Beneficiary activation in the Medicare population

Evaluating the relationship between patient activation and health-related quality of life (HRQOL) in patients with pancreatic cancer (PwPC)

PURPOSE

Advanced pancreatic cancer is synonymous with a high mortality rate, debilitating symptom profile, and minimal prolongation in overall survival. Therefore, health-related quality of life (HRQOL) is important in patients with pancreatic cancer (PwPC). In chronic conditions, patient activation is positively associated and higher HRQOL. However, no known study has evaluated patient activation, HRQOL, and their association in PwPC.

METHODS

A 43-item cross-sectional survey assessed patient activation and HRQOL of patients with locally advanced and metastatic pancreatic cancer undergoing chemotherapy. Variables were analyzed descriptively, and relationships were assessed using bivariate statistics (sig p < 0.05).

RESULTS

Fifty-six patients participating in the study had an average age of 69.5 ± 11.1 years, and the majority were females (51.8%), Caucasians (61.8%), married/partnered (64.3%), and had at least a college degree (59%). Almost half were at stage 4 (48.2%), and most were newly diagnosed (66.1%). Mean patient activation score was 63.5 ± 17.2 (scale range: 0-100), with most at higher activation levels of 3 or 4 (66.7%). Mean HRQOL score of 41.0 ± 12.7 (scale range: 0-72) was low. Patient activation levels, age, education level, and gender explained 21% of variation in overall HRQOL scores. Patients at activation level 4 had significantly higher overall HRQOL versus those at lower activation (level 1 or 2). Higher patient activation was significantly associated with having either private insurance only or multiple insurances and being partnered.

CONCLUSION

Patient activation significantly predicted HRQOL in PwPC despite the low sample size. Initiatives to increase patient activation should focus on patients of low socioeconomic status and those without partner support.

Obesity and Patient Activation: Confidence, Communication, and Information Seeking Behavior

INTRODUCTION/OBJECTIVES

Patient activation describes the knowledge, skills, and confidence that allow patients to actively engage in managing their health. Prior studies have found a strong relationship between patient activation and clinical outcomes, costs of care, and patient experience. Patients who are obese or overweight may be less engaged than normal weight patients due to lower confidence or stigma associated with their weight. The objective of this study is to examine whether weight status is associated with patient activation and its sub-domains (confidence, communication, information-seeking behavior).

METHODS

This repeated cross-sectional study of the 2011 to 2013 Medicare Current Beneficiary Survey (MCBS) included a nationally representative sample of 13,721 Medicare beneficiaries. Weight categories (normal, overweight, obese) were based on body mass index. Patient activation (high, medium, low) was based on responses to the MCBS Patient Activation Supplement.

RESULTS

We found no differences in overall patient activation by weight categories. However, compared to those with normal weight, people with obesity had a higher relative risk (RRR 1.24; CI 1.09-1.42) of "low" rather than "high" confidence. Respondents with obesity had a lower relative risk (RRR 0.82; CI 0.73-0.92) of "low" rather than "high" ratings of communication with their doctor.

DISCUSSION AND CONCLUSIONS

Though patients with obesity may be less confident in their ability to manage their health, they are more likely to view their communication with physicians as conducive to self-care management. Given the high receptivity among patients with obesity toward physician communication, physicians may be uniquely situated to guide and support patients in gaining the confidence they need to reach weight loss goals.

Vision Impairment and Patient Activation among Medicare Beneficiaries

PURPOSE

Low patient activation is associated with poor patient outcomes. People with vision impairment may have low patient activation as a result of communication and access barriers. We examined the association of patient activation with vision impairment.

METHODS

Cross-sectional study using the 2016 Medicare Current Beneficiary Survey. Older Medicare beneficiaries, without dementia, who completed the topical patient activation questionnaire were included. The primary exposure was self-reported vision impairment (no vision impairment, a little vision impairment, a lot of vision impairment), and the secondary exposure was dual sensory impairment (no sensory impairment, vision impairment only, hearing impairment only, dual sensory impairment). Patient activation scores were categorized as low, moderate, or high based on their distribution around the mean. Multivariable-adjusted ordinal regression models examined the association of patient activation with vision impairment, and then with dual sensory impairment.

RESULTS

In total, 6,683 participants were included. Those with a little vision impairment had 20% lower odds of higher patient activation (odds ratio [OR] = 0.80, 95% confidence interval [CI] = 0.71-0.90), and those with a lot of vision impairment had 26% lower odds of higher patient activation (OR = 0.74, 95% CI = 0.55-0.98). In the second model, having vision or hearing impairment only was associated with lower odds of higher activation than having no sensory impairment. Having dual sensory impairment was associated with even lower odds of higher activation.

CONCLUSION

Older Medicare beneficiaries with sensory impairment may be a group to target to improve patient activation levels, which could potentially improve health outcomes and health care utilization patterns in this population.

Patients' Perceptions of Integrated Care Among Medicare Beneficiaries by Level of Need for Health Services

Requirements for integrating care across providers, settings, and over time increase with patients' needs. Health care providers' ability to offer care that patients experience as integrated may vary among patients with different levels of need. We explore the variation in patients' perceptions of integrated care among Medicare beneficiaries based on the beneficiary's level of need using ordinary least square regression for each of four high-need groups: beneficiaries (a) with complex chronic conditions, (b) with frailties, (c) below 65 with disability, and (d) with any (of the first three) high needs. We control for beneficiary demographics and other factors affecting integrated care, and we conduct sensitivity analyses controlling for multiple individual chronic conditions. We find significant positive associations with level of need for provider support for self-directed care and medication and home health management. Controlling for multiple individual chronic conditions reduces effect sizes and number of significant relationships.

Differences in patient perceptions of integrated care among black, hispanic, and white Medicare beneficiaries

OBJECTIVE

This study sought to identify potential disparities among racial/ethnic groups in patient perceptions of integrated care (PPIC) and to explore how methodological differences may influence measured disparities.

DATA SOURCE

Data from Medicare beneficiaries who completed the 2015 Medicare Current Beneficiary Survey (MCBS) and were enrolled in Part A benefits for an entire year.

STUDY DESIGN

We used 4-point measures of eight dimensions of PPIC and assessed differences in dimensions among racial/ethnic groups. To estimate differences, we applied a "rank and replace" method using multiple regression models in three steps, balancing differences in health status among racial groups and adjusting for differences in socioeconomic status. We reran all analyses with additional SES controls and using standard multiple variable regression.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

We found several significant differences in perceived integrated care between Black versus White (three of eight measures) and Hispanic versus White (one of eight) Medicare beneficiaries. On average, Black beneficiaries perceived more integrated support for self-care than did White beneficiaries (mean difference = 0.14, SE = 0.06, P =.02). Black beneficiaries perceived more integrated specialists' knowledge of past medical history than did White beneficiaries (mean difference = 0.12, SE = 0.06, P =.01). Black and Hispanic beneficiaries also each reported, on average, 0.18 more integrated medication and home health management than did White beneficiaries (P <.01 and P <.01). These findings were robust to sensitivity analyses and model specifications.

CONCLUSIONS

There exist some aspects of care for which Black and Hispanic beneficiaries may perceive greater integrated care than non-Hispanic White beneficiaries. Further studies should test theories explaining why racial/ethnic groups perceive differences in integrated care.

Patient Experiences of Integrated Care in Medicare Accountable Care Organizations and Medicare Advantage Versus Traditional Fee-for-Service

BACKGROUND

Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare.

OBJECTIVE

To characterize patient experiences of integrated care within Medicare and identify whether MA or ACO beneficiaries perceive greater integration than FFS beneficiaries.

DESIGN

Retrospective cross-sectional analysis of the 2015 Medicare Current Beneficiary Survey.

SUBJECTS

Nationally representative sample of 11,978 Medicare beneficiaries.

MEASURES

Main outcomes included 8 previously derived domains of patient-perceived integrated care (PPIC), measured on a scale of 1-4.

RESULTS

The final sample was 55% female with a mean (SD) age of 71.1 (11.3). In unadjusted analyses, we observed considerable variation across PPIC domains in the full sample, but little variation across subsamples defined by coverage type within a given PPIC domain. In linear models adjusting for a rich set of patient characteristics, we observe no significant benefits of ACOs nor MA relative to FFS, a finding which is robust to alternative specifications and adjustment for multiple comparisons. We similarly observed no benefits in subgroup analyses restricted to states with relatively high market penetration of ACOs or MA.

CONCLUSIONS

Despite characteristics of ACOs and MA that theoretically promote integrated care, we find that PPIC is largely similar across coverage types in Medicare.

Difficulty Hearing Is Associated With Low Levels of Patient Activation

BACKGROUND/OBJECTIVES

Patient activation encompasses the knowledge, skills, and confidence that equip adults to participate actively in their healthcare. Patients with hearing loss may be less able to participate due to poor aural communication. We examined whether difficulty hearing is associated with lower patient activation.

DESIGN

Cross-sectional study.

SETTING/PARTICIPANTS

A nationally representative sample of Americans aged 65 years and older (n = 13 940) who participated in the Medicare Current Beneficiary Survey (MCBS) during the years 2011 to 2013.

MEASUREMENT

Self-reported degree of difficulty hearing ("no trouble," "a little trouble," and "a lot of trouble") and overall activation based on aggregated scored responses to 16 questions from the MCBS Patient Activation Supplement: low activation (below the mean minus 0.5 SDs), high activation (above the mean plus 0.5 SDs), and medium activation (the remainder). Sociodemographic and self-reported clinical measures were also included.

RESULTS

"A little trouble" hearing was reported by 5655 (40.6%) of respondents, and "a lot of trouble" hearing was reported by 893 (6.4%) of respondents. Difficulty hearing was significantly associated with low patient activation: in analyses using multivariable multinomial logistic regression, respondents with "a little trouble" hearing had 1.42 times the risk of low vs high activation (95% confidence interval [CI] = 1.27-1.58), and those with "a lot of trouble" hearing had 1.70 times the risk of low vs high activation (95% CI = 1.29-2.11), compared with those with "no trouble" hearing.

CONCLUSIONS

Nearly half of people aged 65 years and older reported difficulty hearing, and those reporting difficulty were at risk of low patient activation. That risk rose with increased difficulty hearing. Given the established link between activation and outcomes of care, and in view of the association between hearing loss and poor healthcare quality and outcomes, clinicians may be able to improve care for people with hearing loss by attending to aural communication barriers.

Increased Prevalence of Concomitant Psychiatric Diagnoses Among Patients Undergoing Hip Arthroscopic Surgery

Background

Active patients with musculoskeletal pain are not immune to psychological or psychiatric disease. Observations suggest that patients undergoing hip arthroscopic surgery may have an increased prevalence of comorbid psychiatric conditions.

Hypothesis

Patients undergoing hip arthroscopic surgery have an increased prevalence of concomitant psychiatric diagnoses compared with the general population as well as those undergoing anterior cruciate ligament (ACL) reconstruction.

Study Design

Case-control study; Level of evidence, 3.

Methods

A retrospective review of a medical claims database spanning from 2007 to 2016 was utilized to identify patients with a Current Procedural Terminology (CPT) code indicating that they had undergone hip arthroscopic surgery. This group was then dichotomized to those with or without an International Classification of Diseases, 9th Revision (ICD-9) and 10th Revision (ICD-10) diagnosis code indicating a psychological or psychiatric condition at any time before hip arthroscopic surgery or up to 2 years after hip arthrscopic surgery. As a control, ICD-9 and ICD-10 diagnosis codes for psychological or psychiatric conditions were determined in patients without a CPT code for hip arthroscopic surgery (general population) as well as for 2 surgical groups: those undergoing ACL reconstruction and those undergoing shoulder stabilization surgery. Prevalence was determined in all groups and compared using chi-square analysis.

Results

There were 22,676,069 patients in the database, with 2428 undergoing hip arthroscopic surgery. Those undergoing hip arthroscopic surgery had a 3-fold increased prevalence of concomitant psychiatric diagnoses compared with the general population (52% vs 17%, respectively; P < .0001). There was a significant difference in the prevalence of psychiatric diagnoses in the hip arthroscopic surgery group between male and female patients (46% vs 56%, respectively; P = .0061), with depression and anxiety being the 2 most common comorbid conditions. Those undergoing hip arthroscopic surgery also had a significantly increased prevalence of concomitant psychiatric diagnoses versus those undergoing ACL reconstruction (52% vs 28%, respectively; P < .0001) as well as those undergoing shoulder stabilization surgery (52% vs 42%, respectively; P < .0001).

Conclusion

Patients undergoing hip arthroscopic surgery had an increased prevalence of comorbid psychiatric conditions compared with the general population as well as those undergoing ACL reconstruction or shoulder stabilization surgery. Depression and anxiety were the most prevalent concomitant psychiatric diagnoses.

Functional Impairments Associated With Patient Activation Among Community-Dwelling Older Adults

OBJECTIVES

Activity of daily living stages and instrumental activity of daily living stages demonstrated ordered associations with mortality, risk of hospitalization, and receipt of recommended care. This article explores the associations of stages with the following three dimensions of patient activation: self-care efficacy, patient-doctor communication, and health-information seeking. We hypothesized that higher activity of daily living and instrumental activity of daily living stages (greater limitation) are associated with a lower level of patient activation.

METHODS

Patient activation factors were derived from the 2004 and 2009 Medicare Current Beneficiary Survey. In this cross-sectional study (N = 8981), the associations of activity limitation stages with patient activation factors were assessed in latent factor models.

RESULTS

Greater activity limitation was in general inversely associated with self-efficacy, patient-doctor communication, and health information seeking, even after adjusting for sociodemographic and clinical characteristics. For instance, the mean of self-care efficacy across activity of daily living stages I-IV (mild, moderate, severe, and complete limitation) compared with stage 0 (no limitation) decreased significantly by 0.17, 0.29, 0.34, and 0.60, respectively. Covariates associated with suboptimal patient activation were also identified.

DISCUSSION

Our study identified multiple opportunities to improve patient activation, including providing support for older adults with physical impairments, at socioeconomic disadvantages, or with psychological or cognitive impairment.

Transformation of the Health Care Industry: Curb Your Enthusiasm?

Policy Points: Policymakers seek to transform the US health care system along two dimensions simultaneously: alternative payment models and new models of provider organization. This transformation is supposed to transfer risk to providers and make them more accountable for health care costs and quality. The transformation in payment and provider organization is neither happening quickly nor shifting risk to providers. The impact on health care cost and quality is also weak or nonexistent. In the longer run, decision makers should be prepared to accept the limits on transformation and carefully consider whether to advocate solutions not yet supported by evidence.

CONTEXT

There is a widespread belief that the US health care system needs to move "from volume to value." This transformation to value (eg, quality divided by cost) is conceptualized as a two-fold movement: (1) from fee-for-service to alternative payment models; and (2) from solo practice and freestanding hospitals to medical homes, accountable care organizations, large hospital systems, and organized clinics like Kaiser Permanente.

METHODS

We evaluate whether this transformation is happening quickly, shifting risk to providers, lowering costs, and improving quality. We draw on recent evidence on provider payment and organization and their effects on cost and quality.

FINDINGS

Data suggest a low prevalence of provider risk payment models and slow movement toward new payment and organizational models. Evidence suggests the impact of both on cost and quality is weak.

CONCLUSIONS

We need to be patient in expecting system improvements from ongoing changes in provider payment and organization. We also may need to look for improvements in other areas of the economy or to accept and accommodate prospects of modest improvements over time.

Spotlight on the Patient Health Engagement model (PHE model): a psychosocial theory to understand people's meaningful engagement in their own health care

The concept of patient engagement in health care is gaining more and more attention not only in the scientific literature, but also as a requirement in the everyday practices of health care organizations. In general terms, the growing body of literature devoted to patient engagement is mainly inspired by the sociological and public health perspectives, which have generated various theories and models trying to explain how people become active agents in their health and care management. However, theories focusing on the psychosocial dimensions intervening in the patient engagement experience are still limited. This paper proposes a psychosocial perspective on patient engagement and discusses the Patient Health Engagement model, which is an evidence-based psychological theory built on extensive qualitative narrative research and literature analysis aimed at explaining patient engagement and its development in the patients' perspective. The model has been applied to orient patient and professional educational interventions and has contributed to the generation of the first scientific measure of the psychological experience of patients' engagement in their own care (Patient Health Engagement scale). According to this theory, patient engagement is a developmental process that involves the recovered patients' ability to have a life projectuality and goal directedness - even if living with a disease. The paper will also discuss the theoretical origins of this model and will conduct a critical comparison of the theory with the Transtheoretical Model of Change developed by Prochaska and the five-stage grief theory by Kubler-Ross.

Health Risk Appraisals With Aging Adults: An Integrative Review

Identification of risk factors unique to the aging experience is vital to support health promotion efforts and prevent loss of independence for the increasing aging population. Health risk appraisals are tools capable of identifying a broad range of factors that affect health; however, these tools were designed for use with predominantly healthy working-age adults. The purpose of this integrative review was to describe uses and adaptations of health risk appraisals with aging adults. A total of 43 articles met inclusion criteria, identifying multiple adaptations necessary to effectively identify the risks faced by aging adults, including those related to activities of daily living, pain, depression, social support/network, vision, hearing, and cognitive status. Uses included support for health promotion efforts and to determine risk for depression, falls, and loss of independence. Further research needs to be done to evaluate impact when used as a health promotion and prevention tool for aging adults.

Examining patient-provider relationship (PPR) quality and patient activation in the Medicare population

BACKGROUND

Patient activation describes an individual's willingness and ability to take actions to independently manage health. Additional qualities of the relationship between a patient and provider may play a role in patient decision-making and motivation.

AIMS

(1) To describe patient characteristics for groups who perceive different quality levels of PPR. (2) To examine the association and determine the effect of PPR on patient activation.

METHODS

The Medicare Current Beneficiary Surveys was used to gather information on patient confidence, information seeking behaviors, and PPR. Scores for each variable set were categorized and described. Odds ratios were calculated using multinomial logistic regression models adjusting for sociodemographic variables.

RESULTS

The study included 15,185 beneficiaries, 4198 (27.6 %) were categorized as low PPR, 6752 (44.5 %) were moderate PPR, and 4235 (27.9 %) high PPR. Adjusting for covariates, patients with moderate PPR and high PPR were more likely to have higher confidence when making healthcare decisions and exhibit information seeking behaviors compared to low PPR beneficiaries.

DISCUSSION

This study supports the notion that patients with stronger relationships with their providers are also more active in healthcare decisions. After adjusting for gender, race, age, education, and income, high-quality PPR was still found to be associated with increased levels of activation in the Medicare population.

CONCLUSIONS

High-quality patient-provider relationships are associated with improved patient confidence and information seeking behaviors. Provider-centered strategies to improve patients' connections to their physicians may motivate patients to engage in the healthcare process.

Personalized Strategies to Activate and Empower Patients in Health Care and Reduce Health Disparities

Designing culturally sensitive personalized interventions is essential to sustain patients' involvement in their treatment and encourage patients to take an active role in their own health and health care. We consider patient activation and empowerment as a cyclical process defined through patient accumulation of knowledge, confidence, and self-determination for their own health and health care. We propose a patient-centered, multilevel activation and empowerment framework (individual-, health care professional-, community-, and health care delivery system-level) to inform the development of culturally informed personalized patient activation and empowerment (P-PAE) interventions to improve population health and reduce racial and ethnic disparities. We discuss relevant Affordable Care Act payment and delivery policy reforms and how they affect patient activation and empowerment. Such policies include Accountable Care Organizations and value-based purchasing, patient-centered medical homes, and the community health benefit. Challenges and possible solutions to implementing the P-PAE are discussed. Comprehensive and longitudinal data sets with consistent P-PAE measures are needed to conduct comparative effectiveness analyses to evaluate the optimal P-PAE model. We believe the P-PAE model is timely and sustainable and will be critical to engaging patients in their treatment, developing patients' abilities to manage their health, helping patients express concerns and preferences regarding treatment, empowering patients to ask questions about treatment options, and building up strategic patient-provider partnerships through shared decision making.