Analysis: Boosting patient self-management

Dr. Adam Stewart, like many clinicians, is often frustrated wondering if there isn’t a way to get patients to exercise a greater degree of self-management. “I have a ton of self-education info on my website, for instance. Written for a patient audience to understand. Still, I have people coming in for issues that they could have easily self-managed with that info. What is really frustrating is when capable patients don’t put in any initiative to try,” said the family doctor from Madoc, Ont. Physicians can’t help but be concerned about this when their work day is already overloaded. As well, we know we are in a health system with finite resources so what price are we paying when patients use the health system for things they don’t really need? But increasing “patient accountability” as it is sometimes called, is fraught. In a survey of doctors done by the Medical Post five years ago, one clinician noted: “We are terrible at sharing the truths about hospital costs and billing. Patients truly believe that everything is ‘free.’ (We hear things like), ‘Can you just keep mom in the hospital for a few more days? I am really busy at work.’” But another doctor wrote: “No need to improve patient accountability; that’s why they’re the patients. It would be cruel to ask parents to be able to judge when their children need to see a doctor and when to risk a penalty for going to the emergency room or otherwise. Only healthcare professionals can make those decisions; that’s why we have a long education and high pay. The entire notion of patient accountability is unsettling.” Zombie idea: user fees Indeed, the first solution to increase patient self-management that pops into some people’s minds is user fees. Some health systems in other rich countries such as South Korea, Germany and France do use user fees as a tool to try and moderate health system demand. (In France, for instance, to see an FP the standard consultation fee or co-payment is around €25 and varies slightly based on the location and the specific FP’s charge.) But user fees are often referred to as “a zombie idea” because they keep on coming back despite concerns they lead to the following problems: Disincentive to seek care: Particularly for preventive services, user fees can discourage patients from seeking early medical attention, leading to more severe health issues later on and higher healthcare costs in the long run. Burden on vulnerable populations: User fees may disproportionately affect low-income, marginalized and chronically ill populations, leading to reduced access for those who need them the most. Admin burden: Collecting user fees while having exceptions for low-income patients can take away resources from direct patient care. Besides, user fees or extra billing for medically necessary care are outlawed by the Canada Health Act. Even if not, it would be a challenge for any provincial government to bring in user fees when voters in Canada are so concerned about anything that smacks of “American-style” healthcare. Also: User fees are a stick—rather than a carrot—as a tool to increase personal responsibility by patients. Canada already has a number of those, including waiting (patients know if they go to an ER with a minor issue they are going to wait); and gatekeeping (family doctors may not always enjoy the role but requiring patients to get a referral from them before accessing specialized healthcare is a tool Canada uses to reduce unnecessary visits). Nudge theory Nudge theory—an idea in the field of behavioural economics—uses subtle changes in the way choices are presented to influence patients’ decisions and behaviours in positive ways without restricting their freedom of choice. Examples include sending patients texts or emails to remind them of their appointments to reduce no-show rates and sending out info on social norms by informing patients about high vaccination rates in their community to encourage them to get vaccinated. We need to be sophisticated in how we increase patient self-management. Employing nudge theory or using what we know about human nature (putting apples in a bowl on the kitchen table and cans of coke in the downstairs fridge) offer our best hope. But no matter what: Something has to be done. Between doctor and patient, there must be a therapeutic alliance, many doctors believe. “Today, with alarming rates of burnout, the glue that holds healthcare together is becoming weaker,” said Dr. Irith Lebovich, a Montreal doctor and the founder and CEO of Yagrumo that offers training for human-centred care. “How do we reconcile the focus on the patient in patient-centred care with an increasingly burnt out workforce that is less engaged and, at times, even resentful of patients?” She added: “In our relationships with our patients, we’re expected to be the ‘givers’ yet no relationship can be sustained when one party is consistently expected to give and the other to receive.” (And indeed for any patients who might think, “well, you get paid”—that is not the right attitude. Doctor care is not a completely transactional relationship at core.) The ‘carrot’ solutions So let us look at what the options are in the way of carrots to reduce patient demand. Some locations have financial incentives to encourage healthy behaviour. The U.K. offers shopping vouchers to pregnant women who take steps to quit smoking. Vouchers are usually given either for initial connection with a stop smoking specialist or for coming back after the first appointment and engaging in a quit attempt—and then subsequent vouchers are given for biologically validated quits. A 2019 Cochrane Review found women receiving incentives were more than twice as likely to quit compared to those in non-incentives groups. Singapore’s National Steps Challenge has seen 26% of the population engage with this program as reported in the British Medical Journal in 2000. Walking or running is measured using wearables and smartphone applications and participants earn “health points” for completing certain numbers of steps. The points are redeemable for rewards worth up to $14. Closer to home, Manitoba’s Getting Healthy campaign in June offered prizes for healthy behaviour by patients and had high engagement rates. Of course, the above solutions are on the incentive side and don’t totally answer the question of how best to deal with the lack of self-care that Dr. Stewart sees. It is about somehow getting patients to consider self-management in certain situations before going to the ER or doctor. It is almost like patients should get health points or prizes for using the health system accountably?

Analysis: Boosting patient self-management

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