How Engaged Are American Consumers in Their Health and Health Care?

New Study Offers Baseline Snapshot of Patient Activation Levels for U.S. Adults

News Release
Oct. 16, 2008

FURTHER INFORMATION, CONTACT:
Alwyn Cassil (202) 264-3484 or acassil@hschange.org

WASHINGTON, DC—The level of patient activation—a person’s ability to manage their health and health care—varies considerably in the U.S. population, with less than half of adults (41.4%) at the highest level, according to a national study released today by the Center for Studying Health System Change (HSC).

The Patient Activation Measure (PAM) was designed to assess an individual’s knowledge, skill and confidence in managing their health and consists of a 13-item scale that asks people about their beliefs, knowledge and confidence for taking an active role in their health and health care. Based on responses to the 13-item scale, each person is assigned an activation score.

Prior research using the PAM has relied on relatively small samples or groups, such as health plan enrollees, Medicaid enrollees in several local areas, and older adults with chronic conditions. HSC’s 2007 Health Tracking Household Survey is the first large nationally representative survey—information on 13,500 adults—to include the PAM to assess the level of activation in the U.S. population. HSC is a nonpartisan health policy research organization funded in part by the Robert Wood Johnson Foundation, which funded the survey and the study.

Activation levels are especially low for people with low incomes, less education, Medicaid enrollees, and people with poor self-reported health. Higher activation levels are associated with much lower levels of unmet need for medical care and greater support from health care providers for self-management of chronic conditions, according to study.

"Previous research shows that patient activation levels are linked to important outcomes, such as seeking care, seeking information and health behaviors, and because activation is changeable, it is a potentially important lever for change in the health care system," said Judith Hibbard, Dr. P.H., of the University of Oregon, coauthor of the study with HSC Senior Fellow Peter J. Cunningham, Ph.D.

"It appears that when there’s a good relationship between patients and their doctors, the patients are more engaged, and more likely to receive high-quality health care," said Anne F. Weiss, M.P.P., senior program officer and team leader for the Robert Wood Johnson Foundation’s Quality/Equality strategy. "Doctors need to talk with their patients about setting goals for their health and how to monitor their conditions. And since we know that activated patients fare better and ultimately cost less, policy makers should consider encouraging health systems to find ways to activate their patients."

Four levels of patient activation have been identified. At the first or lowest level, people tend to be passive and may not feel confident enough to play an active role in their own health. At the second level, people may lack basic knowledge and confidence in their ability to manage their health. At the third level, people appear to be taking some action but may still lack confidence and skill to support all necessary behaviors. At the fourth level, people have adopted many of the behaviors to support their health but may not be able to maintain them in the face of life stressors.

The study’s findings are detailed in a new HSC Research Brief—How Engaged Are Consumers in Their Health and Health Care, and Why Does It Matter?—available here.

Other key findings include:

• There is a substantial amount of variation in activation levels across the U.S. population. Those who are younger, more educated and have higher incomes tend to be more activated. Similarly, those with private health insurance tend to have higher activation than those with Medicaid or those with only Medicare. Racial and ethnic differences in activation are also apparent, with Hispanics having much lower activation levels compared with other groups.
• Most of the differences in activation by education, race/ethnicity, age and insurance coverage remain after controlling for other characteristics. The one exception is that income differences narrow considerably after controlling for education, meaning that most of the income difference in activation reflects differences in educational attainment that are correlated with income.
• Activation also varies by the type and number of chronic conditions, as well as other measures of health status. Overall, people with chronic conditions are more likely to have lower levels of activation—about 26% in Level 1 or 2—compared with people without any chronic conditions—about 18% in Level 1 or 2.
• People with chronic conditions who are at lower activation levels are much more likely to report unmet medical needs, to delay care and to have unmet prescription drug needs. Less activated people are also somewhat less likely to have a usual source of care. These differences remain even after controlling for socioeconomic and health status and likely reflect the more passive approach that people at lower activation levels often take in managing their health.
• At the same time, people with chronic conditions who are more activated appear to get more support from their providers in managing their health. For example, 83.6 percent of those at the highest activation level reported that their health care provider helped them to set goals to improve their diet, compared with 48.3 percent at the lowest activation level.

The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by the Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.