Definition

Individual active participation in health (IAP) is centered on the notion that if individuals follow a healthy lifestyle, make good choices such as exercising, maintaining a healthy weight, and not smoking, and are good patients (keeping appointments, heeding physicians' advice, and using healthcare services in an appropriate way) they will be rewarded with increased health, happiness, productivity and eventually financial savings.

IAP is a complex concept influenced in part by external factors outside an individual’s direct control. We must recognize that:

1. Taking responsibility for one’s health, such as proper use of seatbelts and being immunized against disease, may reduce the likelihood of developing a medical condition, but by no means eliminates all risk. Healthy people can still get very sick and accidents still happen.
2. Individuals are one player in a larger healthcare system. Providers, insurers, governments, employers, communities, volunteer health organizations, and families all have a shared responsibility to encourage individuals to actively participate in their health and healthcare decisions.
3. Cultural norms dictate expectations for IAP and vary from one country to another.
4. While health systems differ from one country to another, systems should support individuals by promoting accountability and providing transparency of information.

Successful strategies for promoting IAP include:

1. encouraging individuals at an early age to engage in a life-long commitment to health and wellness;
2. emphasizing the availability of community supports such as providers, families, health advocates, and employers;
3. promoting healthy lifestyle choices by sharing positive aspects and negative consequences of health choices; and
4. providing individuals with the tools to move beyond traditional passive patient roles to become more active participants in their healthcare choices.

Relevance and Challenges

Unhealthy lifestyles are ubiquitous in developed countries and gaining scope and speed in threshold and poor countries. Tobacco use, poor diet and lack of exercise contribute to the four major chronic diseases: heart disease, type-2 diabetes, lung disease and some cancers, and these are responsible for over half of all deaths worldwide.

Experts suggest an estimated 80% of heart disease, stroke and type-2 diabetes, and 70% of all cancers are avoidable if common lifestyle risk factors were eliminated. In 2005, cardiovascular disease, chronic lung disease, cancers and diabetes resulted in more than 35 million deaths - approximately 60% of the world's deaths. Without action, experts project this number will rise by more than 40% by 2020.

Further compounding health issues, lack of health insurance coverage and access to timely interventions and advice often result in inefficient use of healthcare services when early treatment is vital and less costly. As a result, avoidable chronic diseases and delayed treatments place a heavy burden on healthcare systems and patients, resulting in higher health insurance premiums and/or higher taxes to support the system, loss of productivity, and poor health outcomes.

Context

In order to combat these staggering health statistics, individuals along with employers, insurers, health providers, families, educators, public health, and health advocates must be included in programs promoting IAP. Lifetime participation, as well as family involvement and early education are vital for a commitment to wellness to take root.

Successful programs use a variety of financial and non-financial incentives. Research has found that programs that include positive incentives or emphasize the positive aspects of health have proven to be equally if not more successful than those which exclusively emphasize the negative consequences of poor lifestyle choices. Many successful programs, such as smoking cessation programs, “five-a-day” fruit and vegetable nutrition programs, or children’s fitness programs all emphasize positive messages about health along with traditional health information.

Innovative Options – Select Country Cases

There are many exciting emerging and established practices addressing IAP. In the area of emerging practices, Johns Hopkins University is pioneering predictive modeling programs that would permit employers to use diverse criteria to target at-risk employees and direct them to better health choices. Genetic researchers are working on programs that would permit individuals to make preventative health decisions based on their specific genetic make-up. Private and public groups are developing electronic health record systems that would allow information to be accessed by any provider at any point of service.

Other, more established efforts are also being promoted globally. The following section focuses on established evidence-based, country-specific examples of efforts to improve individual active participation in health.

Encouraging involvement in health plan selection

In the Netherlands, the government requires residents to participate in their healthcare choices by mandating health insurance coverage. The Government also requires that providers accept all applicants and charge them the same rate for basic coverage regardless of risk. To aid residents in selecting a plan, the government hosts a website which includes detailed information on all insurance policies with respect to price, services, and consumer satisfaction, as well as performance data comparing hospitals and providers across a multitude of indicators.

The public reporting of performance measures also stimulates managed competition. By providing access to transparent data, patients are able to make informed choices among health plans and providers; insurers have the ability to make informed purchasing decisions; and providers may use consumer/patient experiences to improve the client-centered nature of their services.

The Government also uses financial tools to encourage individual responsibility. The Government introduced a mandatory deductible for insured individuals age 18 or older for all basic health plans to increase efficiency by avoiding unnecessary medical consumption. Financial incentives are also used to encourage self-care management. Reducing the deductable and increasing other financial support for people with unavoidable long-term health expenses due to chronic illness or disability is an incentive to reward them for high levels of engagement in their health care decisions.

Self-Care Management/Shared Decision Making

Self-care management – also termed shared-decision making –is another tool health systems use to promote educated healthcare choices. Used primarily for long-term or chronic illness, self-care management increases an individual’s voice and involvement in the direction and coordination of care. In concept, self-care management reduces fragmentation and overuse of services, by encouraging consumers to 1) assume responsibility for their own treatment plan and lifestyle change goals; 2) seek self-care information; 3) ask for the care that they need; and 4) say “no” to the care that is not right for them.

Health insurance plans may encourage self-care management by providing patients with educational tools and resources to make healthcare decisions. Healthwise, a U.S.-based company, develops consumer health content specifically for hospitals, health plans and disease management companies specifically designed to help individuals decide when to contact health providers, how to talk with physicians, and how to live better with chronic diseases. The concept is to provide individuals with the right information, at just the right time, to help them to have a stronger voice in their health decisions.

Cost Controls and Individual Responsibility

In Japan, IAP exists within the confines of a historically paternalistic culture where providers have not always shared diagnostic information with patients. In 1997, the Japanese Government granted patients access to medical bills, however physicians were still permitted to veto the release of these documents. In this case, expectations for individual responsibility must be measured against cultural traditions.

The Japanese health system has historically permitted open access to specialists in part due to the small number of "general practitioners," or family doctors. The Japanese Government has examined ways to certify more general practitioners, and yet despite the shortage, patients in Japan are more likely to visit physicians that patients in other countries. Supporters of the increased access argue that allowing individuals to take responsibility for their own health and seek medical attention sooner may contribute to lower overall healthcare costs. A comparison of U.S. (the country with the highest healthcare costs in the world) and Japanese healthcare data show that the Japanese generally take earlier action when they feel ill, possibly resulting in lower healthcare costs.

With future changes uncertain, the Japanese Government presently balances open access to care with Government imposed cost containment measures. The Government manages costs by negotiating a standardized fee schedule every two years for all services across all health plans. The Government sets the threshold for which all insurers may reimburse providers for similar services provided to any patient, including those on public assistance. Costs are also contained because the reimbursement system for surgeons and other specialists is salaried rather than fee-based, so there is no financial incentive for hospitals to undertake unnecessary procedures.

Personal Health Records

Though in its infancy in many countries, electronic health records (EHR) or personal health records (PHR) are an innovative option to improve quality, efficiency, and IAP in health care. Private sector companies such as Google, Microsoft and IBM have launched efforts to develop software to make it easy for individuals, with the assistance of primary care physicians, to develop and maintain their own personal health record. The belief is that by granting individuals ownership of their health record, they will be more aware of and responsible for their health.

In 2003, the Danish Minister of Health announced a goal to implement EHRs in general practitioner offices and hospitals by 2005. The National Board of Health developed an information model for EHR systems and for data access between EHR platforms. The model requires information based on period of care, problem orientation and cross-professional documentation. When fully implemented, it will be possible to follow the interventions made and assess the results achieved for a specific patient problem – regardless of which health care party provides the service.

This effort to fully implement EHRs was undertaken with vigor and reached 90% penetration in primary care practices by 2006. Efforts to implement EHRs in hospitals encountered resistance and were not as successful. Experts suggest that the failure was due to a fragmented and expensive system that permitted counties to build their own systems. A 2005 report projected the possibility that hospitals would not fully implement EHRs until 2020.

Denmark is not alone in their efforts to build a coordinated, national EHR system. Governments in Australia, Canada, Finland, France, New Zealand, the United Kingdom, the USA and other countries have announced - and are implementing - plans to build integrated computer-based national healthcare infrastructures based around the deployment of interoperable electronic medical record (EMR) systems. Many of these countries aim to have EMR systems deployed for their populations within the next 10 years.