Patient Engagement: Not Just a Good Idea, It’s the Law

The case for patient engagement has historically been ethical (“It’s how people should be treated”) and clinical (“Engaged patients have better outcomes”). But what happens when patient engagement becomes the law?

That question has become more pressing with the release of the final rule for the Quality Payment Program of the Medicare Access and CHIP Reauthorization Act (MACRA). The regulations usher in sweeping change in how medical care is paid for by the largest healthcare payer in the world. The rule sets out a long list of volume-to-value quality measures that are part of MACRA’s Merit-based Incentive Payment Program (MIPS). Comparable measures will be required for clinicians practicing in a MACRA-defined Advanced Alternative Payment Model.

Support and Rewards for Clinicians

The provisions will “create a more modern patient-centered Medicare program,” said Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services (CMS) in a letter to clinicians posted online. The rule itself promises to support and reward clinicians “as they find new ways to engage patients, families and caregivers.” “Reward” is the key. Clinicians who ignore or do poorly on the measures won’t be thrown in jail or face a fine. By law, however, they will see their pay stagnate as a powerful customer pays more to clinicians whose quality scores meet the new standards. Moreover, it’s a near-certainty that many of the measures will also be adopted by state Medicaid programs and private payers.

Key Areas of Focus

The original law, passed with a bipartisan majority, specifically names “population management” as a performance category. Also mentioned are care coordination and beneficiary engagement, “such as the establishment of care plans for individuals with complex care needs, beneficiary self-management assessment and training and using shared decision-making mechanisms.”

Measures to Facilitate Greater Engagement

The final rule includes a list of beneficiary engagement measures related to electronic health records, building upon previous regulatory efforts. These include: “access to an enhanced patient portal [that]…includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence.” And: “collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of an improvement plan.” And: “participation in a QCDR (Qualified Clinical Data Registry) that promotes use of patient engagement tools.”

A Focus on Shared Decision-Making

The regulations also single out certain conditions for shared decision-making. For example, the total knee replacement measure says doctors should engage in shared decision-making about options such as weight loss or anti-inflammatory drugs before recommending surgery. A measure related to the treatment of hepatitis C calls for “treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness and patient preferences towards treatment.”

Meanwhile, the Consumer Assessment of Healthcare Providers and System (CAHPS) survey for MIPS will include items related to “shared decision-making, access to specialist care and health promotion and education.”

Pay for What Works

Medicare says it wants to “pay for what works.” In that context, patient engagement isn’t just a good idea, it’s the law.

A Catalyst for Cultural Change

Still, cultural change is hard. The new patient-centered measures are mostly part of a menu of allowable choices, albeit “weighted” by CMS to push in a particular direction. MACRA makes patient engagement more important, but transformation of medical practice still lies ahead.