Category: Masters series

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Effectively Measuring Patient Engagement: An Investigation Into Patient Engagement And The Patient Activation Measure

Posted on by Grayson

For the month of April, I shared pieces I wrote in the process of obtaining my MS in Health Care Administration which I finished up this past fall. I wanted to wrap that up by sharing a teaser of my capstone which is available at my Academia site. Enjoy!

Abstract

This capstone project involves observing how patient activation/engagement and the Patient Activation Measure (PAM) are written about and evaluated. The research presented draws from peer-reviewed journal articles. The hypothesis of this work is that patient activation is beneficial as studied by trustworthy sources. This is true regardless of one’s place within healthcare and should be both implemented and studied more thoroughly. Findings suggest that, while the Patient Activation Measure is useful to measure activation, it is not a comprehensive tool. PAM is not optimized for a variety of marginalized identities including race and ethnicity. The findings of this capstone are useful for educational purposes. Additionally, this project can serve as the basis for additional research.
Keywords: Health Care Administration, Derrick Suehs, patient engagement, patient activation, and the patient activation measure.

Project Overview

The aim of this project is to conduct a case study on furthering patient engagement in health care by investigating current research and best practice information on patient engagement and activation. Also, this project will discuss the potential benefits and disadvantages of full patient engagement from the perspectives of patients, healthcare practitioners, and health systems. The paper will be organized to examine potential benefits of patient engagement for the patient first, then the provider, and finally the health system. This is a Health Care Concept Paper that will have relevance to nearly all stakeholders in health care, from patients to practitioners to insurance companies. Patient engagement is an important topic about which there is some controversy regarding responsibility and efficacy of implementation. This project will help to educate various stakeholders in healthcare regarding the terms utilized in the patient engagement realm, potential benefits of patient engagement, limitations of engagement, and findings of the latest research on the subject. While this aim is broad, the impact of this issue is broad as well. In the end, this project will be aimed primarily at patients, healthcare providers, and administrators within care systems.

The proposed hypothesis for this capstone is two parts: 1) that patient engagement is beneficial overall for stakeholders in healthcare, especially patients, providers, and health systems, and, 2) the patient activation measure is an effective tool for measuring engagement. By exploring the various research studies, the reader will develop a more complete understanding of patient engagement.

While most healthcare organizations experience difficulties in making changes while putting patient satisfaction programs in place, the benefits outweigh the negatives. From an economic standpoint, the pay-for-performance principle instituted by the Patient Protection and Affordable Care Act (PPACA) is a significant vehicle for moving healthcare toward a purposeful focus on clinical quality outcomes and patient experience.

Cost is expected to increase in the short-term while healthcare organizations implement interventions to improve the patient experience. In the long-term, these costs should decrease as patient engagement becomes the norm. Organizations are working to set up systems to measure the efficacy of these efforts.
There remain challenges in improving the results of interventions. Differences in experiences for racial and ethnic groups are still reported (Welnick, et al., 2011). These differences also occur with education status, socioeconomic status, gender identity, sexual orientation, age, and other factors (Millenson, 2016).

Context

The Patient Protection and Affordable Care Act

In March of 2010, the PPACA was signed into law (Healthcare.gov, 2010). Two of the biggest assets for consumers were the requirements for insurance plans to cover people with “pre-existing health conditions, including pregnancy, without charging more” and making it “illegal for health insurance companies to cancel your health insurance just because you get sick” (Healthcare.gov, n.d.). Additional benefits included giving younger adults the ability to stay on their parents’ insurance plans up to age 26, education about the coverage a patient is receiving, and regulations placed on insurance companies surrounding increasing premium rates (Healthcare.gov, n.d.).

One of the strategies of the PPACA is the “shifting from a reimbursement system based on the volume of services provided to one based on the value of care” (Abrams, et al., 2015). The shift to pay-for-performance has been an effective way to put an intense focus on improving quality in all elements of healthcare. Sending a “clear signal to providers that they will need to adapt quickly to incentives that reward appropriate, high-quality care and good patient outcomes” has begun to spark improvements (Abrams, et al., 2015). Since December 2015, Medicare has been planning to assess penalties to “758 hospitals that had high rates of patient safety incidents” (Prina, 2016, p. 375).

On a national level, the PPACA produced more patient-focused outcome measurements and surveys aimed at providing more opportunities for patients to be engaged in healthcare. Additionally, it contributed to the creation of PCORI – the Patient-Centered Outcomes Research Institute (Willis Towers Watson, 2012). PCORI aims to not only bring the voice of the patient into research projects but to ensure research is accessible to everyone (PCORI, 2014). To accomplish this, PCORI provides funding for patient-centered research, takes suggestions for research topics from patients, and includes patients on all advisory boards.

Patient Activation and Engagement

The populations most affected by issues of patient
engagement are providers and patients. Patients of all kinds, but especially those with multiple health concerns or complex conditions, can be influenced by paternalism which subordinates a patient’s free will and informed consent to what a provider might choose. Dangers associated with the practice of paternalism include overlooking the costs associated with treatments, treatments that will not work for a patient’s lifestyle, and treatments that are more likely to cause contraindications and side effects. These consequences lead to a lack of adherence or compliance in care, be it not taking medications as prescribed or skipping lab work and followup appointments.

The historical tradition of paternalism in medicine makes it difficult for patients and providers. Health care practitioners and administrators who support the continued development of patient engagement strategies recognize that there are a vast number of roadblocks, from funding to time in the clinic to including patients on various committees. However, many researchers still believe that improving patient engagement can be accomplished (Hibbard & Greene, 2013).

Definition of Terms Used

The following definitions are provided to create an understanding of the key words utilized throughout the project.

Adherence/Compliance: Adherence and compliance are the same in the patient-centered medical world. They represent “the extent to which a person’s behaviour – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider” (World Health Organization, 2003, p. 18).

Informed Consent: Informed consent depends on how competent the patient is from a cognitive standpoint to make a “voluntary choice” regarding treatment and care based on information provided to them (Appelbaum, 2007, p. 1834). This also means that patients must be provided with a substantial amount of information to make their choice, which is known as the Reasonable Patient Standard, rather than going by provider preference or coercion (De Bord, 2014).

Paternalism: Paternalism is defined as the “power and authority one person or institution exercises over another in order to confer benefits on, or prevent harm to, that person, regardless of the person’s informed consent” (Habiba, 2000). In layman’s terms, paternalism exists when a physician or other health care practitioner (nurse, medical assistant, physical therapist, and others) decides upon a course of action without any real input from the patient.

Patient Activation/Engagement: Patient Activation or Engagement describes the extent to which a patient has “the knowledge, skills, and confidence” to manage and take part in their health care (Hibbard & Gilburt, 2014, p. 3). PAM gives a number on a scale of 0-100 with higher scores representing higher levels of activation (Hibbard & Gilburt, 2014, p. 8). When a patient is more activated, their overall health tends to be better. It can play a role in “tackling health inequalities” as well (Hibbard & Gilburt, 2014, p. 4). Throughout this project, patient activation and patient engagement will be utilized interchangeably.

Patient Activation Measure: The Patient Activation Measure (PAM) is a “series of 13 statements designed to assess the extent of a patient’s activation” that the patient completes on their own (Hibbard & Gilburt, 2014, p. 8).

Shared-Decision Making: Shared-Decision Making (SDM) is a process where healthcare providers and patients work together to reach the best conclusions regarding treatments and next courses of action (Elwyn, et al., 2012, p. 1361). Both parties must share information completely and freely to fully participate in the SDM process. SDM can range from a system where patients have slightly more control to those of truly shared decisions.

Strategy, Approaches, and Challenges of This Project

The research method utilized for this capstone is the case study. First, a search throughout peer-reviewed academic journals and other reliable sources was carried out using key terms. This approach allowed for specific research into how patient engagement has been studied. The focus was more retrospective research than prospective research. While some portions of this project will be exploratory for future research, it will mostly be focused on program effects. Heavy reliance on research via the internet and in resources available via libraries will be necessary.

While case study is the ideal method for researching this project due to the time given, it has presented limitations on what could be compiled and analyzed. The planned research was based on prior studies and findings of others in the field. Some research studies were limited in scope, especially since much of the current research recognizing the importance of the subject had been conducted by one major research group – Judith Hibbard and Jessica Greene. This may limit the information available for this case study.

Case studies can be difficult to evaluate. However, this capstone focused on a scholarly work accepted by academic standards. The theories and practices discussed in this capstone identified effective ways patient engagement can influence the industry at large. Bringing new ideas and perspectives to the discussions around engagement would be valuable. Additionally, lessons learned and ideas for future research are included.

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An Exploration of Unique Barriers in Organizational Development – and How to Combat Them

Posted on by Grayson

For the month of April, I will be sharing things I’ve written in the process of obtaining my MS in Health Care Administration which I finished up this past fall.

Organizational development (OD) is the “process of continuous diagnosis, action planning, implementation and evaluation, with the goal of transferring knowledge and skills to organizations to improve their capacity for solving problems and managing future change” (Blalock, et al., n.d.).  While this is popular within business organizations, it also has a growing following within healthcare.  With this growing popularity, though, it is important to address the additional barriers organizational development tactics face when applied to the healthcare realm.  First, let us examine the basics of OD, then barriers, and, finally, how to counteract these barriers for the most efficient use of OD within healthcare.

OD Basics

Organizational development is a path to planned change within an organization.  This change can take place in one or many areas but consists often of ideas from a wide variety of fields such as communication, interpersonal sciences, and business (Anderson, 2015, p. 2).  This is meant to be a long-term change or the use of a one-size-fits-all mentality (Anderson, 2015, p. 9).  OD developed as a way to address practices within management, quality improvement, employee involvement in change, organizational culture, learning, and ways to go about change (Anderson, 2015, pp. 25-36).  This change can vary in size, reach, continuity, and planning (Anderson, 2015, p. 67).

In order to conduct proper OD, the change agent needs to understand that organization in its current state.  This means not only understanding organizational culture but also values inherent to the organization and its employees.  These things are important as “they are the underlying beliefs that are enduring and broader than any single consulting engagement or intervention” (Anderson, 2015, p. 41).

One thing that separates OD from other forms of consulting is the power dynamic between the change agent and the client.  With many forms of consulting, either the client or the change agent is the expert and really takes the lead on anything from gathering information to final changes and evaluation (Anderson, 2015, p. 95).  With OD, however, the role of the expert is a shared one between those in the client organization and the change agent (Anderson, 2015, p. 95).

Another important distinction between OD work and consulting is gathering data.  It is an incredibly important piece of OD work.  Data gathering is very similar to the process of testing for a medical diagnosis – it is a process that takes time to do but is necessary in order to find the correct treatments for a malady (Anderson, 2015, p. 161).  In OD work, this data gathering is key.  At times, people within an organization may see employee burnout, for example, as the main problem when it is a symptom of an organizational culture issue.  In this case, data gathering reveals the real roots of the issues and can bring up additional symptoms or diagnoses that someone within the organization may not have seen.

Just like in the medical diagnosis process, one must be careful to only stick to diagnoses the data supports (Anderson, 2015, p. 168).  This is why a change agent must not necessarily be a part of an organization but from the outside.  It is easier to refrain from jumping to conclusions that support any one person and/or group if there is little to no relationship with these people.

Data gathering is not always as straightforward as simply shooting out a survey or shadowing employees.  The first step is to “determine the approach to be used” – will interviews, surveys, observations, focus groups, or less invasive measures such as environment, historical information, and documents yield the best information (Anderson, 2015, pp. 129-130, 144)?  In order to decide the best steps, one needs to examine the pros and cons to using each for each environment (Anderson, 2015, p. 148).

That said, there are different strategies for dealing with individual, team, and organization-wide changes.  In the individual realm, there tend to be fewer steps to interventions or change as “feedback is given directly to the participant” (Anderson, 2015, p. 211).  A lot of personal growth tools like personality assessments and planning can assist in these changes (Anderson, 2015, p. 214).  Coaching and mentoring are key in individual interventions, from personal to professional development.

With team improvement projects, there are more nuances to work with.  Communication, expectations, trust, and leadership are all needed.  Issues around workgroup roles and conflict come up often here as well.  Within organizations, issues also center on organizational culture and design, values and ethics, and management/training styles.

Just as with enacting change, sustaining it is not an easy task.  Most changes are harder to put in place at first due to resistance.  Still, there are many instances of people falling back into old habits after a short time of sustained change, regardless of their enthusiasm for said change.  In order to act against this possibility, continuous reinforcement and training need to occur across the organization.

Healthcare-Related Barriers

Healthcare today is full of change.  In order to stay relevant, health organizations have to undergo nearly constant changes including those in training to workflows to new equipment.  Those who work in assisting doctors also have a learning curve as many doctors do things differently.  That said, with global forces pushing “individual organizations to change accordingly in order to proceed ahead,” change does not always stick (Al-Abri, 2007).  Due to this constant change, clinic managers and others in leadership positions must focus on perseverance, correcting lapses in training/change quickly, and time with each employee (Al-Abri, 2007).

With most health organizations being larger, a focus on bureaucratic structures over any employee feedback will make it harder for changes to take place (Al-Abri, 2007).  This is an instance where culture is more important than strategy (Rick, 2012).  While important in all organizations, this is especially true in healthcare.  When employees feel valued and are engaged, they work harder and focus more on the overall mission of an organization (Kruse, 2015).

Healthcare as an industry is so involved with our mortality that it presents new problems to traditional OD ideals.  In a normal organization, engagement is important and contributes to lower employee turnover (Dickson, 2015).  In healthcare, engagement can mean the difference between life and death.  Nurse engagement is “the number one variable correlating to mortality, even beating out the number of nurses per patient” (Kruse, 2015).  The variability between engaged employees is “tied to the manager” (Kruse, 2015).  Therefore, managers who know how to create employee engagement and satisfaction actually save lives through improved patient satisfaction and care quality (Sherwood, 2013).

Many healthcare organizations, whether tied to government agencies or free-standing, lack in various qualities deemed important for employee satisfaction.  Healthcare professionals at all levels are being worked hard for low salaries and without many opportunities for advancement (Fields, 2011).  Due to the stresses of the work hours, there are poor fits between employees and managers/bosses and a general poor organizational culture (Fields, 2011).

Like within other organizations, many healthcare professionals do not necessarily see the need to take over tasks from others.  Some changes shift responsibilities from medical assistants to physicians due to changes in licensing requirements or Electronic Medical Record systems.  In these cases, physicians often do not appreciate having extra steps, especially if they perceive these tasks as beneath them.  This contributes to a major resistance to change – a combination of ideas that this change isn’t needed or productive and it requires work below their pay grade (Rick, 2013).  In many clinics, the physicians or head nurses lead the way for everyone else to follow.  If one physician isn’t following a workflow, it becomes easier for everyone else at a site to disregard it, too.

Fixing Barriers

Many healthcare organizations rely on quality improvement departments to work towards the same or similar projects as OD change agents.  While it is beneficial to have people on staff who work within various organization-specific programs, this can compromise how impartial or objective they are when working with others.  In order to have the most impartial data gathering, interpreting, and institutions of change, it is preferable to have an outsider working with departments or the organization as a whole.  This does not mean that a different OD firm needs to be used each time or even a new lead on projects, but simply separate.

Employee engagement issues are central to many of the changes that need to be implemented within healthcare organizations.  There is a high rate of turnover within healthcare fields due to low wages, long hours, poor benefits, and interpersonal issues (Pexton, 2017).  The biggest issue, then, is to solve these problems very unique to healthcare.

In order to limit turnover, employees need to feel valued.  In an ideal world, organizations would increase income while hiring more workers to address both the low wages and long hours.   Unfortunately, this isn’t a reality for many organizations with how their current setup sits.  Even if an organization does not necessarily have the funding to increase income or hire more employees, there are still steps organizations can take to improve employee satisfaction.

Creating interpersonal groups that do fun things off-the-clock together can be beneficial.  The Pediatrics group at the East Clinic at UW Health in Madison, Wisconsin, enjoy spending time with each other’s families, attending events together, and more (Plumb, MD, 2017).  This helps to create a more amiable and supportive setting amongst providers at the clinic (Plumb, MD, 2017).

Improving communication skills will help to improve a feeling of camaraderie as well (Pexton, 2017).  This will additionally help to serve the organization well during any periods of change.  Effective communication will help with the patient side of the world as well.  When communication skills improve overall, there are fewer communication mix-ups with patients and fewer medical errors (Pexton, 2017).  Patients will be more satisfied with their care as well (Pexton, 2017).  With the passage of the Affordable Care Act, the focus of healthcare is supposed to be more on quality (Sebelius, 2013).  Whether or not the ACA will be repealed remains to be seen, but the strides made in a focus on quality and patient-centered care are incredible.

By working on these simple steps to provide employees and patients more security and connection, it has a side effect of being able to improve the organization overall while setting it up to be the most accepting of change.  This also helps employees to become more invested in the change process, bringing their expertise to potential change. 

Conclusion

Organizational development (OD) is a fantastic interdisciplinary tool to guide people in change agent positions and organizations through the change process.  While OD is an effective tool, healthcare organizations face unique challenges in regards to OD change strategies.  There are challenges unique to OD work in healthcare that make it difficult to enact and sustain change.  These barriers can be overcome by preparation, improved employee satisfaction, and communication skills.

References

Al-Abri, R. (2007). Managing Change in Healthcare. Oman Medical Journal, 22(3), 9-10. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3294155/

Anderson, D. L. (2015). Organization Development: The Process of Leading Organizational Change (3 ed.). Thousand Oaks, California: Sage Publications.

Blalock, S. J., Bone, L., Brewer, N. T., Butterfoss, F. D., Chamption, V. L., Epstein, R. E., . . . Wilson, N. (n.d.). Organizational Development Theory. (K. Glanz, B. K. Rimer, & K. Viswanath, Editors) Retrieved from Health Behavior and Health Education: Theory, Research, And Practice: http://www.med.upenn.edu/hbhe4/part4-ch15-organizational-development-theory.shtml

Dickson, G. (2015, November 18). 10 Dead Simple Ways to Improve Your Company Culture. Retrieved from Bonusly: http://blog.bonus.ly/10-dead-simple-ways-improve-company-culture/

Fields, R. (2011, April 05). The Top 10 Challenges Facing Healthcare Workers. Retrieved from Becker’s Hospital Review: http://www.beckershospitalreview.com/hospital-management-administration/the-top-10-challenges-facing-healthcare-workers.html

Kruse, K. (2015, February 26). The ROI of Employee Engagement In Hospitals. Retrieved from Forbes: https://www.forbes.com/sites/kevinkruse/2015/02/26/the-roi-of-employee-engagement-in-hospitals/#64032c5b54ce

Pexton, C. (2017). Overcoming the Barriers to Change in Healthcare System. Retrieved from iSix Sigma: https://www.isixsigma.com/implementation/change-management-implementation/overcoming-barriers-change-healthcare-system/

Plumb, MD, A. J. (2017, January 20). UW Health East Pediatrics. (K. Schultz, Interviewer)

Rick, T. (2012, September 27). Organizational Culture: More Important Than Strategy. Retrieved from Meliorate: https://www.torbenrick.eu/blog/culture/is-culture-more-important-than-strategy/

Rick, T. (2013, March 8). Change is Not The Problem – Resistance to Change is the Problem. Retrieved from Meliorate: https://www.torbenrick.eu/blog/change-management/change-is-not-the-problem-resistance-to-change-is-the-problem/

Sebelius, K. (2013, March 20). The Affordable Care Act At Three: Paying For Quality Saves Health Care Dollars. Retrieved from Health Affairs Blog: http://healthaffairs.org/blog/2013/03/20/the-affordable-care-act-at-three-paying-for-quality-saves-health-care-dollars/

Sherwood, R. (2013, October 30). Employee Engagement Drives Health Care Quality and Financial Returns. Retrieved from Harvard Business Review: https://hbr.org/2013/10/employee-engagement-drives-health-care-quality-and-financial-returns.

photo of a person with long hair and a white overlay with black text: "Market with Me, Not at Me: A Patient’s Plea for Inclusionary Strategic Marketing in Healthcare" and "Not Standing Still's Disease

Market with Me, Not at Me: A Patient’s Plea for Inclusive Strategic Marketing in Healthcare

Posted on by Grayson

For the month of April, I will be sharing things I’ve written in the process of obtaining my MS in Health Care Administration which I finished up this past fall.

In the last thirty years, the healthcare system in the United States has started to shift from a paternalistic (top-down from doctor to patient) view to a more participatory (doctor and patient as equals) model.  This has resulted in great changes to the healthcare system at large, including changes from the Affordable Care Act requiring more participatory medicine.  However, there is still a long way to go in order to reach an ideal state in healthcare marketing.

While participatory changes in medicine itself may have come a long way, the same cannot be said for the pharmaceutical industry.  As healthcare systems move towards patient engagement, healthcare marketing – especially in pharmaceuticals – needs to follow suit or be left behind.  This paper will examine the current state of healthcare marketing and examine what steps organizations need to take in order to reach the ideal states according to patients, pharma, and system viewpoints.

Healthcare Marketing

Strategic marketing is a “plan for getting from a point in the present to some point in the future in the face of uncertainty and resistance” for businesses and organizations (Zuckerman, 2005, p. 3).  Creating an effective strategy involves planning, sustainability, performance improvement, quality, direction, focus, scheduling, analysis, connection, and importance (Zuckerman, 2005).

In the 1980s, healthcare advertising began to grow (Thomas, 2015, p. 13).  In the next decade, marketing within healthcare grew to include the “direct-to-consumer movement” (Thomas, 2015, p. 14).  This led to the rise of consumerism in healthcare, something that had started a few decades earlier.  By the time the 2000s came around, business and marketing practices from other organizations in the pure profit world began to stick in healthcare (Thomas, 2015, p. 16). The use of social media and internet-based marketing also began to rise.

Portions of the Affordable Care Act have “ushered in a new era of strategic planning” (Zuckerman, 2005, p. 7).  This will require a major shift strategic marketing processes for many organizations, some of which is already in the process of happening.  In combination with the ACA, the Precision Medicine Initiative from the White House, released in 2015, has helped to push the envelope in medicine.  The goal of this initiative is: “To enable a new era of medicine through research, technology, and policies that empower patients, researchers, and providers to work together toward the development of individualized care” (The White House, 2015).  The world of medicine has not done a fantastic job of staying ahead of the curve without mandates, but the pharmaceutical world has done worse.

Current State of Pharmaceutical Marketing

Profits in the pharmaceutical industry are incredibly high, up to “three times the average of all industries” (Thomas, 2015, p. 86).  This often leads to a demonization of those in pharma, especially when some medications cost “upwards of $100,000 for a full course, and with the cost of manufacturing just a tiny fraction of this, it’s not hard to see why” (Anderson, 2014).  The costs of medications are often rationalized due to the low number of medications that pan out in the long run and become profitable (Anderson, 2014).  Additionally, pharma companies want to make as much money as possible before medications are able to be reproduced as generics or biosimilars (Anderson, 2014).

Pharma has failed to keep up with demands, let alone staying at the front of innovative ideas (Brozak, 2013).  Pharma seems to rely on their background of creating a handful of one-size-fits-all medication and marketing those as cure-alls.  Just as in marketing, these companies don’t focus on the development of new ways to deliver previously developed medications (Brozak, 2013). As Steve Brozak elaborates:

Companies using new technology and evolving marketing techniques to capture markets and displace predecessors, like Wal-Mart in retailing, Zappos in footwear, Volkswagen in cars, and others, were late entrants into existing markets but eventually surpassed their competitors.  Big pharma, beware, the same could happen to you. (Brozak, 2013)

The vast majority of money spent within the pharma industry is on marketing and not research and development (Swanson, 2015).  Even more troubling, the bulk of these marketing funds are “directed at the physicians who do the prescribing, rather than consumers” (Swanson, 2015).  More than 50% of pharmaceutical expenses, roughly $13 billion, were related to contact with healthcare providers with an additional ten billion through advertisements and other contact (Thomas, 2015, p. 86).  Companies, including big names like Glaxo Smith Kline, have committed bribery in the not-too-distant past in order to get their medications prescribed (Anderson, 2014).  With pharma barons like Martin Shkreli who will price gauge life-saving medications, the reputation of pharma employees and companies continue to take hits.

There is a lot of debate in the pharma industry on whether or not direct-to-consumer marketing is effective – and if this type of marketing is truthful versus convincing the consumer they need a medication.  Unfortunately, this can lead to a number of issues within the patient-health care professional relationship – just as much as it can empower patients by encouraging them to seek treatments and diagnoses (Thomas, 2015, p. 89).  The American Medical Association, in conjunction with a number of other medical associations, has even called for an end to DTC advertising (American Medical Association, 2015).  It’s important to note that the only other nation in the world that allows DTC advertising is New Zealand (American Medical Association, 2015).

There is, of course, a unique set of ethical and legal issues associated with marketing in both pharmaceuticals and medicine in general.  Limitations have been put into place by organizations like the Federal Trade Commission in order to halt improper advertisements (Thomas, 2015, p. 26).  There has also, from a pharmaceutical point of view, been a history of inability to communicate directly with patients or patient groups as a result of some of these limitations (Coe & Deverell, 2015).  This can certainly cause issues even when these barriers have, for the most part, been eliminated as the pharma representatives aren’t used to this line of communication being open (Coe & Deverell, 2015).

Ideal State of Healthcare Marketing: Patient Viewpoint

At the time of writing this paper, Kristin Coppens was the social media lead for Spectrum Health in Michigan.  She is also a renowned patient activist, working with organizations such as Stanford University.  She had this to say:

Often, the communications and marketing industry as a whole struggles with marketing AT people versus engaging WITH them.  The same can be said about healthcare.  I understand physicians and other healthcare providers have a level of education and expertise that the patients often do not have, but I think we [patient activists] are also not saying they don’t know what they’re talking about.  Unlike the flip side of the coin, patients are not pushing an ‘us versus them’ agenda.  We just want to be included and work WITH healthcare professionals.  Some of the ways the industry could do this would be to simply bring patients into the conversation, i.e. health systems using patients as patient advocates/patient experience.  Fill those positions with actual patients.  Or you could even have a patient-led board that regularly makes patient engagement enhancements and decisions.  Another way starts in medical school.  Teach these physicians to engage with patients instead of just talking AT them with jargon.  I think it all boils down to getting patients in “positions of power” so to speak. (Coppens, 2016).

As Ms. Coppens expands on, there is a lack of recognition of patients as experts in their own experience.  In medicine in general, this can lead to the perpetuation of the paternalistic attitudes that medicine as a whole has been trying to move away from.  In marketing, this leads to a lack of connection between the product/brand and patient/consumer.  This is especially true in pharma when commercials depict unrealistic activities for someone with, say, Rheumatoid Arthritis to participate in – no matter what medications they are on.

This lack of connection adds to the demonization of those working in the pharma industry.  Patients like Ms. Coppens often believe that these companies are not focused on their wellbeing as a result of this disconnect.  If pharma doesn’t understand what it’s like to be a patient and handle the symptoms of certain illnesses, how can they display a realistic version of improvement in their advertisements?

Realistically Moving to the Ideal State

As Ms. Coppens mentions, one of the biggest barriers between patients and others within the healthcare system and pharma is how we overcome the ‘us versus them’ mentality.  One of the common occurrences in the pharma world is hiring a third-party organization to conduct market research (Coe & Deverell, 2015).  While this may be best practice in some situations, the removal and seemingly refusal of pharma reps to interact with the patients they serve contributes to this mentality.  It is great to have pharma interested in obtaining reactions of patients, but this is often done through focus groups on already-produced materials instead of including patients in the development of advertisements or other materials (Coppens, 2016).

A bonus of ensuring better brand management and interaction with patients is that there is less need for the urgent use of relationship management personnel and resources.  Obviously, though, the biggest bonus is that these changes would help to contribute to a general sense of working together and removing the demonization of each party for the other.  From a marketing standpoint, these changes have the potential to increase profit while decreasing over-prescription of these medications and, therefore, any potential lawsuits and settlements related to such medication.

Having patients involved with the pharmaceutical marketing process also has the unique opportunity of addressing a variety of quality-of-life issues while promoting medications in very pointed groups or diagnoses.  It has been proven that patients’ individual health improves with an increase of their engagement in their own care (Greene, Hibbard, Sacks, & Overton, 2015).  This can also lead to fewer admissions and readmissions to the emergency room or hospital, fewer complications, and lower healthcare costs overall (Greene, Hibbard, Sacks, & Overton, 2015).  Having patients at large involved in improving healthcare for groups of patients can have an enormous effect on the lives of patients involved as well as patients, healthcare providers, and others who are reached with this information.

One pharmaceutical group already accomplishing this is Jansen, the pharma wing of Johnson & Johnson.  Through their group Joint Decisions, a partnership with arthritis-based site Creaky Joints, they aim to educate others about what it’s like to live with rheumatic diseases, ways patients can empower themselves to become better partners in their care, ways to handle life events such as travel with illness, and more (Joint Decisions, 2016).  Patients involved with Joint Decisions are among the leading rheumatic patient activists in the Western Hemisphere and are compensated for their involvement, something that is not the norm in patient activism (personal communication, June 2015).  Through this partnership between a non-profit organization, pharma, medical professionals and patients, better materials are being released for patients living with types of arthritis.

Conclusion    

As highlighted in this paper, there has been quite a lot of change within marketing in the last several decades.  However, there is still a lot of work to be done.  This is especially true in the pharmaceutical industry.  Patients are often left out of the marketing process or only brought in on the back end after materials have already been developed.  Organizations will need to include patients more in the front end of development, which will become especially important in the future as the United States focuses more on pointed care and inclusionary medicine.  If organizations within healthcare want to follow an example, investigating the partnership occurring with Joint Decisions – pharma, healthcare professionals, and patients – will lead to new best practices for inclusionary medicine and marketing.

Works Cited

American Medical Association. (2015, November 17). AMA Calls for Ban on Direct to Consumer Advertising of Prescription Drugs and Medical Devices. Retrieved from American Medical Association: http://www.ama-assn.org/ama/pub/news/news/2015/2015-11-17-ban-consumer-prescription-drug-advertising.page

Anderson, R. (2014, November 6). Pharmaceutical industry gets high on fat profits. Retrieved from BBC News: http://www.bbc.com/news/business-28212223

Brozak, S. (2013, May 25). Big Pharma Learned The Wrong Marketing Lesson. Retrieved from Forbes: Pharma & Healthcare: http://www.forbes.com/sites/stephenbrozak/2013/05/25/big-pharma-learned-the-wrong-marketing-lesson/#7060824346c4

Coe, J., & Deverell, C. (2015, March 23-24). Amgen. (P.-e. Wrap-up, Interviewer)

Coppens, K. M. (2016, June 17). Healthcare Marketing. (K. Schultz, Interviewer)

Coulter, A. (2011). Engaging Patients in Healthcare. Maidenhead, Berkshire, England: McGraw Hill/Open University Press.

Greene, J., Hibbard, J., Sacks, R., & Overton, V. (2015). When Patient Activation Levels Change, Health Outcomes And Costs Change, Too. Health Affairs, 34(3), 431-437. doi:doi:10.1377/hlthaff.2014.0452

Joint Decisions. (2016, May). Joint Decisions. Retrieved from Joint Decisions: http://www.jointdecisions.com/

Ouschan, R., Sweeney, J., & Johnson, L. (2000). Dimensions of Patient Empowerment. Health Marketing Quarterly, 18(1-2), 99-114. doi:doi:10.1300/j026v18n01_08

Sanchez, P. M. (2003). Refocusing Website Marketing. Health Marketing Quarterly, 20(1), 37-50. doi:doi:10.1300/j026v20n01_04

Swanson, A. (2015, February 11). Big pharmaceutical companies are spending far more on marketing than research. Retrieved from The Washington Post: https://www.washingtonpost.com/news/wonk/wp/2015/02/11/big-pharmaceutical-companies-are-spending-far-more-on-marketing-than-research/

The White House. (2015). The Precision Medicine Initiative. Retrieved from The White House: https://www.whitehouse.gov/precision-medicine

Thomas, R. K. (2015). Marketing Health Services. Chicago, IL: Health Administration Press.

Weber, L. J. (2006). Profits Before People?: Ethical standards and the marketing of prescription drugs. Bloomington: Indiana University Press.

Zuckerman, A. M. (2005). Healthcare Strategic Planning. Chicago, IL: Health Administration Press.

photo of a doctor and a nurse looking at a computer with a green overlay at bottom and white text: "Accounting Procedures for Government-Operated Healthcare Facilities" and "Not Standing Still's Disease"

Accounting Procedures for Government-Operated Healthcare Facilities

Posted on by Grayson

For the month of April, I will be sharing things I’ve written in the process of obtaining my MS in Health Care Administration which I finished up this past fall.

Government-operated healthcare facilities can be run the by state or federal government.  Rules can change based on which group is involved. With around 20% of urban hospitals falling under government rule, it’s imperative to understand how accounting works in government-operated healthcare facilities (Horwitz, 2005).  There are differences related to actual accounting, funds, and reporting (Rose & Office of the Controller, 2007, p. 11).  Overall, the process is straightforward once an understanding of the guidelines and rules is had.

Funds

Governmental health care organizations utilize a method of accounting called fund accounting (Elmerraji, n.d.).  Unlike for-profit organizations, the goal of these is not to make money or profit (Elmerraji, n.d.).  Instead of profit, then, a surplus may lead to lowered taxes for taxpayers in the area (Elmerraji, n.d.).  Funds can be separated into governmental, proprietary, and fiduciary categories.

Governmental Funds

Governmental funds are funds that are generally “tax supported activities” (Rose & Office of the Controller, 2007, p. 14).  These funds come from sources such as taxes, grants, and investments (Rose & Office of the Controller, 2007, p. 15).  Funds include basic/general funds, special revenue, and others (Washington Office of Financial Management, 2015).  These funds must have budgets in place, both to keep track of spending and to ensure proper accounting rules are followed (Rose & Office of the Controller, 2007, p. 15).  For example, grants are one time of special fund that requires separate accounts and accounting measures in order to satisfy accounting and purchasing rules (Rose & Office of the Controller, 2007, p. 16).  The focus with accounting measures here is on fiscal accountability (Rose & Office of the Controller, 2007, p. 37).  Required statements for governmental funds include the “balance sheet, statement of revenues, expenditures, and changes in fund balances” (Rose & Office of the Controller, 2007, p. 37).

Proprietary Funds

Proprietary funds help account for actions that border on business-like, such as “trash collection” (Elmerraji, n.d.).  These can be separated into “internal service funds” and “enterprise funds” (Rose & Office of the Controller, 2007, p. 19).  Internal service funds are those applied to business-like expenses within the government, such as locksmith services on college campuses.  Enterprise funds are those which involve customers outside of the government (Rose & Office of the Controller, 2007, p. 19).  The focus with regard to accountability here is on operations (Rose & Office of the Controller, 2007, p. 37).  Required financial statements include the statement of net assets, statement of revenues/expenses/changes in fund net assets, and statement of cash flows (Rose & Office of the Controller, 2007, p. 37).

Fiduciary Funds

Fiduciary funds are those “held in the interest of a third-party,” like those utilized for retirement funds (Elmerraji, n.d.).  Pensions are the most common form of these (Rose & Office of the Controller, 2007, p. 20).  Additional kinds include investments on behalf of others, private-purpose, and agency funds (Washington Office of Financial Management, 2015).  The focus regarding accountability here is on operations (Rose & Office of the Controller, 2007, p. 37).  Necessary financial statements include the statement of fiduciary net assets and a statement of changes in fiduciary net assets (Rose & Office of the Controller, 2007, p. 37).

Accounting Methods

The measurement focus helps accountants to determine “what financial transactions and events will be recognized in the accounting records and reported in the financial statements” (Washington Office of Financial Management, 2015).  The two most important focuses are the flow of economic resources and the flow of current resources (Washington Office of Financial Management, 2015).  The flow of economic resources takes into account assets and liabilities of all types, while the flow of current resources focuses on cash or assets that are easily convertible (Washington Office of Financial Management, 2015).  The modified version, used for governmental funds, only counts revenue when it is received and available for use (Washington Office of Financial Management, 2017).

Under the basis of accounting, there are two ways in which government organizations can account for revenues – on an accrual or modified accrual basis (Washington Office of Financial Management, 2015).  Accrual is used for proprietary and fiduciary funds (Washington Office of Financial Management, 2017).  This method revenues as they’re earned, even if the collection time is much longer.

Generally Accepted Accounting Principles (GAAP) state that governments should have budgets, though this is not technically required (Washington Office of Financial Management, 2015).  In order to properly balance the books, transactions are entered using the double entry accounting system (Rose & Office of the Controller, 2007, p. 40).  This means that each transaction has both a debit and credit.

GASB

The Governmental Accounting Standards Board (GASB) was set up in 1984 to “build an effective structure for creating and implementing consistent accounting standards for state and local governments” (FAF: Financial Accounting Foundation, n.d.).  GASB is run by seven people, including a chairperson and board members chosen by the Financial Accounting Federation (FAF: Financial Accounting Foundation, n.d.).  The standards set up by GASB help others to “shape public policy and make investments” (FAF: Financial Accounting Foundation, n.d.).  GASB sets up GAAP for the United States’ governments, both at a state and federal level (FAF: Financial Accounting Foundation, n.d.).  GAAP requires that governments follow GASB statements first and other pieces, such as technical bulletins, second (Washington Office of Financial Management, 2015).

GASB asks governments to publish a Comprehensive Annual Financial Report (CAFR) (Rose & Office of the Controller, 2007, p. 139).  This is generally done by what is considered to be the primary government, but includes all funds under their umbrella (Washington Office of Financial Management, 2015).  For example, this would be like the State of Wisconsin reporting for all organizations under the state’s financial umbrella, from the University of Wisconsin to the Department of Natural Resources to UW Health.  The CAFR consists of three sections (Washington Office of Financial Management, 2016).  The introduction is straightforward and can include a letter, certificates, a list of elected officials, and an organization chart (Washington Office of Financial Management, 2016).  The financial section includes analyses and a variety of reports from basic financial statements to detailed information on various funds (Washington Office of Financial Management, 2015).  This section also includes the Management’s Discussion and Analysis (MD&A).  This report contains a narrative on the financial records being presented (Washington Office of Financial Management, 2015).  Finally, there is a section that includes statistics and demographics (Washington Office of Financial Management, 2015).

There have been numerous clarifications to ensure government healthcare organizations are aware they must follow GASB standards, such as GASB statement 20 (Duis, 1994).  Statement 20 clarifies SAS 69, stating that GASB standards apply to healthcare organizations (GASB, 1993).  This was initially slightly unclear (Duis, 1994).

One major difference between other organizations and healthcare organizations run by the government is that employees at the hospital may not actually be employed by the hospital.  At the University of Wisconsin’s health system – UW Health – this is the case .  Physicians are employed jointly by the UW Medical Foundation and the state government. Other organizations have employees “organized into a separate entity that bills for their services, or they can be employees of the hospitals with their costs built into the hospital’s costs and revenues for their services credited to the hospital as well” (Needleman).  This can affect the profits and expense reports for these organizations, leaving “some of their costs unreported on their revenue and expense statement or balance sheet, or results in apparently higher expenses” (Needleman).  Government healthcare organizations only have to report net assets (restricted and unrestricted), investments/activities, cash flows, and debt (Horowitz, 2010).  Still, they must report both “operating and nonoperating activities” (Horowitz, 2010).  In-kind donations are reported “at their fair value” (Horowitz, 2010).

Conclusion

Government health institutions receive both “income and property tax exemptions” (Horwitz, 2005).  Because of this, they must be transparent in their financial dealings, even more so than for-profit and private healthcare organizations.  Therefore, it is imperative for governmental organizations to follow the rules set by the GASB and others found under GAAP guidelines.  Methods outlined here show only rules which apply to all such organizations, but individual states may have further requirements.

References

Duis, T. (1994). Unravelling the confusion caused by GASB, FASB accounting rules. Journal Of The Healthcare Financial Management Association, 66, 68-70.

Elmerraji, J. (n.d.). Navigating Government And Nonprofit Financial Statements. Retrieved from Investopedia: http://www.investopedia.com/articles/basics/07/government_nonprofit_statements.asp

FAF: Financial Accounting Foundation. (n.d.). What We Do: GASB. Retrieved from FAF: Financial Accounting Foundation: http://www.accountingfoundation.org/jsp/Foundation/Page/FAFSectionPage&cid=1351027541296

GASB. (1993). Statement No. 20 of the Governmental Accounting Standards Board: Accounting and Financial Reporting for Proprietary Funds and Other Governmental Entities That Use Proprietary Fund Accounting. Retrieved from GASB: Governmental Accounting Research System.

Horowitz, K. J. (2010). Accounting for Health Care Organizations. Retrieved from Mercer County Community College: Professor Kenneth J. Horowitz: http://www.mccc.edu/~horowitk/documents/Chap017_000.pdf

Horwitz, J. R. (2005, May). Making Profits And Providing Care: Comparing Nonprofit, For-Profit, And Government Hospitals. Health Affairs, 24(3), 790-801. Retrieved from http://content.healthaffairs.org/content/24/3/790.full

Needleman, J. (n.d.). Assessing the Financial Health of Hospitals. Retrieved from AHRQ Achrive: https://archive.ahrq.gov/data/safetynet/needleman.htm

Rose, P., & Office of the Controller. (2007, September). Government Accounting, Reporting & Budgeting Workshop 2007. Retrieved from San Francisco Controller: http://sfcontroller.org/sites/default/files/FileCenter/Documents/1932-Workshop_Presentation_092707.pdf

Washington Office of Financial Management. (2015). Generally Accepted Accounting Principles. Retrieved from Washington Office of Financial Management: http://www.ofm.wa.gov/policy/80.20.htm

Washington Office of Financial Management. (2016). 2016 Comprehensive Annual Financial Report. Retrieved from Washington Office of Financial Management: http://www.ofm.wa.gov/cafr/2016/default.asp

Washington Office of Financial Management. (2016). Comprehensive Annual Financial Report. Retrieved from Washington Office of Financial Management: http://www.ofm.wa.gov/cafr/

Washington Office of Financial Management. (2017). Glossary. Retrieved from Washington Office of Financial Management: http://www.ofm.wa.gov/policy/glossary.asp

white background surrounded by a blue outline with blue text: "The Economics of Patient Engagement"

The Economics of Patient Engagement

Posted on by Grayson

For the month of April, I will be sharing things I’ve written in the process of obtaining my MS in Health Care Administration which I finished up this past fall.

For this paper, several terms not generally utilized in economics will be needed necessitating definitions of these key terms.

Shared-decision making (SDM) is a term utilized in opposition to paternalism.  The latter is a form of practicing medicine in which the physician dictates what the patient is supposed to do without taking into account what the patient’s lifestyle is, the patient’s opinion, or other factors.  The former is a form of practicing medicine that is gaining traction and requires the physician to work alongside the patient in order to come to a mutually agreeable decision.  Informed Consent is needed in order to form this decision, meaning that the patient needs to receive education – from the healthcare team or elsewhere, but preferably the former – in order to give consent for treatment.

Quality of Life is a term that can mean many things to individuals.  Overall, this is how well a patient is able to live their life.  Many items can factor into the Quality of Life (or QOL) from whether a medication is an injectable or an infusion to how often blood tests are required to the efficacy of treatments to even more.

Adherence or compliance is how closely a patient may stick to their treatment regime.  There are, however, a variety of things that can affect a patient’s adherence or compliance to any given regime, including but not limited to transportation, access, cost, childcare, Quality of Life, health literacy, socioeconomic status, and social support.

Patient Engagement is how involved a patient is in their medical care.  This can be affected by health literacy, socioeconomic status, education, access, cost, Quality of Life, rapport with clinic/hospital staff, insurance, social support, and how involved their healthcare team is with shared decision making as opposed to paternalism. The Patient Activation Measure is a way to measure Patient Engagement via “a valid, highly reliable, unidimensional, probabilistic Guttman-like scale that reflects a developmental model of activation” (Hibbard, Stockard, Mahoney, & Tusler, 2004).

Patient Protection and Affordable Care Act

In March of 2010, the Patient Protection and Affordable Care Act (PPACA) was enacted (Healthcare.gov, n.d.).  Two of the biggest draws for the consumer side were the requirement for insurance plans to cover people with “pre-existing health conditions, including pregnancy, without charging more” and making it “illegal for health insurance companies to cancel your health insurance just because you get sick” (Healthcare.gov, n.d.).  Additional draws include giving younger adults more options including the ability to stay on their parents’ insurance plans up to age 26, education about the coverage a patient is receiving, and regulations placed on insurance companies surrounding increasing premium rates (Healthcare.gov, n.d.).

One of the innovations of the PPACA has been the “shifting from a reimbursement system based on the volume of services provided to one based on the value of care” (Abrams, et al., 2015).  The shift from fee-for-service to pay-for-performance is a great idea in order to bring more of a focus on quality to all parts of healthcare.  Sending a “clear signal to providers that they will need to adapt quickly to incentives that reward appropriate, high-quality care and good patient outcomes” has already begun to make improvements (Abrams, et al., 2015).

Among the many improvements already noted with the PPACA is “lowered annual increases in Medicare payment rates for hospitals and other facilities” (Abrams, et al., 2015).  As we are reminded of constantly, the reserved funds for Medicare and Social Security are running out of money (Reuters, 2016).  Paying out fewer dollars to providers can potentially help to extend the life of these programs by a few years.  Even overpayments to “private plans administering Medicare benefits through the Medicare Advantage program,” which will help with this as well (Abrams, et al., 2015).

Quality has directly been targeted as well (Abrams, et al., 2015).  Hospitals with high rates of “adverse medical events,” or such as Hospital Associated Infections (HAIs), have begun to be fined for subpar performance on key quality metrics (Abrams, et al., 2015).  Other innovations to improve quality include the Center for Medicare and Medicaid Innovation (CMMI), the Patient-Centered Outcomes Research Institute (PCORI), the Medicare-Medicaid Coordination Office, and the National Strategy for Quality Improvement in Health Care (Abrams, et al., 2015).

With education surrounding a patient’s coverage as well as the emphasis on quality, the theory has been that the PPACA will be able to increase a patient’s engagement with their own health.

Patient Engagement

Several studies have shown that increased Patient Engagement as measured by the Patient Activation Measure lead to overall improvements in health as well as economic benefits.  In addition, healthcare is moving towards Patient Engagement per request from patients and patient-led organizations.

Patients who are more activated or engaged in their own healthcare take part in more preventative measures such as check-ups than their less-engaged counterparts (Hibbard & Greene, What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs, 2013).  These same patients do not delay seeking medical care and have a higher likelihood of having better overall health (Hibbard & Greene, What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs, 2013).  These patients are also more likely to have better healthcare experiences when seeing the same physicians as their less-activated counterparts (Greene, Hibbard, Sacks, & Overton, When Seeing The Same Physician, Highly Activated Patients Have Better Care Experiences Than Less Activated Patients, 2013).  Patients who had more provider support in education and participated in more shared decision-making processes with their healthcare team were more engaged in their own care (Greene & Hibbard, Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes, 2011).

One study in Minnesota showed that “for every additional ten points on a Patient Activation Measure score, the predicted probability of having an emergency department visit was one percentage point lower” (Hibbard & Greene, What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs, 2013).  Taking this further, patients who were not as engaged as seen on the Patient Activation Measure had “significantly higher costs than more activated patients” (Hibbard & Greene, What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs, 2013).  Activated patients also had fewer emergency department visits and hospital readmissions, leading to lower costs overall (Greene, Hibbard, Sacks, Overton, & Parrotta, When Patient Activation Levels Change, Health Outcomes And Costs Change, Too, 2015).

Intersectionality and Further Issues

There are some issues with Patient Engagement/Activation in that several barriers exist to many people achieving this state.  While similar expectations and wishes for physicians happen across racial and ethnic groups, differences in experiences are still reported (Welnick, et al., 2011).  This still occurs with other variables such as education status, socioeconomic status, gender identity, sexual orientation, age, and more (Millenson, 2016).  In the pediatric world, these barriers are often necessary to work around and work with in order to provide the most exceptional care to the patients as needed.  Several of these barriers can be worked around to increase engagement and education through understanding and education (Cox, et al., 2012).

Conclusion

The benefits of Patient Engagement far outnumber any negatives one might be able to find.  While there are difficulties in making changes in order to put programs in place, there are few negatives to even be found.  From an economic standpoint, the pay-for-performance principle instituted by the PPACA can be a vehicle for moving healthcare to focus more on Quality of Life and Patient Engagement.  Costs can be expected to increase in the short-term in order to provide education to both healthcare providers and patients as well as setting up a system to measure the efficacy of these efforts.  However, in the long-term, these costs can be expected to go down as Patient Engagement and Activation become the norm across the country.

References

Abrams, M. K., Nuzum, R., Zezza, M. A., Ryan, J., Kiszla, J., & Guterman, S. (2015, May 7). The Affordable Care Act’s Payment and Delivery System Reforms: A Progress Report at Five Years. (C. Hollander, Editor) Retrieved from The Commonwealth Fund: http://www.commonwealthfund.org/publications/issue-briefs/2015/may/aca-payment-and-delivery-system-reforms-at-5-years

Greene, J., & Hibbard, J. H. (2011, November 30). Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes. Journal of General Internal Medicine, 520-526.

Greene, J., Hibbard, J. H., Alvarez, C., & Overton, V. (2016, March/April). Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels. Annals of Family Medicine, 148-154.

Greene, J., Hibbard, J. H., Sacks, R., & Overton, V. (2013, July). When Seeing The Same Physician, Highly Activated Patients Have Better Care Experiences Than Less Activated Patients. Health Affairs, 1299-1305.

Greene, J., Hibbard, J. H., Sacks, R., Overton, V., & Parrotta, C. D. (2015, March). When Patient Activation Levels Change, Health Outcomes And Costs Change, Too. Health Affairs, 431-437.

Healthcare.gov. (n.d.). Health Coverage Rights and Protections: Rights & Protections. Retrieved from Healthcare.gov: https://www.healthcare.gov/health-care-law-protections/

Healthcare.gov. (n.d.). Patient Protection and Affordable Care Act. Retrieved from Healthcare.gov: https://www.healthcare.gov/glossary/patient-protection-and-affordable-care-act/

Hibbard, J. H., & Greene, J. (2013). What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs. Health Affairs, 207-214.

Hibbard, J. H., Mahoney, E. R., Stock, R., & Tusler, M. (2007, August). Do Increases in Patient Activation Result in Improved Self-Management Behaviors? HSR: Health Services Research, 42(4), 1443-1463.

Reuters. (2016, June 22). Medicare Is Going to Run Out of Money a Lot Sooner Than Expected. Retrieved from Fortune: http://fortune.com/2016/06/22/medicare-reserves-exhausted-soon/

Skolasky, R. L., Mackenzie, E. J., Riley III, L. H., & Wegener, S. T. (2009, December). Psychometric Properties of the Patient Activation Measure among Individuals Presenting for Elective Lumbar Spine Surgery. Quality of Life Research, 1357-1366.