A BED'S EYE VIEW OF HEALTH REFORM

1. A BED'S EYE VIEW OF HEALTH REFORM The New Landscape and What it Means for Communicating with Patients Chuck Alston Senior Vice President/Director of Public Affairs MSL Washington DC

2. Today’s 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

4. We mean well, but sound scary Take Care With How You Talk About Health Care

5. The Way “We” Talk About Health Care

6. Do They Hear What You (Think You) Say? The new landscape of delivery and payment reform is covered with language landmines

7. Come Again? Source: Ross M, Igus T and Gomez S. “From Our Lips to Whose Ears? Consumer Reaction to Our Current Health Care Dialect.” ThePermanente Journal.13(1):8-16. 2009.

8. 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.” ThePermanente Journal. 2009;13(1):8-16.

9. 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

10. Reform Fatigue • Improvements, sure • Changes, maybe • But please, no more reform REFORM

11. 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.” ThePermanente Journal.13(1):8–16. 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.

12. Who’s 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.” ThePermanente Journal.13(1):8–16. 2009. • Talking About Health Care Payment Reform with U.S. Consumers. Princeton, N.J.: Robert Wood Johnson Foundation, 2011. (No authors given.)

13. The journey FROM Volume to value You Want to Go Where with My Health Care?

14. From Volume to Value This mantra works for: What could be wrong with that?

15. Just Ask Them They think Valu is a four letter word

16. What Value Looks Like People equate value with “bargain-basement pricing” not high-quality care

17. Health Care: I Don’t 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.

18. 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.

19. 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, sky’s the limit • Third-party payment system – patients only see their portion of the costs* * Let’s talk more about this later!

20. Park Your ACO in a Medical Home Garage Takeaways:Consumers resist being consumers when it comes to their health care • Consumers don’t want to talk about delivery system typology, or how doctors and hospitals are paid • They don’t know volume from value, and don’t want to • The get mad that money influences the way care is delivered Conclusion: Put the “We’re Your New Hometown ACO Campaign” on hold

21. So what, who cares, what’s in it for me? The Path to Patient-centered Messaging

22. 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.)

23. The Conversation About Care Starts Here The doctor-patient relationship is the foundation for messaging about quality improvement or delivery and payment reform. Start here and build out.

24. 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.)

25. What Do Patients Want? An ACO wrapped around a medical home. (Just don’t call it that.)

26. ENOUGH ABOUT WHAT NOT TO SAY The ABCs of Delivery Reform Communications

27. “It’s All About Me” • Patients want to hear what’s 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.

28. 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: • DON’T focus messaging on keeping people out of the hospital • DOfocus messaging on the solution—improving care for patients when they return home—because it will be seen as a benefit

29. 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 doctor’s recommendation Source: “Talking About Health Care Payment Reform with U.S. Consumers.” Princeton, N.J.: Robert Wood Johnson Foundation, 2011.

30. 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.

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

32. Patient engagement The Blockbuster Drug of the Century

33. Framing question When it comes to your patients, are you better off if you do things: TO THEM? FOR THEM? OR WITH THEM?

34. Framing question When it comes to your patients, are you better off if you do things: WITH THEM

35. 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 individual’s 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

36. 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

37. Even the Doctors Don’t Mind “Weeks after my visit, I thought, wasn’t 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 didn’t 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

38. 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

39. Communicating about medical evidence Put Evidence in the Context of Shared Decision-making

40. 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

41. 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

42. Put Evidence Under an Umbrella Concept Making an informed decision about the care that’s right for you

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. Finding Language that Resonates

50. Why Certain Language Resonates Source: Alston C, et al. “Communicating with Patients on Health Care Evidence.” Washington, D.C.: Institute of Medicine. September 2012