As a crossword puzzle enthusiast, I am always amazed at how many words have multiple meanings. And completely unrelated meanings, at that. Is the answer for “leaves” foliage or departs? Is the answer for “foil” to stymie or a food wrap?
Grammarians refer to a word of a given spelling that has two or more different meanings as a homograph. And in the sphere of consumer engagement, we are having a homograph problem.
The very words that we have long used to talk about our goals for health care: consumer centeredness, consumer engagement, patient empowerment and consumer direction have taken on multiple meanings. While these multiple meanings are currently uneasily co-existing, the shifting political landscape promises to put them on a collision course.
For example, think about consumer or patient engagement, something we promote and implement in our work here at the Center. Our vision for consumer engagement regards patients as active partners in their care and aligns with definitions developed by the Institute of Medicine, reflected in the National Quality Strategy and incorporated in a number of innovative care models. A new National Academy of Medicine publication defines patient- and family-engaged care as care which is planned, delivered, managed and continuously improved in active partnership with patients and their families to ensure integration of their health and health care goals, preferences and values.
This vision of consumer engagement is important in value-based payment models, where providers have financial incentives to improve the cost and quality of care. Consumer engagement can help contribute to the success of this work, improving the health system in the process, and is an important component of person-centered care.
Yet, there is an alternative vision of consumer engagement driven by a different perspective on “value,” which emphasizes the patient’s role as a “shopper” for health care services. This vision typically emphasizes insurance arrangements in which patients must pay a higher share of the costs of services they use, such as through a high-deductible health plan or a health plan that has high point-of-care cost-sharing. The idea is to incentivize consumers – sometimes even very low-income consumers – to make cost-conscious decisions.
Speaker Paul Ryan’s health care proposal, “A Better Way,” describes the need to “empower Americans and put them in the driver’s seat of their health care decisions.” Rep. Tom Price’s health care proposal was titled the “Empowering Patients First Act.” Seema Verma, President Trump’s pick for administrator of the Centers for Medicare and Medicaid Services (CMS), described the development of the Healthy Indiana Plan, which charges $1 premiums even to very low-income individuals (making less than $500 per year), as “encourage[ing] members to stay engaged with their health plan, providers, and overall personal health.” Under this program, individuals who don’t pay premiums can be downgraded to coverage that has fewer benefits and which requires paying more for each doctor’s visit, prescription and hospital admission, or they can be blocked from Medicaid coverage altogether.
So, here we have two very different visions employing an overlapping lexicon, one that includes the words “consumer-directed,” “consumer-centered,” “patient engagement” and “patient empowerment,” but with each term conveying wholly different meanings. While there are situations where the two ideas might not directly conflict, those of us who care for (and about) low-income patients with complex health and social needs should be concerned about this etymological appropriation.
This is because some of the program features currently being described as “patient empowerment” – such as requiring patient cost-sharing at the point of care or imposing “lockout” periods from coverage from patients who miss premium payments – make it harder for both patients and providers to establish a care partnership and for patients to obtain the care they need. In particular, research has shown that low-income consumers are more likely to forgo needed care and face worse health outcomes when faced with financial barriers to care.
More subtly, a fundamental premise of promoting shopping behavior – encouraging consumers to seek out the lowest-cost care – can be problematic for patients with complex needs, such as frail elders or people with multiple chronic illnesses, who might be better served by establishing an ongoing care relationship with a team of providers, rather than fragmenting care across many different providers or institutions.
What’s happening now is that established words and phrases with specific meanings are being appropriated to mean something very different. If used often enough in the new context, the new usage can delegitimize the original meaning, or at the least create enough confusion that the power of the terms may be devalued in all contexts. For the appropriators, that is a success in itself.
So what can we do?
I suggest that we, as a community dedicated to advancing consumer engagement as a partnership between patients and providers, be forceful and clear in what we are – and aren’t – talking about. We need to differentiate these two models by talking about “patients as partners,” in contrast to “penalties for patients.” We also need to speak up and call out when policies that are potentially harmful (particularly to low-income consumers) are being misleadingly promoted as patient-centered.
What do you think? Do you have other phrase suggestions or ideas on how to make sure the clarity of our syntax is preserved? Tweet us at @ccehi to share your thoughts!