Abstract
The cost of care is shifting to the individual in the form of high-deductible health plans and health savings accounts. The public demands and expects innovation in health care and health delivery and is using quality and cost data to make purchasing decisions. Public expectations for convenience are demonstrated in the use of walk-in clinics, telemedicine, and other technologies. As a result of the responsibility for paying and managing one’s own health, consumerism involves a curated approach to selecting health services. This Health Policy Perspectives column examines how consumerism influences health care policy, in particular occupational therapy service delivery. Issues that consumerism creates include (1) a lack of publicly shared cost and quality data about occupational therapy; (2) confusion in measurement of client-centered care, patient satisfaction, and patient experience; (3) inadequate incorporation of patient shared decision-making throughout the occupational therapy process; and (4) payment model restrictions in service delivery. Occupational therapy practitioners must help consumers learn, through patient shared decision-making, that occupational therapy is evidence based and produces desired outcomes, thereby both improving the quality and lowering the cost of health care. Occupational therapy practitioners must advocate for lower cost and convenient service options in the community through an array of technologies. Practice scholarship of the clinical doctorate in occupational therapy must focus on conducting consumer research related to patient experience; enhancing service delivery through quality improvement; and innovating practice for new sites and methods of service delivery, including the use of technology.
This Health Policy Perspectives column examines how consumerism influences health care policy, in particular occupational therapy service delivery.
Health care innovation is driven partially by the cost of care, which has been shifting to the individual in terms of high-deductible health plans and health savings accounts. According to DeMarco (2023), 55.7% of workers were enrolled in a high-deductible health plan, contributing in 2021 to the 10.4% increase in out-of-pocket spending of $433.2 billion (Centers for Medicare & Medicaid Services [CMS], n.d.-c). The rising costs, along with the growth in purchasing power of the public, create a demand for understandable quality and cost data.
Purchasing decisions also reflect the public’s expectation for convenience; there is an increasing prevalence in use of walk-in clinics, telemedicine, and concierge medicine (a health care model in which a patient pays a fee to see their providers; Ho & Offodile, 2018). This trend for convenience and for a curated approach to selecting health care and health services is referred to as consumerism, defined as the “personal choice and responsibility in paying for and managing one’s own health” (Heath, 2020, “What Is Healthcare Consumerism?” section). In this Health Policy Perspectives column, I discuss how consumerism influences the evolution of health care policy, in particular noting the way occupational therapy service delivery is expected to innovate within systems, meet demands for convenience, and incorporate digital applications for the delivery of health and health care. Because of the focus on health care delivery, the term patient is used except when using the occupational therapy term client-centered care.
Components of Consumerism
In Table 1 the forces or trends for consumerism are listed (Reese, 2020); one can see that the movement depends on accessible and easily understandable cost and quality data, as originally outlined in the Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148). Evidence for the effectiveness of this public sharing of cost and quality data in curtailing costs and decreasing utilization remains mixed, partially because of inefficiencies in the health care system.
Alignment of Consumer Trends With CMS Strategic Plan Pillars
Note. CMS = Centers for Medicare & Medicaid Services; EHR = electronic health record.
In addition, there remains a consumer perception that more costly services reflect higher quality care (Ho & Offodile, 2018). Health care providers must practice patient shared decision-making (SDM) so that patients learn, regardless of literacy level, how evidence may support the quality of lower cost options in producing desired outcomes (Politi et al., 2023). Elwyn et al. (2012) defined SDM as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options to achieve informed preferences” (p. 1361).
Occupational therapy practitioners should examine the CMS (n.d.-d) strategic plan, which includes six strategic pillars. In Table 1, the consumer trends discussed previously are aligned with the CMS strategic plan to demonstrate how the strategic pillars promote consumerism. As one example from the strategic plan (see Table 1), the pillar “Engage partners and communities” reflects the agency’s stated commitment to give beneficiaries a strong voice in all aspects of policy development and implementation. Therefore, researchers and practitioners should understand the patient experience in occupational therapy, thereby creating important recommendations for CMS policy (Picotin et al., 2021).
Occupational Therapy and Consumerism
Issues in Publicly Shared Cost and Quality Data
CMS requires various quality reporting, such as the Skilled Nursing Facility Value-Based Purchasing Program for skilled nursing, among others (CMS, n.d.-e). CMS shares with the public provider organizational data from the required quality reporting (CMS, n.d.-a). Thus, occupational therapy practitioners must explain to patients how their services contribute to the overall cost and quality rating of a particular organization.
Issues in Client-Centered Care
Law et al. (1995) defined client-centered practice as “an approach to providing occupational therapy that embraces a philosophy of, respect for, and partnership with, people receiving services” (p. 253). The terms client-centered, patient satisfaction, and patient experience are not the same (Agency for Healthcare Research and Quality [AHRQ], n.d.-b). For example, patient experience encompasses the range of interactions that patients have before, during, and after occupational therapy with a variety of health plan administration staff and health care providers and their administrative personnel. Patient experience surveys focus on provider communication, coordination of care, timeliness of care, and access to information. Because patient experience includes and goes beyond the occupational therapy encounter or patient visit, patients may not view occupational therapy practitioners as client centered because of barriers to health care access (Mroz et al., 2015). Patient satisfaction refers to whether a patient’s expectations have been met, and satisfaction may vary across patients for the same type of visit because of their differing expectations (AHRQ, n.d.-b).
Because these terms have subtle differences, their measurement has different contributions to determining quality. Client centered refers to what the occupational therapy practitioner does in respecting and partnering with the patient and their family (Mroz et al., 2015), including creation of client-centered goals (Kessler et al., 2019). Patient satisfaction is often measured after each patient visit, with surveys asking the patient to weigh satisfaction against their expectations (Kupfer & Bond, E., 2012). To assess patient experience across the totality of the patient visit (i.e., interactions with multiple organizational administrative staff, the providers of care, and health plan administrators), the focus is on what should happen and whether components of this experience, such as communication, happened (AHRQ, n.d.-b). Good communication with the patient involves using jargon-free dialogue, repeating information, giving clear and concise explanations, using teach-back techniques to check understanding, listening, encouraging questions, and offering supplemental materials (Quigley et al., 2013).
To ascertain patient experience, health care organizations use the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys, a part of CMS’s value-based purchasing initiatives (CMS, n.d.-b). There are versions that target the site of service delivery, such as a hospital or skilled nursing facility. Incorporating the results of these CAHPS surveys into quality improvement may be useful for occupational therapy practitioners; however, occupational therapy practitioners may need to collect additional data about patient centeredness, satisfaction, and experience with occupational therapy that would inform specific service delivery redesign and policy development.
Issues in Patient Shared Decision-Making
Patient SDM is not widely implemented in occupational therapy as an aspect of evidence-based practice and client-centered care (Moyers et al., 2021). It should occur throughout the occupational therapy process whenever patient decisions require an understanding of the evidence for an intervention or a care transition, its outcomes and cost benefits, and delivery methods (Weaver et al., 2021).
Many occupational therapy practitioners are reluctant to share with patients the decision-making process about selecting various cost-effective and evidence-based options (Delany & Galvin, 2014). This reluctance often arises from the occupational therapy practitioner’s concern about their productivity and time restrictions (Cahill & Richardson, 2022) along with the safety concerns resulting from the patient’s capability (e.g., persons with dementia or persons with severe mental illness) to participate in decision-making (Moyers et al., 2021). The occupational therapy practitioner may also be concerned with their own limitations in providing evidence-based information about care that can accommodate patient preference (e.g., fewer patient visits than what is recommended) and can be adapted to the patient’s level of cognition and literacy (Cahill & Richardson, 2022).
Issues in Service Delivery
Occupational therapy sites of service delivery are limited by restrictive policies of health plans, such as inconsistent support for occupational therapy in primary care (Rouch et al., 2022) or for occupational therapy as a part of ambulatory services in federally qualified health centers (Murphy et al., 2017), innovative home services models (Li et al., 2022), or community-based mental health programs (Stoffel, 2013). The convenience of occupational therapy services is often jeopardized because of inadequate discharge planning for service implementation at the next site for care (e.g., transferring from acute care to outpatient), which often results in lengthy delays from referral to implementation of occupational therapy services at the transition site (Asif et al., 2020). Another issue is restriction of the number of patient visits outlined in health plans for outpatient services (Pergolotti et al., 2018). Occupational therapy research and evidence should support the number of visits given the expected outcome associated with the patient’s service need (Carvalho et al., 2017).
Consumer-Based Occupational Therapy
To address the driving forces of consumerism, in this section I focus on three strategies, including practice scholarship as the focus of the clinical occupational therapy doctorate (OTD), infusion of patient SDM throughout the occupational therapy delivery process, and design of and advocacy for innovative services to meet consumer demand.
Scholarship of the OTD
The practice scholarship of the OTD, partially because of Accreditation Council for Occupational Therapy Education (ACOTE®; 2018) accreditation standards for entry-level OTD programs, overemphasizes the student production of research that may or may not advance practice. The initial draft of revisions to the ACOTE standards (ACOTE, n.d.) to be implemented when approved in 2025 currently requires the student to participate in scholarly activities and to design a scholarly study. I recommend that ACOTE define practice scholarship for the OTD as including quality improvement, outcomes measurement, and the fidelity of the data collection and analysis of value-based quality information. Practice scholarship also involves expertise in consumer research, program development and evaluation, evidence-based practice, implementation science, and innovation. With a clear definition of practice scholarship, engaging in scholarly practice activities and designing a scholarly practice study prioritize the advancement of occupational therapy practice. The profession should incentivize this practice scholarship through dissemination in occupational therapy journals.
Patient Shared Decision-Making
The current SDM literature has focused on decisions about surgery, medications, and procedures (Ottawa Hospital Research Institute, n.d.-a). Occupational therapists should make a concerted effort to develop these SDM resources (e.g., decision guides and templates) that incorporate evidence-based interventions targeted to a variety of preferences for site of service delivery and frequency and duration of services. The American Occupational Therapy Association’s (AOTA’s) practice guidelines, systematic reviews, and other evidence-based resources are foundational to developing these SDM guides (AOTA, n.d.). A generic template from the Ottawa Hospital Research Institute (n.d.-b) helps organize the evidence-based occupational therapy interventions for patient discussion and decision-making. In the future, AOTA should not only create these decision guides but also adopt criteria for their development. Continuing education and infusion of SDM into entry-level curricula would foster implementation throughout the occupational therapy process (AHRQ, n.d.-a).
Advocacy for Innovative Services
Advocacy for policy change at the federal and state levels, as well as with private health insurance companies, is needed to promote the consistent expansion of sites for service delivery, to include primary care, innovative home services, community-based mental health, health promotion, and telehealth and other digital technologies. Evidence for cost savings when occupational therapy is provided in less intensive care settings is basic for this advocacy (Kjerstad & Tuntland, 2016). Advocacy must also target the consumer, who is making purchasing decisions to control their own out-of-pocket costs. Occupational therapy practitioners must make a concerted effort to share data with the public about patient satisfaction, experience with occupational therapy in comparison with cost incurred, and how demands for choices that reflect their values and preferences are met.
Conclusion
With the advent of growing out-of-pocket costs, consumers expect changes in health care and health service delivery. Demands for innovation in occupational therapy service delivery will continue as information about patient experience and public reports of cost and quality are incorporated into value-based payment. Occupational therapy practitioners must advocate for changing the sites of service delivery, to lower cost options in the community and to facilitate service delivery through an array of technologies. In their advocacy, they also must help consumers learn that occupational therapy improves the quality and lowers the cost of health care. Scholarship for the OTD must focus on practice, including quality improvement, patient SDM, outcome measurement and reporting, and evidence-based practice change methodologies.