Does Patient Engagement Cultivate Cherries or Prevent Sour Grapes?

The question, does patient engagement cultivate cherries or prevent sour grapes, is a pertinent one in a milieu of healthcare reform, given recent reports of increased cherry picking of patients. Cherry picking in the healthcare field, which is the tendency for medical practices to selectively choose patients to treat who have fewer health problems and for whom reimbursement is better, is said to be gaining momentum as a result of changes linking reimbursement to outcome and quality measures, and because of busier practice schedules and administrative burdens on physicians.

Although cherry picking is not a new strategy which health insurance companies deployed for many years up until the Affordable Care Act made it unlawful for them to decline coverage for patients with pre-existing illnesses, it is likely to gain increasing attention as more patients enter the healthcare delivery system and patient-empowerment responsibilities are defined. If cherry picking is truly a poison in the healthcare system, patient engagement may be the antidote, inasmuch as it makes it more possible for doctors to provide high quality care and achieve favorable patient outcomes, which supersedes financial gain.

Cherry picking is not totally unchecked inasmuch as HMO healthcare plans, which are fairly prevalent, prohibit primary care physicians from rejecting patients who have selected them as their primary providers. Doctors however, have the option of terminating relationships with patients, particularly if they are not inherent or compliant with the treatment provided them. Moreover, physicians have the freedom to not accept patients with other forms of insurance as long as the reason is not discriminatory based on ethnicity, creed or gender. In either case, selectively rejecting or terminating a patient engenders the attitude on the part of the patient, “the grapes were sour anyway.”

It is difficult to know at this time how prevalent patient cherry picking is or will become over time, but most likely can be tempered by the fact that many physicians derive great satisfaction from providing quality healthcare and experiencing good patient outcomes, particularly in patients that are very sick with severe medical problems. By empowering patients or their caregivers with health-literacy enhancement resources that enable them to become engaged in their healthcare in ways that are mutually beneficial with respect to achieving quality improvement in health care, many will be the types of patients doctors selectively prefer to treat, or essentially cherries instead of sour grapes.

So, back to the original question, does patient engagement cultivate cherries or prevent sour grapes? The answer is, probably both. After all, the fox called sour not only those grapes that he could not reach, but also those that he did reach, but had taken from him. The math will just have to play itself out.

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Days Gone By – Adapting to a New Reality in Health and Wellness

Success: A Challenge to Change.

Western medicine systems based around hospitals, highly trained professionals and high-tech equipment with little role for patients and care-givers has been remarkably successful. Indeed, science and technology are continuing to revolutionize healthcare: who would argue many infectious diseases have been controlled, maternal health (mother/newborn mortality) improved and that vaccine development has curtailed large-scale viral epidemic.

However, as our populations grow older and they suffer more from long-term conditions such as diabetes, cancer, Alzheimer treatment/care and coronary disease — they can’t simply be treated with a system of diagnosis and control set up to fight the diseases of a half century ago.

The basic problem in all wealthy countries is diseases have changed but health services haven’t really. The health problems of the early 21st century are not the same as those of the middle of the 20th century — when current western healthcare systems were formed.

They require services in the home and community as well as in the hospital and, critically, the involvement of patients and care-givers.

Larger Effect on Disease than Smoking

As reported in 2010, an analysis (of the Behavioral Risk Factor Surveillance System data from1993 to 2008 of 3.5 million adults) by researchers at Columbia University and The City College of New York showed that obesity now had a larger effect on disease, while smoking had a greater impact on deaths. Why? The number of adult smokers decreased 18.5 percent over that time, while the proportion of obese Americans increased 85 percent.

Findings like these now account for an increasing majority of illness and healthcare costs in richer countries.

Of course, as witnesses by highly publicized healthcare reform last year, changes are trying to be made. Yet, reimbursement systems reinforce the old model, institutions and professional training are largely constructed around it, commercial interests promote it and the public see hospitals as the bedrock of healthcare.

Dread Cost of the Clinic; Fear Change Even More

As we’ve seen most challenging of all are questions about resources. What should someone do if they can’t afford the system but fear approaching (generally) more affordable alternative or complementary medicinal techniques?

The answer appears to lay in grassroots wellness training of health workers and introducing technology that is “translatable in education and practice” to the mainstream. Today many emerging health professionals are very interested in global health and eager to experience and learn from cultures and countries unconstrained by our healthcare history.

Competence, Professionalism and Cooperation in Holistic Healthcare

For example a small but vibrant educational institution in the Pacific Northwest of the USA is training people differently, creating new sorts of viewpoints, engaging families and communities and concentrating more on promoting health rather than on just tackling disease. The American College of Healthcare Sciences (ACHS) fosters competence, professionalism and cooperation in holistic healthcare. Graduates build a holistic foundation for personal health care and rely on finding ways to use, preserve and share knowledge in natural medicine to provide for patients. ACHS students are gaining the all-round expertise that will help them to become the health professionals we need for the 21st century.

And governments can do much more to support efforts such as these, just as the US Department of State relies on a “3-D” philosophy to advance their mission: defense, diplomacy and development. Governments can promote the exchange of ideas and people and help health and wellness workers from richer countries to work in poorer countries. In doing so they will learn for themselves the subtitles of cultural and social health practice and, at the same time, help to repay a debt for the many professionals who have migrated to richer countries. As the Department of Defense has shown it can be a win-win situation from which we will all gain. Security can beget peace which can lead to even greater sustainable development.

As Lord Nigel Crisp, former chief executive of the NHS and Secretary of the Department of Health in England notes in his new book Turning the World Upside Down: The Search for Global Health in the 21st Century: “when old methods no longer work, are we willing to look outside the mainstream for new ideas? Or are we content to stick with professional structures and working arrangements created 50 years ago?”

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