Revisiting Patient Engagement and Empowerment Within the NIMHD Health Disparity Framework

The US health care delivery system is at a pivotal juncture in addressing and reducing health disparities.¹ The COVID-19 pandemic has underscored how vulnerable patient populations in our US health care system are disproportionately experiencing barriers to accessing health care and receiving needed care.² Such health disparities, or rather “the health differences closely linked to economic, social, or environmental disadvantage [that] adversely affect groups of people who have systematically experienced greater social or economic obstacles in health,” have revealed worse health outcomes by gender, race, ethnicity, socioeconomic status, religion, and other factors.^3(p6) In this issue of AJPH, Call et al. (https://bit.ly/3B4RWXj) examined insurance-based discrimination in Minnesota. The study showed that patients who were uninsured or had public insurance experienced higher rates of insurance-based discrimination than patients with private insurance.

Framing this work within the National Institute on Minority Health and Disparities Research (NIMHD) Framework can offer insights into the study’s observed findings.¹ According to the NIMHD Framework, health disparities persist across multiple domains (biological, behavioral, physical or built environment, sociocultural environment, and the health care system) that influence health outcomes at numerous levels (individual, interpersonal, community, and societal).¹ To adequately tackle multiple complexities and barriers to health—including insurance-based discrimination—policies must address both interpersonal and systemic issues in our country through policy reform, patient engagement, and overall better patient care for vulnerable and minority communities.

ENHANCING PATIENT–PHYSICIAN INTERACTIONS

The NIMHD Framework highlights various levels for improvement, starting at the individual and interpersonal levels. At the individual level, health literacy limitations and patients’ responses to discrimination are stressors that have biological, behavioral, and interpersonal implications. Secondly, interpersonal levels of influence within the sociocultural environment and health care system, such as patient–provider (interpersonal) relationships and trust, as well as medical decision-making between patients and providers, are factors that cannot be overlooked. By focusing solely on one domain or level, we may fail to consider policies that can best lead to better-quality health care.

Thus, we must consider interventions starting with the patient–physician relationship. This relationship is bidirectional; therefore, approaches can be calibrated toward each group. Physicians have cited difficulties communicating with patients as one of the challenges faced in providing high-quality care.⁴ Providing culturally sensitive personalized interventions can help sustain patient involvement in taking an active role in health care decision-making. As mentioned by Call et al., cultural competency training among physicians can improve the overall patient experience.

Additionally, the importance of patient activation, confidence, and empowerment—core components of the personalized patient activation and empowerment model for improved population health and reduction of racial and ethnic disparities—cannot be understated.⁵ Patient empowerment, defined as the process through which people gain confidence and power over decisions and actions affecting their own health, calls for patient knowledge, participation, self-efficacy, and health literacy, and for facilitation of a workplace promoting empowerment.^6,7 By being encouraged to gain knowledge of their health conditions, treatment plans, or health care access from providers, patients can be more motivated to communicate about their health needs, express their health concerns, and be activated and more engaged in their health care and with the providers with whom they interact.

Other approaches, such as improving patient–physician concordance and tackling language barriers and related issues inhibiting patient-driven health care, may enhance patient experiences. Studies have shown that physician–patient concordance improves health outcomes.⁸ By using approaches that consider key elements between patients and physicians, we as a nation are taking important steps toward better health outcomes and quality health care.

PROMOTING POPULATION HEALTH

Although the interaction between patients and physicians is an important determinant of patient care, there are other factors that impede patient care, particularly for vulnerable populations. According to the NIMHD Framework, interventions must address numerous facets to enhance patient and provider experiences collaboratively.

The study by Call et al. captures one of the disparities observed at the societal level of the NIMHD Framework: insurance-based discrimination. The authors call attention to different reimbursement rates of public and private insurance. Indeed, Medicaid has a lower reimbursement rate than either Medicare or private health plans. The reimbursement rate of Medicaid is associated with physicians’ decisions to accept new Medicaid patients, influencing access to high-quality patient care and health outcomes in the long run. Recent research suggested that closing the gap in reimbursement between Medicaid and private insurance would reduce disparities in access among adults by more than two thirds.⁹ Access to high-quality health care and resources is a key component of social determinants of health, according to the NIMHD model.

To advance population health, pragmatic integration of the financing (e.g., reimbursement model), delivery (e.g., a coordinated health care system instead of siloed health care sectors), and health production (e.g., patient–physician relationship) sectors are needed in the United States. It is also important to acknowledge the interrelationship and interdependence of these components.

SYSTEMATIC APPROACH TO IMPROVE PATIENT-CENTERED CARE

Increasingly, policymakers, researchers, and health advocates have promulgated the quadruple aim as end goals for advancing health care delivery, where enhancing the patient experience, improving population health, reducing cost, and improving the work life of health care providers are fundamental paths to resolving health disparities and improving health care for all.¹⁰ To achieve these aims, policies must center around patients. Recognizing the disparities in our system is one step toward achieving these aims; by actively enabling patients to participate in their care, we can move closer to equitable health care for all.

Incorporating patient–provider relationships into innovative health care delivery models, such as the patient-centered medical home (PCMH) model, presents an untapped opportunity to promote patient-centeredness and the patient experience. As suggested by its name, the PCMH model’s core element centers around patient experience.¹¹ Implementing Consumer Assessment of Healthcare Providers and Systems surveys may help shed insight into modifiable factors of patient experiences, such as physician communication and the patient–provider relationship.

In addition, investments in care coordination practices and integration, along with innovative health care delivery models such as accountable care organizations, present an important opportunity for promoting continuity of care and patient experience.¹² As such, policies incentivizing approaches that enhance the patient–provider relationship can help tackle discrimination and promote health equity in the US health care system.

Future policies must look to the new normal post-COVID-19 era and consider innovative solutions that can enhance the patient experience while addressing structural-level barriers, social determinants of health, and other factors limiting access to affordable, quality health care. Understanding and enhancing the patient experience stems from addressing individual-level factors and factors affecting the environment, community, and organizations entrenched in delivering health care.