‘Patient engagement’ has been used as a general term to describe what patients do for their own health. What’s required for engagement? Motivation, either imposed on us (precipitating events like heart attacks can get people’s attention and motivate them to refine lifestyle habits–but not everyone, and not always), driven by personal values, or–for some–rewards.
Other factors matter as well. Health literacy–understanding basics like terms and body systems concepts is often necessary. Technology access and competence matter more and more: much of health care, information, and soon access too and purchasing of health services requires access to the Internet. Ethnicity, race and culture matter: ingrained cultural norms, differences in values, relationship approaches, language, information and activities between caregiver and patient can affect participation, engagement and outcomes. And perhaps the most profound driver of engagement is the tribal cohort factor: peer group activities shape and motivate what its members do.
Some things in health care can be done to a person, but most efforts in recovering and maintaining health and optimal function mean the person has to do something. The provider’s role is one of facilitation and limited intervention. So engagement (motivation) matters: the more I do on my own, the less I need others’ services–so the less I cost the system. “Patient engagement 1.0” has been defined and largely managed by system-side resources. But with the new, consumer-focused retail health care marketplace, the locus of power and control is shifting–and the basis for engagement is changing. We’re likely to see it substantially revised: “Patient Engagement 2.0.” What is it, and what can we do to be prepared?
In contrast to Western medicine’s mechanistic paradigm of controlling disease (the “fix me” model), doctors of chiropractic have long depended on patient engagement because the profession’s clinical and philosophic paradigm is so different. Education has always been important to DCs for an effective clinical relationship; the profession’s approach is fundamentally different in its role of supporting innate capacities for health and healing instead of exerting external controls over disease. While functional and neurologic losses from accident, subluxation and adaptation move many to seek the services of a chiropractor, symptoms aren’t an accurate indication of either problem or solution, so education–and successful engagement–is important.
But behavioral change isn’t easy. Research shows that those individuals who are activated on behalf of their own health (and wellness) do more (adopt and maintain healthier choices and habits) on their own. So efforts that lead to greater engagement result in lower costs. For those who design systems and processes to improve population health, identifying the elements that result in greater engagement is critical. One main biopsychosocial ‘transtheoretical model’ (often called the Prochaska model after Prochaska and DiClemente) has shaped efforts in this field for years. It uses a ‘stages of change’ continuum as a model, seeing each stage defined by barriers and requirements that need to be resolved before someone can move to the next–more permanent–stage.
The dominance of this model and its congruence with a mechanistic approach to health has contributed to an orthodoxy: the goal of working with someone whose risk-based status is elevated is to get that individual to the next (healthier) stage in behavioral change. This model acknowledges where a person is, but does not necessarily honor it; a risk tier is seen in actuarial terms as a liability. But in practice, an individual may not view themselves as being ‘stuck’ at a stage, but ‘living at that stage’ for deeply held, unconscious and self-reinforcing reasons. Getting someone to change when their ‘stage’ is deeply rewarding (even in negative ways) is difficult; external rewards often aren’t enough.
The difference between acknowledging where someone is and honoring where someone is fundamentally goes to the difference between mechanism and neo-vitalism. There is tacit, dismissive paternalism in acknowledging where someone is but then trying to help them move on, even if they consciously agree with the goal. Honoring where someone is in their growth and wholeness–even in the face of morbid pathology–permits the cultivation of internally-sourced health and healing. To honor someone’s place–with the presumption that there is an innate level of wisdom and accommodation at work–caregiver or coaching relationships require a type of respect that’s challenging when we’re trying to control ‘risk.’ The goal of the coach/provider is often to foster and support change; the goal of the patient/consumer is often to preserve the status quo. From the health system’s perspective, imposing a stage model over someone’s often-complex emotional ecosystem makes it tempting to see it inaccurately as a two dimensional problem.
Despite this deeply shaded picture of individual health, much good work is being done by those working with a mechanistic approach. Risk-based biometric tiering is a popular if not fully-understood model, and proponents can point to legitimate gains, improved biometrics, lowered costs, and by inference improved health. But if perspectives like the review in Dan Pink’s book Drive are to be believed, for sustained behavioral change the source of an individual’s motivation matters. As Dan reports, social science research tells us that in general extrinsic motivators (incentives) don’t tend to result in sustained behavioral change, but intrinsic motivators do. So acknowledging where someone is may be important; identifying barriers to change may be helpful; but honoring the innate intelligence behind where an individual is may hold much greater prospects for improved and sustained health and healing. The framing of questions shifts importantly, from ‘what do we need to do to get someone to change?’ to ‘what do we need to understand about how this person views their own health?’
What’s the relevance of all this in the new consumer-facing retail health care marketplace? In a new health care world where consumers are shopping for benefits and products online, paying more out of pocket than ever before, and seeking the greatest value they can (outcomes over costs), services, processes and therapeutic relationships that most effectively support health and healing will be the most successful. For some, the mechanistic model is fine. But for many others, what we’re likely to discover is that new approaches that honor health as being intrinsically present and which explore how to cultivate further, intrinsically-driven strategies to achieve individualized goals will become more and more important–and potentially winners in the marketplace.
How do we anticipate this and work toward it? I believe there are four basic things we should be working toward as a way of improving population health.
- Emulate retailers. When I walk into Target (and most stores), I don’t get messages about what I don’t have; I get messages (implicit and explicit) about how good I’ll feel if I buy something. Stores are rewarded to the extent they are able to help cultivate that longing in me to feel better. Risk tiering forces people to think of themselves as defective, and despite the impact of shame, fostering that self-image rarely creates sustained behavioral change.
- Make explicit social contracts with shared power. Health care is becoming more ‘retailized’ with online shopping, comparison tools, user reviews and ratings, etc. The ‘shared power’ position retail shoppers increasingly demand is relevant in health care, too, and the markedly different values and expectations of the Millennial demographic simply won’t tolerate system-side solutions that don’t support this requirement.
- Honor and respect personal values. At a conference a few years ago, Don Berwick (former head of CMS) gave a very personal account of what it was like for him as he sought to get knee pain addressed. It took a series of providers (and unsuccessful therapies) before someone asked him, ‘what does this keep you from doing?’ His answer–his insight and his motivation–was that while in pain, he could not walk some distance to a favorite, quiet forest glade and listen to the birds. That admission–and the provider’s willingness to honor it–framed what services were then required and set the healing process in motion.
- Evaluate health and wellness by more complex data models. As powerful, important and orthodox as risk-based actuarial tables are, ‘a person isn’t a risk tier.’ It’s inarguable that the US health care system has terrible, expensive outcomes when compared with many other countries, and one very possible reason for this is that we’re asking the wrong questions about what makes someone healthy and “well.” The so-called ‘big data’ movement sees opportunities in exploring new insights gleaned from very complex data relationships. In a retail health care marketplace with consumers activated by their own economic self-interest, new data acquisition, analysis and stewardship models are likely to yield important insights as a basis for improving population health. Are we asking the right questions of people about their own health? Are we asking the right questions of ourselves about how we’re responding?
‘Patient Engagement 2.0’ is, at present, a fuzzy concept, because the health care marketplace still is likely to undergo some convulsive and disruptive changes before the supply and demand dynamic of retail is ‘normalized’ into health care. But make no mistake: it is coming. Establishing a strategic understanding of each stakeholder’s version of this future can permit analysis and comparison of current efforts, and help design effective plans to shift and effectively anticipate these unavoidable changes.