For generations, the relationship between health care providers and patients was a one-way street: doctors, hospitals and nurses told you what to do and you did it without question.

Not only is that way of delivering health care outmoded in the Internet age, it may also be the least cost-effective, particularly in fee-for-service Medicare. But what if patients were engaged in their own health care decision-making? Would beneficiaries receive better care at a lower cost?

Patient engagement, or "activation," is the focus of the entire February 2013 issue of the journal Health Affairs. Various authors have pooled research to reach some conclusions about the possibilities of involving patients directly in their own care.

The logic behind patient activation is that patients who are more informed about their health care choices may use fewer tests, procedures or surgeries. Once they are educated about each phase of their treatment, they may opt for less costly options or for those with fewer side effects. There is some evidence to support this theory, although much more research is needed.

One study in the issue, conducted by Judith Hibbard, Jessica Greene and Valerie Overton, found that those with lower engagement scores tended to have higher health care costs.

“In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences. What’s more, patient activation was a significant predictor of cost even after adjustment for a   commonly used ‘risk score’ specifically designed to predict future costs.”

What was important for these researchers was a patient's “ability and willingness to manage their health.” The basis for high engagement is involving patients in their health care decision-making and educating them about their treatment options. Once a patient is informed, though, there must be a commitment to apply that knowledge to a sound care model, which takes homework and additional time on the part of providers.

According to the study, one of the reasons that patients may have a better overall experience if they are engaged is that they have an increased stake in their care. No longer are they being exclusively "treated" by a raft of providers, but they are participating in self-healing. This philosophy runs counter to the current American paradigm of giving providers nearly complete control in treatment regimens.

How to Implement Patient-Centered Care

How would greater engagement, or patient-centered care, work in practice? Some institutional change would be necessary, according to an accompanying Health Affairs article coauthored by Kristan L. Carmen and colleagues. A "multidimensional framework" is needed that would involve the entire health care system, including the patients, their families, and individual providers. The change must be systemic, the article suggests. Best practices would need to be drafted and implemented, a review process of some kind would be required, and patient engagement would need to be monitored on a regular basis.

Deborah Roseman and colleagues, a third group of researchers featured in the journal, examined some early efforts at patient-centered care in California, Pennsylvania and Oregon. They found that "actively engaging patients in improving ambulatory care improves provider–patient communication, identifies and avoids potential challenges to new services, and improves provider and patient satisfaction."

Hospitals would even need to consider a "quality control" process that brings in ombudsmen or outside consultants to objectively measure patient-centered care. Some measures might include: whether patients are getting all of their questions answered;  whether providers are checking on the progress of care on a regular basis; whether hospital stays are shortened; and whether the care experience be improved.

I would suspect that currently many patients, doctors, or hospital administrators are ever asked these questions.

How Patient-Centered Care Would Work in the Real World

While patient-centered care is still in its infancy and represents what would be a culture shock to the fee-for-service system if introduced too quickly, it has great potential for improving the overall quality of care.

When my daughter was hospitalized in a pediatric intensive care unit at a highly rated suburban hospital a few years ago, we initially had a bad experience with the doctors who examined her. As it was a teaching hospital, a wave of interns came in to ask the same questions without offering any treatment. Then a doctor who was obviously not trained as a pediatrician walked in. In a brusque, hostile tone, without even examining her, he threatened my teenage daughter with a treatment she knew nothing about, leaving her in tears. (I was not there at the time). It was only shortly thereafter, when a nurse interviewed my wife and I on hospital quality control measures, that we learned that we could lodge a complaint and request a physician who might be better able to diagnose and treat our daughter properly. While we had to endure some unnecessary hurdles en route to finding the best treatment, it represented a first step in improving my daughter’s overall care.

Clearly, progress on patient-centered care as it relates to Medicare will need a great deal more education in order for health care providers, institutions and patients to form a working relationship.

Here are a few points to consider as the health care system and patients explore this subject in depth:

• Patients need a basic ability to evaluate medical studies and treatments, need to remember that not every study is conclusive, and that some research is compromised by conflicts of interest.
• Doctors and hospitals need to offer a detailed understanding of available options to patients.
• Patients will need the cognitive ability to understand their diagnoses and be able to review their best options. Will providers offer cognitive tests before they engage in patient-centered care?
• To what degree can providers involve family members without compromising HIPAA privacy concerns?
• What if a patient is unwilling or unable to participate in his or her own care?

Much more research must be done on patient engagement, but it may very well become an essential element in the tandem goal of improving health care while lowering cost.