Presented by Susan Dentzer, MA, on March 12, 2015 at the fifth Center for Health Literacy Conference: Plain Talk in Complex Times.

1. Plain Talk with US Consumers and Patients:
Achieving the Triple Aim
Presentation by Susan Dentzer
Senior Policy Adviser to the Robert Wood Johnson Foundation
To Maximus Plain Talk Conference – March 12, 2015

2. This Presentation at a Glance
 Achieving the Triple Aim: Needed now more than ever
 How do we talk with patients/consumers about
 Changes in insurance coverage, delivery and payment
 Appropriateness of care
 Cost and quality of care
 Being proactive about their health and care
 “Plain Talk” is necessary but not sufficient; other strategies
to improve communication also important
 Case Examples
 Some conclusions

3. The Triple Aim
 Better health
 Better health care
 Lower cost
 Core principle at heart of
Affordable Care Act and major
U.S. payment and delivery
system reform efforts that
have followed
 Better communication central
to achieving these goals
Donald Berwick, MD
Former Administrator
Centers for Medicare
and Medicaid Services

4. Scope of the Communications
Problem
 Nearly 9 in 10 adults have
difficulty using everyday
health information broadly
available in health care
facilities, communities,
media
 Source: Health Literacy: A Prescription
to End Confusion. Institute of
Medicine, 2004

5. “Universal Precautions” Approach
 Adopted from infectious
disease field
 Notion that clear
communication should be
basis for all exchanges of
health information
 Source: National Action Plan to Improve
Health Literacy, 2010

6. But the Problem Cuts Two Ways
 75 percent of orthopedic
surgeons surveyed believed
that they communicated
satisfactorily with patients
 Only 21% of their patients
reported satisfactory
communication with their
doctors
 Source: JR Tongue et al, Journal of Bone Joint
Surgery Am. 2005; 87:652-658

7. Patient Engagement
First-ever
National
Quality
Strategy,
mandated
by the
ACA

9. Confusion over health insurance

11. Explaining health insurance coverage
 Many enrolling in coverage under ACA have obtained it for
first time
 When explaining health coverage to consumers, critical to
confirm that they understood what was said – e.g.,
“deductible,” “co-pay”
 Ideally should explain back concepts in their own words
(teach-back method)
 If they still don’t understand, use other concepts to convey
meaning
 Source: IOM Discussion Paper, K Patel et al, “Helping Consumers Understand and
Use Health Insurance in 2014.”

12. HealthCare.gov gets better – and clearer

13. Communicating with patients
about their care

14. Realities of Patient-Physician
Communication
Source: The Decisions Study: Medical Decision Making, 2010,
30 Supplement I

15. Patient Satisfaction on Physicians, University
of Utah
© 2014 Press Ganey
Associates, Inc.

16. Shared Decision Making
 “A collaborative process that
allows patients and their
providers to make health
care decisions together…
 “..taking into account the
best available scientific
evidence …
 “..as well as the patient’s
values and preferences.”
 Incorporated into Affordable
Care Act, but as yet not
widespread
 Source: informedmedicaldecisions.org

17. Patients Want Shared Decision Making But
Are Afraid
 Focus groups run by Dominick Frosch and colleagues at
Palo Alto Medical Foundation
 Patients strongly embraced shared decision making but felt
trapped in “socially sanctioned roles” – e.g., deference to
physicians
 Found many physicians authoritarian
 Feared being categorized as “difficult” patients
 Source: DL Frosch et al, Health Aff, May 2012, vol. 31 no. 5, pp. 1030-1038

18. Shared Decision Making:
Process and Tools

19. Shared Decision Making at Group Health
 Over six months, use of decision aids associated with
26 percent fewer hip replacement surgeries
 38 percent fewer knee replacements
 12-21 percent lower costs
Source: D Arterburn et al, Health Affairs, September 2012

20. Angelo Volandes & Aretha Davis,
Harvard Medical School
Advance Care Planning Decisions
Videos at acpdecisions.org

21. Shared Decision Making at Mayo Clinic

22. Communicating with patients about
inappropriate care

23. “Choosing Wisely” Survey,
2014
 73 percent of physicians said the
frequency of unnecessary tests and
procedures is a “very or somewhat
serious problem.”
 53 percent say that even if they
know a medical test is
unnecessary, they order it if a
patient insists.
 72 percent of physicians say the
average medical doctor prescribes
an unnecessary test or procedure
at least once a week.
 (PS: They blame malpractice)

24. “Choosing Wisely” Campaign
 Launched by American Board of Internal Medicine
Foundation
 More than 35 specialty societies participating
 Developed lists: Five Things Physicians and Patients
Should Question – for each
 Examples: colonoscopy; imaging for a headache; pre-term
induction of labor; white blood cell growth factors or
colony-stimulating factors (CSFs) to boost white blood cells
during cancer chemotherapy
 www.choosingwisely.org

26. Activating patients about their health
and heath care

27. Patient Engagement and Activation
 Engagement = actions that
people take for their health or
health care
 Activation = understanding
own role in care process and
having knowledge, skills and
confidence to take it on
 Increasingly understood as a
distinguishable factor in
achieving Triple Aim

28. Patient Activation Measure
 Gauges the knowledge, skills and confidence essential to
managing one’s own health and healthcare
 13-item questionnaire; patients rate selves on a scale
 Statements include
 “When all is said and done, I am the person who is responsible
for managing my health condition.
 “I am confident that I can take actions that will help prevent
or minimize some symptoms or problems associated with my
health condition.
 “I know what each of my prescribed medications do.”
 Measure segments consumers into one of four progressively
higher activation levels

29. Patient Activation Measure
 Patient activation and the “3 M’s”
 It can be measured
 It can be moved – patients’ low scores can be improved via
engagement over time
 It matters – the degree to which patients are activated
predicts their factors such as their success in medication
adherence, use of emergency department, and their
likelihood of having avoidable readmissions
 Source: JH Hibbard, J Greene, Health Aff, Feb. 2013 vol 32 no. 2, 207-214

30. Engaging the Seriously Disabled
 Minnesota-based Courage
Kenney Rehabilitation
Institute serves disabled
and injured
 Has substantially raised
Patients’ Activation
Measure scores
 Reducing hospital stays
for this population by 71%


31. Technology to Support Communication and
Patient Engagement

32. Disruptive Technologies
 Digital health, mhealth
(mobile), apps
 Pushing care out of
institutions and into homes
and offices
 Enabling more self care
 Engaging patients and
enhancing sense of
knowledge, confidence,
activation

33. Physicians and founders Tom Delbanco and Jan Walker,
Beth Israel Deaconess Medical Center, Boston
Started giving patients access to physicians’ notes through EHRs

34.  12-month pilot of patients at Beth Israel Deaconess,
Geisinger, and Harborview Medical Center, Seattle WA
 77-87 percent of patients who opened at least one note
reported feeling more in control of their care
Source: Annals of Internal Medicine, Oct. 2012

35. New entrants into health care: Apple
 Apple Health dashboard allows
consumers to compile and view health
care information
 Apple’s HealthKit: new platform for
health apps
 Apple Watch has heart rate sensors;
annual sales of 485 million predicted
 Link with Epic EHR
 Exploring incorporation of blood pressure
and glucose monitoring into iPhone

36. “Symple” Symptom Tracker and
Health Diary
Natasha
Gajewski,
Founder,
Symple Health

37. Ease of communication
with doctors

38. Mobile Health: Text4Baby – free mobile text
messages

39. Big White Wall
• Safe online community
• Professionally led support groups
• Ability to speak to clinician in real time
• Affiliations with National Health Service in England; Kaiser Permanente
• See video at http://www.bigwhitewall.com/landing-pages/landingV3.aspx#.VPiBKLPF-yw

40. Some conclusions

41. Context Matters

42. “Think like a wise man but communicate in
the language of the people.”
--William Butler Yeats

43. “The good physician treats the disease; the great
physician treats the patient who has the disease.”
--William Osler, one of four founding professors of
Johns Hopkins Hospital

44. The End