Patient engagement and accountable care mean payers and providers have to collaborate on change and also to help patients rethink health and health care -- including death and the quest for a good one.
There are several ways Aetna is helping providers in accountable care ventures redesign their practices and reach patients, as Jan Oldenburg, the company's VP of patient and provider engagement for accountable care solutions, told Healthcare Payer News in part one of this interview.
In the second part of the interview, Oldenburg talked about engaging patients for exercise and nutrition, how her time at Kaiser Permanente shapes her views on insurance's future, and the concept of a "good death."
HPN: You came from Kaiser Permanente, whose former CEO, George Halvorson, is a big proponent of walking as sort of this basic thing almost anyone can do for good health. Do you think patient engagement and ACOs can help incentivize simple behavior changes, like getting people to walk a few miles a day?
Oldenburg: One of the things incidentally that I think we're trying to do even in our behaviors is walking meetings. We're on the phones for so many meetings; we might as well be taking a walk around the neighborhood. Lots of times you don't have to be looking at your PC in order to do those. That's exactly the kind of thing we're talking to doctors about: It's okay to do some of this with your patients and share that you are working yourself on getting more active and some of the things that are working for you as ways of engaging the patients. The first thing that Aetna sent me in the mail, after my employment contract, was a pedometer, with a note that said, "We are invested in your health."
HPN: And what about diet, which in some ways is a fundamental piece of personal and population health outcomes?
Oldenburg: A fundamental piece of it and a fundamental piece of patient engagement. I think one of the areas where we really believe there's opportunity is the health coaching arena -- identifying the people who are either at high risk of developing chronic illness or are already in the midst of it. We have a high investment, both in our traditional businesses but also -- it's one of the things that we're bringing in as part of the ACO -- the care managers and wellness and behavioral health coaches, so that people have a caring individual that they may be able to talk to about their health, maybe asking them specifically what they've done in the last day or week to exercise. Those kinds of personal touches, I think, help a lot.
But beyond that, as you think about ACOs and how they are charged with the health of a population, one of the dimensions of that is more involvement with community organizations, more thinking about the community as an extension of the healthcare system and vice versa, the healthcare system as an extension of the community. I think you will see more healthcare systems and ACOs looking at wellness -- that's traditionally been the purview of employers or insurers -- and thinking about things they can do and sponsor to keep people out of the hospitals. This alignment of incentives of the ACO brings a lot of ferment and innovation in how you help people understand what behaviors make sense. Sponsoring farmers markets, thinking about food deserts and how you can affect what food purchasing options are available if you can for the health of a population, those are concerns you have to have.
HPN: How does your experience at Kaiser shape what you're doing at Aetna?
Oldenburg: I think a core thing I'm bringing is the understanding of the value of integration and the value of those aligned incentives. Some of the kinds of things that can be accomplished with patient engagement, as far as effects on the system as a whole, I know work because I saw them work at Kaiser. And I think the ACOs offer another place that they can work, where you can look at the dynamics between the two. We're looking at, in the ACO context, rewriting the materials so they sound like they come from doctors and in fact engineering things so they do come from doctors, as opposed to from an external third party. And that's about the value of the trusted relationship that people have, the way we can build on that trusted relationship to help them understand that they've got a community that cares for them.
HPN: Some critics of the Affordable Care Act say that ACOs are basically HMOs repackaged. Is there the possibility of patient backlash against ACOs, considering the controversy and mixed record of HMOs?
Oldenburg: I think there are things that ACOs need to do to ensure that there's not a backlash. Part of it is keeping the patient at the center. I think it's one of the things HMOs forgot in the early 1990s, when there was a backlash, was that they had captive audiences and they didn't pay attention to some of the issues about how you really make people feel like individuals who are being cared for, as opposed to herds. Nobody wants to feel like a population; people want to feel like individuals. That really is an emphasis on how they feel about the care they are getting.
A person talking to me from a healthcare system in Kentucky, where they have engineered online care, said 90 percent of their patients prefer to get their care virtually than in the office, when they have a chance. I thought, Wow, who knew? It's another example of convenience actually as a selling point. We already know that sometimes people tell disembodied voices on the phone more than when they're face to face. That's a dimension that has to be present for ACOs not to feel like the HMOs of the early 1990s. It seems as if the ways that the rule base and the measures have gone -- because satisfaction is a critical dimension of how they're measured -- it keeps that at the forefront. I also think we'll see innovative plan designs that help reward patients.
HPN: How is Aetna addressing the reimbursement issues of digital consults, because at least some doctors have been reluctant to email patients knowing they might not be able to bill for it?
Oldenburg: That's part of what we're working through, and we're working through it a plan at a time. In an ACO model, you need to be rewarded as a physician for delivering the right care at the right time, not too much, not too little. Figuring out what that looks like, understanding that email can very much be the right channel, building the ability to do teleconsults so that you've got a visual confirmation of what's going on -- all of those are part of how we help docs and systems think through the right level of care for different situation. How do you make those sometimes difficult judgements: this has to be taken out of email, we need to really see this, it's urgent. Doctors do this by phone all the time, so it's really more a matter of taking those skills that they already have and just adding a dimension to it.
HPN: Do you see the work of patient engagement as being part of end-of-life planning and choices?
Oldenburg: Very much so. Aetna has done a lot of work with the Compassionate Care Program that really is about end-of-life care and helping people make those decisions. One of the things that we're doing in the ACO context is bringing that program into the provider organizations and working with them to make it their own, so it's not the insurance program over here. It's something that even if your doctor isn't super comfortable with having that conversation -- although we try to educate them about that -- they may be comfortable handing you or your mother or father or whomever a little brochure that says, 'These are people who might be able to help you. Why don't you give them a call?' That's not so hard; it's not as hard as doing the conversations themselves. That's part of community care as well, thinking about the resources that a compassionate care nurse can help connect people to in their community.
HPN: The concept of a good death seems to be gaining traction.
Oldenburg: I think it's something we've avoided for a while. One of the statistics we've got in the book, Engage! Transforming Healthcare Through Digital Patient Engagement, is when you ask a lot of doctors about what they think patients will want at end of life, it's all about extreme measures and prolonging life at all costs. But when you talk to patients, it's all about quality of life. So getting those aligned so that the right things happen and people really get the kind of death that they want is important.