Eliciting Patients’ Perspectives on Value to Prioritize Quality Improvement

From the 2018 HVPAA National Conference

Matthew DeCamp (Johns Hopkins University Berman Institute of Bioethics and Division of General Internal Medicine), Carlessia Hussein (Maryland Office of Minority Health and Health Disparities (retired)), Sarah Himmelrich (Office of Johns Hopkins Physicians), Lindsay Hebert (Johns Hopkins Health Care), Sarah Conway (Johns Hopkins School of Medicine and Johns Hopkins Medicine Alliance for Patients, LLC), Arielle Alvaro (Johns Hopkins Health Care), Vadim Dukhanin (Johns Hopkins Bloomberg School of Public Health Center for Health Services & Outcomes Research), Scott Feeser (Johns Hopkins Community Physicians and Johns Hopkins Medicine Alliance for Patients, LLC), Scott Berkowitz (Johns Hopkins School of Medicine and Johns Hopkins Medicine Alliance for Patients, LLC)


Value in health care can be defined from different perspectives, including those of society, payers, health care organizations, and patients. Value-based quality improvement activities are likely to be more successful and patient-centered when they align with the expressed needs and preferences of patients.


To elicit patients’ perspectives on which health care services they would value within the context of a Medicare accountable care organization (ACO), the Johns Hopkins Medicine Alliance for Patients (JMAP)


From May-July 2017, we conducted a mail-based survey of all 31,687 Medicare beneficiaries attributed to JMAP with a valid mailing address in the electronic health record. The survey included previously validated survey items and de novo items developed in collaboration with JMAP’s Beneficiary Advisory Council, a volunteer group of JMAP beneficiaries spanning the network that helps improve the quality and value of care JMAP provides.


3,061 beneficiaries responded (response rate, 9.6%). Respondents’ self-reported health care utilization was consistent with the general Medicare population: 29% of respondents reported having obtained care 5 or more times in the past 6 months and 49% reported having obtained care 1-4 times. Respondents reporting “poor” or “fair” overall health status were slightly underrepresented in our sample. Over half of respondents (51%) were aware of JMAP; among these, 23% reported learning of JMAP through mailings or clinic signage and 21% reported learning via their medical care team.  The top two services respondents would be “likely” or “very likely” to use were access to urgent appointments with specialists (81%) and care coordination services (72%).  Regarding other queried services, respondents held split opinions. For instance, while nearly half (44%) of respondents were “unlikely” or “very unlikely” to use video visits with providers (the least preferred potential service), 30% would be “likely” or “very likely” to use video visits.  Similar bimodal distributions were observed regarding wearable home-based self-monitoring devices (e.g., pedometers or blood pressure cuffs), behavioral therapy in primary care offices, and pharmacist support services.


Eliciting patients’ direct preferences regarding the types of health care programs they would be likely to use can help ensure value-based quality improvements are consistent with patients’ values. In this case, because JMAP had implemented programs coincidentally to improve access to urgent appointments with specialists and enhance care management for particular patient populations, the survey with input from JMAP beneficiaries offered support for those programs. At the same time, survey findings suggested additional consideration prior to widespread implementation of video visits and other services.  Additional research is needed to understand which patients may be eager to use some new programs (while others may not) and why patients hold these differing opinions.

Implications for the Patient

Health care system transformation requires incorporating the patient’s perspective on value, in that care programs are only likely to succeed when patients desire them or when they are targeted to the patients who desire them. Patient surveys may help health systems prioritize among the many value-based quality improvement activities.

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