Kristin LanningIn a recent interview, Suzanne Delbanco, PhD, director of an organization called Catalyst for Payment Reform, describes how she sees payers, hospitals, physicians, and patients being affected as the healthcare industry advances toward the goal-advocated by her organization-of having 20 percent of payments to hospitals and physicians be value-oriented by 2020.

As I read the interview, I wondered, "Where am I, the patient, in all this?" Near the end of the article, Delbanco makes the following comment:

"The employers and other health care purchasers we work with are going to pair patients with education and information, coaching and decision support as well as financial incentives to make choices tending toward higher quality and more efficient providers."

This is great for people who are able to take advantage of such support. My employer pays more than lip service to health engagement in two ways: first, by implementing a wellness program that allows you to get regular wellness coaching sessions (among other wellness benefits such as a paid gym membership), and second, by fostering a culture where taking care of your health is not just encouraged, but celebrated.

These are all pretty rich benefits by any measure, but they are also a smart investment, and one that is paying off (my cholesterol is down 26 points since the start of the year). However, I'm probably in the minority of patients who are fortunate enough to have such resources at their disposal. Hospitals and physicians have to deal with all kinds of patients, some of whom may have substance abuse and/or undiagnosed mental health issues. How much can hospitals invest in terms of manpower and dollars to make sure these patients are treated on the front end of the healthcare delivery system (an outpatient clinic), rather than on the back end (the emergency department)?  

Note the word used: investment rather than spend. Engaging patients, especially those with underlying issues, whether they are health or socioeconomic issues, will always require an expenditure of money and time. The difference, though, is that there is a return on an investment in hopes of a good result. Investing $100 in a nurse practitioner who can spend a half hour with a patient not only to make sure the patient is taking his or her medicines properly, but also to check to see whether the patient has heat in the house, is the kind of spending that hospitals will need to embrace whole-heartedly as value-based payment becomes more common.

Which brings me back to the original question: Where is the patient in all of this? Although it's true my health coach and employer gave me ample opportunity to improve my health, it was ultimately up to me to go to the gym and get on that treadmill. I had the means to regularly buy fresh vegetables and other healthy food. Are we going to penalize patients who live in "food deserts," or who can't afford gym memberships (or who live in neighborhoods unfit for walking)? If physicians and hospitals are rewarded for performance, should we then penalize patients for nonperformance? It's an uncomfortable question for patients, physicians, and hospitals, but it's one that will increasingly become important as we move into the value-based payment frontier.

Kristin is webmaster/content editor,

The opinions expressed by author do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association. Read the interview with Dr. Delbanco or listen to the podcast.

Publication Date: Monday, December 17, 2012