kinds of care that has been transformed because of the portal.”

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What if doctors achieved all of the ACA’s ideals?

As with most significant pieces of legislation, some of the ACA’s ideals may not have been realized. But what would healthcare look like if they had been?

A 2012 report from the Urban Institute and the Robert Wood Johnson Foundation paints a picture of that:

Nearly a decade after the Institute of Medicine (IOM) designated ―patient-centeredness as one of six goals for a 21st century health care system, the Patient Protection and Affordable Care Act (ACA) has mandated the use of measures of the quality of care, public reporting, and performance payments that reflect this ambitious aim. The law repeatedly refers to patient-centeredness, patient satisfaction, patient experience of care, patient engagement, and shared decision-making in its provisions. Even when the law only uses the more general term ―quality measures, patient-centered assessments are being required when these provisions are turned into regulations for specific programs such as with Medicare’s Value-Based Purchasing Program.

As detailed in that passage, the ACA included numerous patient-centered requirements and standards, all aligning with the IOM’s call for patient-centered care. Had providers managed to accomplish all of these mandates, and had they all gelled properly, healthcare would appear as a truly patient-first system.

Going forward, the ACA is shifting its approaches toward patient-centered care.

Most notably, providers are facing implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), which aims to promote more patient-centered healthcare.

Through its Merit-based Incentive Payment System and the Advancing Care Information program, MACRA is expected to help deliver more patient-centered healthcare.

These are measures that reflect the potential to improve patient-centered care and the quality of care delivered to patients. They emphasize the importance of collecting patient-reported data and the ability to impact care at the individual patient level, as well as the population level. These are measures of organizational structures or processes that foster both the inclusion of persons and family members as active members of the health care team and collaborative partnerships with health care providers and provider organizations or can be measures of patient-reported experiences and outcomes that reflect greater involvement of patients and families in decision making, self-care, activation, and understanding of their health condition and its effective management.

As full MACRA implementation looms, and the healthcare system continues to make revisions to meaningful use and the ACA, healthcare professionals will also fine-tune their patient engagement strategies. This will ideally result in a patient-centered healthcare system falling into place.

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