The measure is the percentage of patients who achieve a 3-point increase in their Patient Activation Measure® (PAM®) survey score within 12 months. The outcome measure demonstrates how a clinician group performed in providing best care to its patients by quantifying the proportion of patients who had at least a 3-point score change.
The PAM surveys the knowledge, skill, and confidence necessary for self-management on a 0-100 point scale that can be broken down into 4 levels from low activation to high activation. The 13 (or 10) item survey has strong measurement properties and is predictive of most health behaviors, many clinical outcomes, and patient experience. PAM® scores are also predictive of health care costs, with lower scores predictive of higher costs.
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1.5 Measure Type1.6 Composite MeasureNo1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.9 Care Setting1.10 Measure Rationale
The Patient Activation Measure® (PAM®) is a 10- or 13- item questionnaire that assesses an
individual´s knowledge, skills and confidence for managing their health and health care. The measure
assesses individuals on a 0-100 scale that can be converted to one of four levels of activation, from low (1) to high (4). The PAM performance measure (PAM-PM) is the proportion of patients who achieve a 3-point change in the 0-100 scale score on the PAM from baseline to follow-up measurement (CBE #2483). A positive change would mean the patient is gaining in their ability to manage their health. The measure is not disease specific but has been successfully used with a wide variety of chronic conditions, as well as with people with no medical diagnosis.
The PAM is predictive of most health outcomes, including such diverse outcomes as how a patient fares after orthopedic surgery; remission of depression over time; the likelihood of hospital re-admission or
ambulatory care sensitive (ACS) utilization; the trajectory of a chronic disease over time; and even the
likelihood of a new chronic disease diagnosis in the coming year. PAM scores are also predictive of
health care costs, with lower scores predictive of higher costs.
The PAM is in use both in the US and internationally in research (including more than 850 peer-reviewed
journal articles) as well as clinical settings. It has been translated into more than 30 languages. Because
researchers all over the world use PAM, we have been able to validate the instrument with people of
different racial and ethnic backgrounds, and with people from different socio-economic levels. The
measure has been shown to be valid and reliable in different clinical settings and under different
payment models.
1.11 Measure Webpage1.20 Testing Data Sources1.25 Data SourcesThe performance measure makes use of PAM survey data to quantify changes in patient activation over time. Administrative data, electronic health records, and/or paper patient medical records may also be used to help identify denominator exceptions and exclusions.
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1.14 Numerator
The numerator includes eligible patients whose PAM score increased by at least 3 points in a 6-12 month period.
1.14a Numerator DetailsThe numerator includes the count of eligible patients in a clinician group who had an increase of PAM survey score of at least 3 points, based on the difference between the baseline PAM survey and a second score taken between 6-12 months of the baseline.
The below rules should be applied to ensure appropriate patients are selected:
- All patients who have taken at least two valid PAM surveys between 180 and 365 days (6-12 months).
- The first survey should be set as the patient's baseline.
- The last survey administered between 180-365 days after the baseline survey should be selected as the follow up measurement.
- In the case where survey completion dates are not available, and data is organized by year at the patient level, one year may be joined to the following year.
- Patients with PAM level 1-3 in their baseline survey should only be included.
The following rules should be applied to ensure appropriate surveys are selected:
- Each PAM-13 survey has less than 4 missing responses; each PAM-10 survey has less than 3 missing responses.
- Surveys that have PAM scores between, but not including, 0 and 100 are included.
- Only surveys where answers come directly from the patient are included.
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1.15 Denominator
The denominator includes eligible patients with two PAM scores no less than 6 months and not more than 12 months apart who were seen for a qualifying visit at least once during the performance period.
Clinician groups would need to have two PAM scores on a minimum of 50 patients.
1.15a Denominator DetailsPatients aged 14 and older with two PAM scores no less than 6 months and not more than 12 months apart who were seen for at least one qualifying visit at least once during the performance period. Qualifying visits include visits with CPT codes 99201-99205; 99212-99215; 99324-99337; 99341-99350; 99381-99387; 99391-99397; 99490; 99495-99496; 98966-98968, 98969-98972, 99421-99423, 99441-99443, 99444 .
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1.15b Denominator Exclusions
Diagnosis of Dementia (ICD-10-CM): F01.5, F02.80, F02, F03.9, F10.27, F10.97, F13.97, F13.27, F18.17,
F18.27, F19.97, F19.17, F19.27, G31.0
OR
Diagnosis of Huntington's disease (ICD-10-CM): G10
OR
Diagnosis of Cognitive Impairment or Alzheimer’s disease (ICD-10-CM): A81.00, A81.09, G20.0, G30.0,
G30.1, G30.9, G31.01, G31.84, G40.909, I67.850, R41.0
1.15c Denominator Exclusions DetailsThe denominator exclusions are ICD-10 codes and do not require calculations.
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1.22 Are proxy responses allowed?No1.18 Calculation of Measure Score
Information for the measure calculation is collected via the PAM survey instrument, which is provided as an appendix to this application. The below steps should be completed to minimize bias and reduce workload burden on programs. Entities using the measure will be responsible for identifying eligible cases using electronic/automated queries, fielding the survey in the appropriate timeframes, and receiving, cleaning, and summarizing survey data for group-level quality improvement.
- Identify the denominator
- Patient aged 14 or older?
- Yes – Eligible
- No – Not eligible and do not include in the denominator
- Patient was seen for at least one qualifying visit during the performance period, defined as a visit with CPT codes 99201-99205; 99212-99215; 99324-99337; 99341-99350; 99381-99387; 99391-99397; 99490; 99495-99496; 98966-98968, 98969-98972, 99421-99423, 99441-99443, 99444?
- Yes – Eligible
- No – Not eligible and do not include in the denominator
- Patient does not have a diagnosis of dementia, Huntington’s disease, cognitive impairment or Alzheimer’s disease, as defined by ICD-10-COM codes (F01.5, F02.80, F02, F03.9, F10.27, F10.97, F13.97, F13.27, F18.17, F18.27, F19.97, F19.17, F19.27, G31.0, G10, A81.00, A81.09, G20.0, G30.0, G30.1, G30.9, G31.01, G31.84, G40.909, I67.850, R41.0)?
- Yes – Eligible
- No – Not eligible and remove from denominator
- Patient aged 14 or older?
- Identify eligibility for numerator within target respondent population
- Patient has taken at least two valid PAM surveys between 180-365 days (6-12 months)?
- Yes – Eligible
- No – Not eligible
- The baseline PAM survey score is between Level 1-3?
- Yes – Eligible
- No – Not eligible
- Each PAM-13 survey has less than 4 missing responses? OR Each PAM-10 survey has less than 3 missing responses?
- Yes – Eligible
- No – Not eligible
- PAM surveys have PAM scores between, but not including, 0 and 100?
- Yes – Eligible
- No – Not eligible
- Did the patient have an increase of PAM survey score of at least 3 points?
- Yes – Include in proportion who achieved measure
- No – Do not include.
- Patient has taken at least two valid PAM surveys between 180-365 days (6-12 months)?
- For those patients who meet the denominator criteria but have not achieved the 3 point increase, have denominator exceptions (Patients who are at PAM® Level 4 at baseline or patients who are flagged with extreme straight line response sets on the PAM®) been documented?
- Yes – remove from the denominator
- No – include in the denominator and performance is not met.
- Summarize performance on the measure
- Did the patient in the clinician group have an increase of PAM survey score of at least 3 points?
- Yes – Include in proportion who achieved measure
- No –performance is not met.
- Did the patient in the clinician group have an increase of PAM survey score of at least 3 points?
1.13a Data dictionary not attachedYes1.24 Data Collection and Response RateIndividual clinicians would need to have two PAM® scores on a minimum of 50 patients with two PAM® scores. We recommend groups attempt to survey each eligible patient to reach this minimum threshold.
The Patient Activation Measure® (PAM®) is a 10- or 13- item questionnaire that assesses an individual´s knowledge, skills and confidence for managing their health and health care. The survey assesses individuals on a 0-100 scale that can be converted to one of four levels of activation, from low (1) to high (4).
The PAM performance measure (PAM-PM) is the change on the 0-100 PAM scale score from baseline to follow-up measurement. To help prevent or mitigate against poor response rates that can be prevalent with PRO-PMs, there is evidence of flexibility in how the PAM is administered both from a methodological and linguistic perspective. Substantial research has shown that the PAM survey can be administered by an interviewer, self-administered on paper, and self-administered digitally with similar results.1 The PAM is available in English, Spanish, and over 30 other languages.
- Greene, J., Speizer, H., & Witala, W. (2008). Telephone and Web: The Mixed-Mode Challenge. Health Services Research, 43(1). 230-248
1.17 Measure Score InterpretationBetter quality = Higher score1.21b Attach Data Collection Tool(s)1.23 Survey Respondent1.26 Minimum Sample SizeIndividual clinicians would need to have two PAM® scores on a minimum of 50 patients with two PAM® scores in the measurement period.
The threshold for reliability is 50 cases. Additional parameters, such as a percentage threshold for re-administration may be advisable based on specific program design and intent.
1.19 Measure Stratification DetailsThis measure is not intended to be stratified based on risk.
1.16 Type of Score - Identify the denominator
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StewardMeasure Developer Secondary Point Of Contact
Hilary Hatch
Insignia, LLC, a wholly owned subsidiary of Phreesia
1521 Concord Pike, Suite 301 PMB 221
Wilmington, DE 19803
United StatesMeasure Developer Secondary Point Of Contact Email
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2.1 Attach Logic Model2.2 Evidence of Measure Importance
The PAM measure is cross-cutting and is relevant to any clinical situation where the patient has a role to play. At this point, there are enough studies in the literature that multiple systematic reviews have been published based on existing PAM studies. For example, a recent systematic review examined utilization among patients with chronic illnesses. The authors were able to include ten studies and found that patients with low PAM scores were more likely to seek care in an emergency department.1 Another systematic review examined which measures of self-management were most useful to clinicians. The authors reviewed ten studies and concluded that patient activation and Health Related Quality of Life (HRQOL) were the most useful to clinicians.2 Finally, one systematic review examined the effectiveness of interventions to increase patient activation in patients with a chronic condition.3 That study concluded that most of the examined interventions (including individual coaching, group intervention, telephone-based support, and motivational interviewing) resulted in significant improvements in patient activation and in patient behaviors. The authors further noted that tailoring care to the patient’s PAM Level was the most effective approach to increasing activation.
When patients are appropriately supported by their clinical teams, they typically gain in their ability to self-manage. Research shows that when the least activated (measuring at levels 1 or 2) are provided appropriate support, they will typically gain 6-9 points on the 0-100 scale within 6 months. This level of change in PAM scores is significant in terms of changing patients’ clinical trajectory, as well as their cost trajectory.4
- Kinney RL, Lemon SC, Person SD, Pagoto SL, Saczynski JS. The association between patient activation and medication adherence, hospitalization, and emergency room utilization in patients with chronic illnesses: a systematic review. Patient Educ Couns. 2015;98(5):545-552. doi:10.1016/j.pec.2015.02.005
- Newland P, Lorenz R, Oliver BJ. Patient activation in adults with chronic conditions: A systematic review. J Health Psychol. August 2020:135910532094779. doi:10.1177/1359105320947790
- Cuevas H, Heitkemper E, Huang Y-C, Jang DE, García AA, Zuñiga JA. A systematic review and meta-analysis of patient activation in people living with chronic conditions. Patient Educ Couns. February 2021. doi:10.1016/J.PEC.2021.02.016
- Lindsay A, Hibbard JH, Boothroyd DB, Glaseroff A, Asch SM. Patient Activation Changes as a Potential Signal for Changes in Health Care Costs: Cohort Study of US High-Cost Patients. J Gen Intern Med. 2018;33(12):2106-2112. doi:10.1007/s11606-018-4657-6
The above is a sampling of over 850 peer-reviewed publications that have demonstrated the relationship between PAM scores and aspects of healthcare structure, process, intervention, or service.
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2.6 Meaningfulness to Target Population
We are aware of a few studies that provide evidence that the target population values the PAM survey and finds it meaningful.
The first is the Patient Engagement Scale (PES) Consumer Testing Analysis, prepared for Pfizer Health Solutions, 2006. For this study, investigators conducted structured interviews with 48 patients to assess their perceptions of patient activation and their experience being administered the PAM. Respondents interviewed for this study included patients with diabetes, asthma, COPD, and cardiovascular disease with varying levels of literacy. 94% of respondents reported a positive perception of the PAM.
Other studies that address perceived satisfaction and meaningfulness of the PAM include the following. More activated patients or members (as assessed by the PAM survey) are more interested in and able to participate in and experience satisfaction with their shared decision making:
Smith, S, Pandit A. Rush S. et al The role of patient activation in preferences for shared decision making: Results from a national survey of U.S. Adults. Journal of Health Communication (2016) 21(1) 67-75
Poon BY, Shortell S, Rodriguez H. Patient Activation as a Pathway to Shared Decision-making for Adults with Diabetes or Cardiovascular Disease. Journal of General Internal Medicine. October 2019. https://doi.org/10.1007/s11606-019-05351-6
Kidd, L. Better patient activation is a precursor to engagement in shared decision making. Evidence-Based Nursing, 24(2): 2021. https://doi.org/10.1136/ebnurs-2019-103241
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2.4 Performance Gap
Table 1 provides the distribution of mean performance (proportion of patients with 3-point change) by practice across 32 practices in Dataset 3. See description of Dataset 3 under Scientific Acceptability.
[Please see Supplemental Attachment for Table 1]
The overall performance for the clinician groups in Dataset 3 is 0.40, or on average, 40% of patients at a clinician group achieve a 3-point change in their PAM score. The range of performance ranges from 0.33 to 0.48 for deciles 1-10, which demonstrates a wide range of performance and an overall opportunity for improvement across clinician groups.
Additional performance gap data can be seen in Tables 6a-6c for datasets used for reliability testing.
[Please see Supplemental Attachment for Tables 6a, 6b, and 6c]
Table 1. Performance Scores by DecilePerformance Gap Overall Minimum Decile_1 Decile_2 Decile_3 Decile_4 Decile_5 Decile_6 Decile_7 Decile_8 Decile_9 Decile_10 Maximum Mean Performance Score 0.4 0.3 0.33 0.37 0.38 0.38 0.4 0.42 0.43 0.44 0.45 0.48 0.5 N of Entities 32 1 4 3 3 3 3 3 3 3 3 4 1 N of Persons / Encounters / Episodes 11367 53 915 1180 2136 967 1265 2074 862 643 748 577 1482
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3.1 Feasibility Assessment
Given that the PRO-PM is based on the PAM survey, which asks about a patient’s knowledge, skills, and confidence regarding their ability to self-manage their healthcare, we consider the risks associated with the quality measure to be relatively low.
The PAM survey has been demonstrated to show equivalent results whether administered by an interviewer, self-directed by a patient using a paper form, or through digital means. Adding to that flexibility is the fact that the measure is available in English, Spanish, and over 30 other languages.
We acknowledge that there is the potential for some missing data, given that the measure requires administration of a patient-reported outcome measure that is not generally part of routine care. However, we have seen, for example, the ability to collect high volume, high quality PAM data both on the Phreesia platform and within the context of programs like the CMMI Kidney Care Choices (KCC) model.
Across the various implementations of the PAM-PM since the last CBE review, we have neither observed nor been told of any unexpected findings or unintended impact on patients.
3.3 Feasibility Informed Final MeasureOur experience with the PAM survey and the PAM Performance Measure, along with the signficant published literature on the survey, allowed us to align our final measure specifications with those learnings. This allowed for flexibility in terms of how the survey is administered while also focusing on patients who provided reliable and valid scores, that are likely to improve with intervention.
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3.4a Fees, Licensing, or Other Requirements
Patient Activation Measure® and PAM® are registered trademarks of Insignia Health, LLC, a Phreesia company. Copyright © 2003-2024, University of Oregon. All Rights Reserved.
The Patient Activation Measure® (PAM®) was developed and is owned by the University of Oregon. A license is required for all commercial and non-commercial uses of PAM and related assessments (e.g., Parent PAM, Caregiver PAM, language translations of PAM). This license is executed with Insignia Health, a Phreesia company, which licenses the PAM survey and scoring resources on behalf of the University of Oregon.
The PAM is a component of the “Gains in Patient Activation Measure (PAM) Scores at 12 Months” performance measure. Currently there are two permitted uses of the PAM for performance measure reporting, for the Centers for Medicare and Medicaid Services (CMS) Merit-Based Incentive Payment System (MIPS) and for select, Centers for Medicare and Medicaid Innovation (CMMI) model participants. For MIPS, we have made an online version of the PAM survey and scoring tool available at https://www.phreesia.com/mips via a no cost licensing agreement, to Medicare providers for the permitted use of submitting the measure to MIPS. The second currently permitted use is within CMMI. In that instance the voluntary participants in select CMMI models have access to the PAM through a CMMI contract covering survey instrument administration, training, analysis and scoring support. More information is publicly available on SAM.gov.
The University of Oregon holds the copyright for PAM and all related assessments. The PAM and all related assessments may not be modified by anyone other than the University of Oregon or Insignia Health.
THE PAM AND ALL RELATED ASSESSMENTS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
3.4 Proprietary InformationProprietary measure or components with fees
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4.1.3 Characteristics of Measured Entities
Table 2 outlines the number of clinician groups used for scientific acceptability testing from each data source and descriptive statistics on the number of patients per clinician group.
[Please see Supplemental Attachment for Table 2]
4.1.1 Data Used for TestingFour datasets were used to empirically test the reliability and validity of the PAM-PM measure score at the clinician-group level. Below are descriptions of the time period of the datasets and how the accountable entity is defined. Testing methods and results will refer to the dataset number indicated below to facilitate review.
- Dataset 1 –January 2022 to July 2023 PAM measure score results from the CMS Kidney Care First (KCF) program. The accountable entities in this dataset are physician group practices.
- Dataset 2 – January 2022 to May 2023 PAM measure score results from a kidney care management group. The accountable entities in this dataset are physician practices at nephrology practices.
- Dataset 3 – November 2022 to December 2023 PAM measure score results from Phreesia. The accountable entities in this dataset are primary care clinician groups that had Phreesia collect PAM data during this time period. Clinician groups were validated from the NPPES NPI Registry1 and mapped to the CMS provider taxonomy2. The dataset is used for empirical testing of reliability and risk adjustment justification.
- Dataset 4- Consists of clinician groups from Dataset 3 where net promoter scores (NPS) on providers were collected during the same time period. This dataset is used for validity testing of the measure.
- Dataset 5 – April 2021 to August 2022 PAM measure score results from a yearly health and wellness survey study. This dataset consists of patient level information used for validity testing of the risk adjustment model. Specifically, a patient-level analysis was conducted to empirically test the presence of differences in performance scores across multiple patient-level socio-demographic variables.
- CMS NPPES NPI Registry Downloadable File. https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/DataDissemination
- Find Your Taxonomy Code. https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/health-care-taxonomy
4.1.4 Characteristics of Units of the Eligible PopulationAll accountable entity level analyses were performed using patients included in the measure specification. Patient-level identifiable demographic data was unavailable for Dataset 1 and Dataset 2. Table 1b provides age and gender, and median household income1 demographics for Dataset 3. It should be noted that income information is not available for 17.2% of patients.
[Please see Supplemental Attachment for Table 3]
Table 4 shows the demographics of the patients used for Dataset 4. It should be noted that income information is not available for 18.6% of patients.
[Please see Supplemental Attachment for Table 4]
- Median household income is proxied by mapping the patient's location, where available, to the S1901: Income in the Past 12 Months (in 2022 Inflation-Adjusted Dollars) dataset from the United States Census Bureau. (Source: https://data.census.gov/table/ACSST5Y2022.S1901?q=median%20income&g=010XX00US$8600000).
4.1.2 Differences in DataMultiple datasets were used in the empirical testing for reliability and validity of the measure score results. A detailed description of the multiple datasets is included earlier in the Section 4.1.1 (Data Used for Testing).
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4.2.1 Level(s) of Reliability Testing Conducted4.2.2 Method(s) of Reliability Testing
Reliability was calculated using established reliability testing methods described in The Reliability of Provider Profiling: A Tutorial (2009). A beta-binomial approach is used for estimating the reliability of a simple pass/fail rate measure and calculates the ability for the measure to distinguish performance between clinician groups. 1
The beta-binomial is computed on all clinician groups, and mean reliability of clinician groups was calculated for the clinician groups for the measure specification range.
- Adams JL. The Reliability of Provider Profiling: A Tutorial. RAND Corporation; 2009. Accessed May 10, 2023. https://www.rand.org/pubs/technical_reports/TR653.html
4.2.3 Reliability Testing ResultsTable 5 displays the mean reliability of the beta-binomial at the clinician group level across the three data sources using the minimum sample size of 50 patients, as outlined in the measure specification.
[Please see Supplemental Attachment for Table 5]
Tables 6a-6c show reliability results for each dataset.
[Please see Supplemental Attachment for Tables 6a, 6b, and 6c]
4.2.4 Interpretation of Reliability ResultsAcross all three datasets the mean reliability of the beta-binomial exceeds 0.8. This value demonstrates high reliability of the measure score, and this is further supported by the consistent highly reliable results across multiple datasets.
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4.3.1 Level(s) of Validity Testing Conducted4.3.2 Type of accountable entity-level validity testing conducted4.3.3 Method(s) of Validity Testing
Empirical validity testing was conducted to test the pathway defined in the logic model that increased PAM scores lead to the improved health behaviors, navigation, and communication, which in turn leads to improved patient satisfaction with care. The hypothesis tested was the following: as average measure performance improves at the accountable entity, average ratings of patient satisfaction with care at the accountable entity also improves.
Patient satisfaction can be operationalized in healthcare settings using a Net Promoter Score. 1
Specifically, the calculation of Net Promoter Score is as follows:
- A patient is asked on a 1-10 scale of their likelihood to recommend a practice.
- Answers 9-10 are considered promotors, 7-8 are considered neutral, and 6 or less are considered detractors:
- NPS = (count of promotors - count of detractors) / total count of respondents.
- The average net promotor score was calculated for each practice for all patients who responded to the likelihood to recommend question during the study period of Dataset 4.
Testing was conducted by performing an Ordinary Least Squares (OLS) regression analysis using Dataset 4. The regression coefficients that return from the analysis, in addition to calculating Pearson’s correlation coefficient, give indication to the direction and magnitude of the association between the average measure performance and NPS rating.
- Healthcare Net Promoter Score: Definition, Formula, & Benchmarks. https://www.driveresearch.com/market-research-company-blog/healthcare-net-promoter-score-definition-formula-benchmarks/
4.3.4 Validity Testing ResultsOLS regression results show a statistically significant positive association between the performance measure and patient satisfaction with coefficient effect size 1.13 (0.1->2.16) and p-value 0.03. The Pearson’s correlation coefficient showed a similar statistically significant positive association between the PAM-PM measure and patient satisfaction of 0.43 with p-value 0.03.
The PAM-PM was not tested with denominator exclusions; however, we note that the self-report of individuals with significant cognitive concerns may be of questionable reliability and validity and for that clinical reason, the measure includes these denominator exclusions.
4.3.5 Interpretation of Validity ResultsThese results demonstrate a statistically significant correlation between PAM-PM and patient satisfaction in the hypothesized direction. Clinician groups that achieve a greater proportion of patients who improve their PAM scores by at least 3 points also have a greater proportion of patients who indicate they are satisfied with care from their providers.
A graphical representation of the regression results can be found in Figure 2. The plot shows on the x-axis the PAM-PM performance measure scores, and the y-axis shows patient satisfaction operationalized as the average net promoter score for each clinician group. Each point on the plot represents a clinician group in the validity analysis sample. The regression trendline trending upward indicates that a better performance on the PAM-PM is associated with better patient satisfaction.
[Please see Supplemental Attachment for Figure 2]
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4.4.1 Methods used to address risk factors4.4.1a Describe other method(s) used to address risk factors
We used several methods to assess potential risk factors, including a random effects logistic regression model (Dataset 3) to predict the probability of meeting measure performance. We also looked at potential patient-level differences looking at fixed effects in the regression model (Dataset 3), with additional review of chi-square results from Dataset 5. More details on the testing and results are available in section 4.4.1b.
4.4.1b If an outcome or resource use measure is not risk adjusted or stratifiedEmpirical testing to determine whether to consider risk adjustment or stratification for the measure was performed using Dataset 3 and Dataset 5. One consideration was to assess whether measure performance is affected by the case-mix of patients across available socioeconomic (SES) factors, while controlling for any accountable entity level effects. It is important to note that no accountable entity level characteristics and/or patient level clinical features were available for consideration in our analyses.
To do this, a random effects logistic regression model was built using Dataset 3 to predict the probability of meeting measure performance.1 The limited SES factors available for analysis (Age Group, Gender, and Median Household Income) were considered as predictors in the model as fixed effects, plus a random intercept to account for the effects of the accountable entities. A variance component analysis from the model concluded that there is limited contribution from the accountable entities to the total variability in the performance outcome. Given lack of significant between-group variance, decision would be to not control for this factor in a potential risk adjustment model.
Given this, the focus shifted to assessing patient-level differences. No statistically significant differences were concluded from the Gender and Median Household Income fixed effects in the regression model. However, the p-values did indicate small differences in measure performance amongst older age groups, specifically the 65+ age group. Additional patient level testing performed using Dataset 5, where similar SES factors were available (Age Group, Gender, Income Range, as well as Education Level) however came away with contradictory results. Empirical testing of the measure score in Dataset 5 using Chi-square tests showed no statistically significant differences in measure scores across all SES factors available. We present these results in Table 7.
[Please see Supplemental Attachment for Table 7]
Interpretation of results:
The results from Dataset 3 and Dataset 5 are mixed in terms of the conclusions that can be drawn from the effects of patient level differences. or specific SES factors in the form of a risk adjustment model, the decision remained to not risk adjust this measure. Regardless of their sociodemographic characteristics, the conceptual model rationale indicates that patients are able to report improved activation scores. This finding is consistent with a body of literature on the relationship of socio-contextual factors and the PAM survey itself. As the measure is expanded in its use, we will continue to monitor the impact of socio-contextual factors in assessments of accountable entity performance.
1. Bouwmeester, W., Twisk, J.W., Kappen, T.H. et al. Prediction models for clustered data: comparison of a random intercept and standard regression model. BMC Med Res Methodol 13, 19 (2013). https://doi.org/10.1186/1471-2288-13-19
4.4.2 Conceptual Model RationaleWe have attached a conceptual model (Figure 3) that illustrates our rationale for not risk-adjusting the PAM-PM, that builds on our overall measure logic model.
Based on prior research, we know that certain clinical and/or socioeconomic status categories may impact baseline levels of patient activation; however, activation is not a static trait; in fact, once a patient’s care team is aware of their PAM level, teams can intervene to improve patient activation. Through appropriate interventions, like tailored support, anyone (regardless of their starting PAM level) can become more activated and have better health outcomes. We anticipate variability in accountable entities’ ability and skill in delivering those activation interventions, related to resources, intervention competence, potential biases/discrimination, and other organizational factors.
In all populations, regardless of demographic characteristics, when interventions are tailored to a specific patient’s PAM level, we see that lower activated patients are able to achieve higher score changes. When PAM is used in Medicaid, duals and uninsured populations, we still see a full range of PAM levels in each group. When resources are focused on the low activated patients within the group, we see increase in scores and meaningful reductions in utilization and costs. Said another way, while we see a full range of PAM scores across patient groups, and while there may be differences in baseline PAM scores, what we find is that the ability to improve in PAM-assessed activation is not bound by demographic and health factors. Patients, when appropriately supported, can improve their PAM scores. The resulting changes in activation have been shown to lead to improved clinical outcomes, decreased healthcare utilization, decreased healthcare costs, and improved patient satisfaction with care through improved health behaviors, navigation, and communication.
4.4.2a Attach Conceptual Model4.4.3 Risk Factor Characteristics Across Measured EntitiesTable 8 provides descriptive statistics from Dataset 3 of how risk variables considered in the analyses are distributed across the measured entities.
[Please see Supplemental Attachment for Table 8]
4.4.4 Risk Adjustment Modeling and/or Stratification ResultsN/A
4.4.6 Interpretation of Risk Factor FindingsN/A
4.4.7 Final Approach to Address Risk FactorsRisk adjustment approachOffRisk adjustment approachOffConceptual model for risk adjustmentOffConceptual model for risk adjustmentOff
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5.1 Contributions Towards Advancing Health Equity
PAM does not assess a static trait; in fact, once a patient’s care team is aware of their PAM level, teams can intervene to improve patient activation, which in turn helps to reduce health disparities. Through appropriate interventions, like tailored support, anyone (regardless of their starting PAM level) can become more activated and have better health outcomes.
Unlike other predictive tools used in healthcare, PAM is squarely patient-focused and doesn't rely on proxy methods of assessing risk, such as claims data which may overemphasize those patients who access care vs unhealthy participants who are under-utilizers.1 Predictive tools based on claims can also focus precious care management resources on highly activated patients with high-cost conditions vs low activated patients whose outcomes and costs can be impacted.
We have specifically looked at the available evidence on the impact of racial/ethnic or socioeconomic factors on an individual’s activation level. The evidence suggests that factors such as education, income, ethnicity, and gender account for less than 10% of the variance in PAM scores (vs. explaining upwards of 25%+ variance in concepts like health literacy).2
In all populations, regardless of demographic characteristics, when interventions are tailored to a specific patient’s PAM level, we see that lower activated patients are able to achieve higher score changes. When PAM is used in Medicaid, duals and uninsured populations, we still see a full range of PAM levels in each group. When resources are focused on the low activated patients within the group, we see high score change and meaningful reductions in utilization and costs.
Evidence from the successful use of PAM in underserved communities suggests improving patient activation has the potential to reduce the impact of health disparities, such as racial or ethnic minority status and low income, on health outcomes.
- Obermeyer Z, Powers B, Vogeli C, Mullainathan S. Dissecting racial bias in an algorithm used to manage the health of populations. Science. 2019 Oct 25;366(6464):447-453. doi: 10.1126/science.aax2342. PMID: 31649194.
- Unpublished internal data.
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6.1.1 Current StatusYes6.1.3 Current Use(s)
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Name of the program and sponsorMerit-based Incentive Payment System (MIPS)URL of the programPurpose of the programMIPS encourages improvement in clinical practice and supports advances in technology that allow for easy exchange of information.Geographic area and percentage of accountable entities and patients includedMIPS eligible providers may earn performance-based payment adjustments for the services provided to Medicare patients in the USA.Applicable level of analysis and care setting
Clinician; office/ambulatory care
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6.2.1 Actions of Measured Entities to Improve Performance
Providers are using the PAM survey score to help them understand how to be most effective in supporting a patient. If the patient scores low, the clinical team recognizes that the patient is likely overwhelmed with the task of managing his or her health, has low confidence, and/or is likely have had several disappointments when trying to manage his or her health and consequently feels discouraged. The provider then understands that it is important to avoid further overwhelming the patient with too much information and too many suggested changes. At the same time, it is important to give the patient an opportunity to experience a success such as suggesting a small step that the patient might take toward improving his or her health. The step may be quite small and thus not in itself, clinically meaningful, but if the patient is successful, it can feel like a win that, in turn, increases a patient’s motivation to take further steps.
In a recently published meta-analysis1 summarizing the evidence about what works best for supporting gains in patient activation, the approach of tailoring goals to the patient’s activation level was identified as an effective strategy. This is different than usual care management, as the focus is on meeting the patient where they are, rather than a one-size-fits-all approach.
There are specific steps the clinical team can take to support gains in activation among their patients. Those steps involve tailoring suggested action steps to the patient’s level of activation (described above), problem solving with the patient to overcome barriers, giving encouragement, and showing caring and concern. The work of supporting gains in activation can be carried out mostly by a trained medical assistant. It does not have to be a clinical person doing this work. The clinician only needs to understand in a general way what the approach is, and support it in their interactions with the patient.
The PAM can also help reduce the burden on providers in another way; by helping them be more targeted and efficient in how they deploy their resources (e.g. care managers, social workers, nurses) in managing their patient population. For example, because more activated patients are more ready to use self-management resources, the provider can just push out digital tools to that segment of their patient population. They can then save their limited people resource to support less activated patients. Instead of using a one size fits all approach to counseling and educating patients, this more targeted approach will yield better results with the expenditure of less time resources.
- Cuevas H, Heitkemper E, Huang Y-C, Jang DE, García AA, Zuñiga JA. A systematic review and meta-analysis of patient activation in people living with chronic conditions. Patient Educ Couns. February 2021. doi:10.1016/J.PEC.2021.02.016
6.2.2 Feedback on Measure PerformanceThe PAM-PM has primarily been tested in large ambulatory primary care practices and subsets of health plan populations. In our review of the available research in which two PAMs have been administered, the attrition rate is relatively low. Some studies show re-assessment rates in the order of 55%, but many studies show re-assessment rates in the 75-85% range. We recognize that different use cases or programs may mandate or expect different levels of data capture and our own analyses suggest a minimum of 50 cases is enough to establish a reliable and valid measure. We also know that there do not appear to be any mode effects when administering the PAM, and so there is flexibility to administer the survey on paper, digitally, or via an interviewer.
In the CMMI KCC Model, we have implemented a monthly opportunity for groups to provide us feedback on the PAM and its implementation, which has provided us with an opportunity to provide continuous education on the PAM while also hearing from end users on implementation strategies.
6.2.3 Consideration of Measure FeedbackWhen we have implemented PAM-PM, at scale, we have sought out and been open to feedback from all stakeholders involved in the project. For example, in the KCC program, we have solicited input on the measure at regular meetings with stakeholders. Every piece of information that we have received has been carefully considered. When possible, we have conducted additional testing to assess the impact of potential changes to the measure specification on reliability and validity. We also anticipate receiving feedback on the measure from our inclusion in the MIPS program, which we will review carefully to the extent it suggests any modifications may be necessary or appropriate.
6.2.4 Progress on ImprovementDataset 1 was used to study progress on improvement of measure performance across measured entities. Patients were evenly split into two groups based on the date of their baseline PAM survey, with Group 1 representing patients who took their baseline PAM survey earlier in time. The mean PAM-PM score across the entities was taken for both groups. We expected patients in the second group to show improvements in the measure, compared to those in the first group, due to measured entities having more experience activating patients in the cohort.
Table 9 provides the summary of the results across the two patient groups. The results show an increase in the mean score across the two groups, which we interpret to be a positive trend in performance of the measure.
[Please see Supplemental Attachment for Table 9]
6.2.5 Unexpected FindingsGiven that the PRO-PM is based on the PAM survey, which asks about a patient’s knowledge, skills, and confidence regarding their ability to self-manage their healthcare, we consider the risks associated with the quality measure to be relatively low. In fact, across the various implementations of the PAM-PM since the last CBE review, we have neither observed nor been told of any unexpected findings or unintended impact on patients.
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PAM support Letter to PQM Workgroup
OrganizationStanford School of MedicineThe PAM demystified how empowerment works.
Dear PQM Workgroup,
I am writing to provide my full-throated support of Phreesia’s Patient Activation Measure (PAM).I'm a survivor of a near-fatal kidney cancer (2007) whose oncologist later said in the BMJ, "I'm not sure you could have tolerated enough medicine if you hadn't been so well prepared." http://dave.pt/davebmj1
When I first got that diagnosis the best available data said my median survival was 24 weeks, yet before the year was out they said I'd beaten it. 17 years later I've had no recurrence - but I've become an avid advocate for patient empowerment, delivering hundreds of keynote speeches and panel appearances in 26 countries.
What did he mean by being "prepared"? I didn't sit back and wait for the system to save me - I did everything in my limited power to gather information and take action in whatever way I could. In today's language, I was activated, not passive.
When conferences started asking me to speak about empowerment, the content I chose was intentional: there is a *mechanism* to activation and empowerment - it's not some fairy dust, so I would articulate why and how awakening people's potential was good for the whole health system, not just the individual. Though I'm "just a patient" medically, in school was educated to think like an engineer. So I evangelize by teaching the method, not just by cheerleading. Everything the PAM leverages is part of this thinking.
In these years of speeches I was sometimes saddened by encountering physicians, insurers, and policy people (and patients!) who would respond by saying "Look, YOU might be that way, but I don't know any patients like you." This is exactly why when I discovered the PAM I immediately asked Dr. Hibbard for some of her slides, and started blogging about it. (My first post about the PAM was in 2011, with many subsequent posts and tweets.) Because the PAM's methods are solidly thought out and well validated, I've been able to *explain* (not complain) what's missing when patients aren't activated and healthcare thus falls short of its potential.
I can't emphasize that enough. I'm a co-founder of the Society for Participatory Medicine, which is all about patient-clinician partnerships, and one of our core beliefs is that healthcare cannot achieve its potential if either partner is underpowered for any reason.
As life has gone on I've aged and acquired other conditions. In 2014 I was diagnosed pre-diabetic, but I was activated: at age 65 I ran a mile for the first time in my life and reversed the diagnosis by 2017. Today I have glaucoma in one eye due to a surgical accident, and I'm proactive in tracking and managing it (with a home tonometer). And despite my love of sunshine I've accepted that if I want to stop having skin cancers, it's up to me to follow the guidelines. Of course all this is classic PAM: what I do matters, and yes I can learn (perhaps with effort) to do what's important.
One last thought: in my advocacy I sought insights from other fields, and a vitally important one popped up from the World Bank in its work in understanding empowerment. They introduced three pillars in a Dec. 2023 brief and women & girls' empowerment: agency, resources, and context (environment). The PAM shows up most under Agency (skills and self-efficacy), but the PAM's effect on culture is also important, and that falls into the Context domain.
I bring this up because in any scientific field when a new truth is discovered and verified, you see signs of it everywhere. So it is with the principles the PAM puts into action, in a way that everyday clinicians can use to produce real change in the world.
I'm passionate about it both because of the benefits to patients and because I've seen how gratifying it can be for a clinician when their patient upgrades their skills and everyone wins.
So, obviously, I urge the committee to re-endorse the PAM as a Patient Reported Outcome Performance Measure (PRO-PM).
I'm happy to discuss if you want. 603-459-5119 or [email protected]
Dave deBronkart aka "e-Patient Dave"
Nashua NH
OrganizationDave deBronkartPublic Comment Shared During May 29 Listening Session
Hi, thank you for having this and having the public opportunity. I'm sorry I didn't read all the way through this. But I'm curious, for individuals like myself…I'm sorry I'm a patient partner engaged in measurement and research. And so, I'm pretty activated right? I think I probably score at the highest level. So I wonder if this ends like, if you top out as an individual, if you're counted for at that higher level for the next year? I wonder if you know anything about that? Because we have a threshold where a measure might top out. Does the same thing happen at the individual level? That's my question. Thank you.
OrganizationJanice TufteRe-endorsement of Gains in the PAM at 12 Months
Partnership for Quality Measurement
ATTN: Re-Endorsement of CBE ID 2483: Gains in Patient Activation (PAM) Scores at 12 Months
RE: Public Comments to the Partnership for Quality Measurement (PQM) regarding re-endorsement of CBE ID 2483: Gains in Patient Activation (PAM) Scores at 12 Months.
Submitted electronically
Dear PQM Workgroup,
I am writing to provide the following comments to the PQM on behalf of Phreesia’s Patient Activation Measure (PAM). In my personal experience living with kidney disease, activation was a wake-up call. I will always remember the evening of April 10, 2010, when I looked at myself in the mirror at home and decided that if I wanted to have a full recovery from kidney failure, I had to take charge of my health and not wait around for miracles to happen. It wasn’t easy, but I learned to manage my care with the help of my care team, adopt new healthy behaviors, and eventually receive a kidney transplant from a deceased donor in 2015. The PAM has positively impacted my health and well-being in multiple ways, and I urge you to re-endorse it as a Patient Reported Outcome Performance Measure (PRO-PM). Doing so will support its continued utilization in important healthcare programs and its role in increasing patients’ involvement and motivation for improving our health.
I encourage the PQM advisory group to consider the value the PAM can bring to the patient care journey. Thank you for the opportunity to provide these comments and share my positive experience with the PAM. If I can provide additional information, please get in touch with me at [email protected].
Sincerely,
David M. White
OrganizationN/ASupport for re-endorsement of the PAM-PM
Dear PQM Workgroup,
As the lead author of the Patient Activation Measure (PAM), I am writing to encourage the PQM to re-endorse the PAM-PM. As you know, the PAM is a brief survey that can help providers understand patients’ ability to manage their own health care by measuring their knowledge, skills, and confidence. PAM scores provide insights that help the clinician meet the patient where they are. It can help the clinician to know who needs more support and what kind of support they need to become better self-managers. That is to say, the PAM can help inform and improve the medical encounter, as well as serve as the basis for a performance measure. 800 peer reviewed studies have been published over the course of nearly two decades indicating the PAM’s validity and reliability with different conditions, demographic groups and in different settings. Over 300 health care organizations in nearly a dozen countries are using it. PAM-PM is truly a unique measure and is currently the only Consensus-based Entity-endorsed patient activation measure.
The PAM-PM is currently in use in one Center for Medicare and Medicaid Innovation Center (CMMI) model programs: the Kidney Care Choices (KCC) model. Within the KCC program, one large provider group has seen a decrease in hospital admissions and readmissions which they attribute largely to increases in patient activation. Most recently, the PAM-PM was finalized for inclusion in MIPS in the CY 2024 Physician Fee Schedule. Specifically, the PAM-PM was finalized for addition in five MVPs and 18 specialty measure sets.
My own research, and that of others, shows that with appropriate support, it is possible to increase PAM scores. When PAM scores do increase, clinical outcomes improve and costs go down. We know that increasing activation is critical to health and mental outcomes, medication adherence, disease self-management, and treatment satisfaction across numerous patient populations and chronic diseases.
To achieve the over-arching goals of improved outcomes, reduced costs, and greater equity, it is essential that we support patients in their role as self-managers. To that end, it is critical that support for patient self-management be a key part of accountability.
Please do contact me if you have any question.
Sincerely,
Judith Hibbard
Professor Emerita
University of Oregon
OrganizationUniversity of OregonPAM Essential to the Provision of Chronic Care Management
To Whom It May Concern,
Crouse Medical Practice is providing the following comments to PQM on behalf of the Patient Activation Measure (PAM). Research and practice have shown that patient activation helps patients to become more empowered in their care and that they are more likely to adopt new, healthy behaviors and engage in self-management, ideally improving care outcomes and cutting health care spending. As you consider measures, Crouse Medical Practice urges you to re-endorse the PAM as a Patient Reported Outcome Performance Measure (PRO-PM).
The PAM leverages a brief survey that helps providers understand patients’ ability to manage their own health care by measuring their knowledge, skills, and confidence. With this data, patients are grouped into one of four activation levels that provide insight into health-related characteristics, including attitudes, motivators, and behaviors. This measure supports our ability to authentically engage patients, meet patients where they are, and support resource allocation and care planning activities. The PAM serves as the only Consensus-based Entity-endorsed patient activation measure and is backed up by over 800 peer reviewed studies that have been published over the course of nearly two decades. Over 300 health care organizations, including ours, in nearly a dozen countries are using it.
The PAM-PM is already in use in one Center for Medicare and Medicaid Innovation Center (CMMI)
model programs: the Kidney Care Choices (KCC) model. Within the KCC program, one large provider
group has seen a decrease in hospital admissions and readmissions which they attribute largely to
increases in patient activation. Most recently, the PAM-PM was finalized for inclusion in MIPS in the CY 2024 Physician Fee Schedule. Specifically, the PAM-PM was finalized for addition in five MVPs and 18 specialty measure sets.
Our experience with the PAM has demonstrated immense value, providing key support to our chronic care management program. The PAM allows our chronic care management nurses to personalize care plans and track improvements, which are shared with patients. Crouse Medical Practice encourages the PQM advisory group to consider the benefits of the PAM and urges you to re-endorse the measure. To successfully achieve patient-centeredness through value-based care, patients should feel enabled and armed with the tools to be more active in their care. In the long term, this will also reduce burden to the system and help lower health care costs. We appreciate the opportunity to provide these comments and share the positive experiences we have had with the PAM. If I can provide additional information, please contact me at [email protected]
Sincerely,
Christina Pavetto, MS
Director, Population Health
Crouse Medical Practice
Syracuse, New York
OrganizationCrouse Medical PracticePublic Comment Shared During May 29 Listening Session
My name is David White. I'm a very grateful kidney transplant recipient. I'm also a patient advocate and a consultant. But I'm just speaking for myself. I am strongly in support of re-endorsing this measure. Because I am activated now myself, just like Janice, and I was not at one time. I know the importance of being an active participant in my care. When I started dialysis, I was just a terrible patient. I didn't know the importance of self-management, but it was brought to my attention during one of my care plan meetings where I basically read the Riot Act. But then we started discussing why I was missing dialysis and put together a care plan to take care of things like transportation, etc. But at the end of the meeting, my charge nurse kind of put it on me to take charge of my health. She said, “if I don't start going to dialysis 3 times a week, I won't be around much longer", and that message sank home within hours. I remember going home looking in the mirror and saying to myself, “this is on you, and you're the only one that can really be the captain of your care team,” I guess, is the best way of saying it. So here we are almost 15 years later. I stopped smoking. I became an activated patient of dialysis. I started exercising regularly over 200,000 push-ups, and because of my improved self-management, I'm now a really grateful kidney transplant recipient. Thank you very much for allowing me to speak.
OrganizationDavid WhiteRe-endorsement of the Gains in Patient Activation at 12 Months m
June 11, 2024
Partnership for Quality Measurement
ATTN: Re-Endorsement of CBE ID 2483: Gains in Patient Activation (PAM) Scores at 12 Months
RE: Public Comments to the Partnership for Quality Measurement (PQM) regarding re-endorsement of CBE ID 2483: Gains in Patient Activation (PAM) Scores at 12 Months.
Submitted electronically via https://p4qm.org/measures/2483
To Whom It May Concern,
HealthLinc is providing the following comments to PQM on behalf of the Patient Activation Measure (PAM). Research and practice have shown that patient activation helps patients become more empowered in their care. They are more likely to adopt new, healthy behaviors and engage in self-management, ideally improving care outcomes and cutting healthcare spending. HealthLinc urges you to re-endorse the PAM as a Patient Reported Outcome Performance Measure (PRO-PM) as you consider measures.
The PAM leverages a brief survey that helps providers understand patients' ability to manage their health care by measuring their knowledge, skills, and confidence. With this data, patients are grouped into one of four activation levels that provide insight into health-related characteristics, including attitudes, motivators, and behaviors. This measure supports our ability to engage patients authentically, meet patients where they are, and support resource allocation and care planning activities. The PAM is the only Consensus-based Entity-endorsed patient activation measure supported by over 800 peer-reviewed studies published over nearly two decades. Over 300 healthcare organizations, including ours, in almost a dozen countries are using it.
The PAM-PM is already used in one Center for Medicare and Medicaid Innovation Center (CMMI)
model program: the Kidney Care Choices (KCC) model. Within the KCC program, one large provider
group has seen a decrease in hospital admissions and readmissions, which they attribute primarily to
increases in patient activation. Most recently, the PAM-PM was finalized for inclusion in MIPS in the CY 2024 Physician Fee Schedule. Specifically, the PAM-PM was finalized for addition in five MVPs and 18 specialty measure sets.
Our experience with the PAM has demonstrated immense value, ranging from higher patient satisfaction to less burden because of improved patient self-management, appropriate utilization, significant time saved for community health workers to meet more patients’ individualized needs, and more. HealthLinc encourages the PQM advisory group to consider the benefits of the PAM and urges you to re-endorse the measure. To successfully achieve patient-centeredness through value-based care, patients should feel enabled and armed with the tools to be more active in their care. In the long term, this will also reduce the burden on the system, improve the efficiency and effectiveness of health center visits, and help lower health care costs. We appreciate the opportunity to provide these comments and share our positive experiences with the PAM. If I can provide additional information, please contact me at 219-465-9503.
Sincerely,
Melissa Mitchell
OrganizationHealthLinc, Inc.Re-endorsement of CBE ID: 2483- Gains in Patient Activation
I am writing to provide comments to the Partnership for Quality Measurement (PQM) with regard to the Patient Activation Measure (PAM) as you consider measures for endorsement this year.
The PAM measures a person’s knowledge, skill, and confidence in managing their own health and health care. I have conducted a considerable amount of research using the Patient Activation Measure (PAM), and have published over 10 peer-reviewed research papers on the topic. I have consistently found, in fact never not found, that people with higher PAM scores have better health and health care related behaviors. I have examined the relationship with different patient populations and with different health conditions, and the findings have always been consistent. Most of my research has been cross sectional in nature, but my research that has examined change in PAM score have been related to better outcomes. The findings from my studies have been consistent with a large body of research- over 800 peer reviewed studies that has found PAM scores are related to positive health and health care outcomes.
I have also conducted research with physicians whose patients have increased PAM scores in order to identify clinician practices that support patient activation. These behaviors include emphasizing patient ownership, showing caring and concern for patients, partnering with patients, and identifying small doable steps towards self-management. All of these are key behaviors for clinicians to engage in for improved activation, trust, and health outcomes. High quality care should result in gains in the patient’s ability to self-manage their health and healthcare, the PAM is therefore an important measure to track and encourage clinicians to improvement. I am very pleased there will be a free version of the PAM, which will make it accessible to many more potential users.
I encourage the PQM advisory group to consider the benefits of the PAM and urge you to re-endorse the measure. I appreciate the opportunity to provide my positive experience with the PAM.
Sincerely,
Jessica Greene
Professor & Luciano Chair of Health Policy
Baruch College, City University of New York
OrganizationBaruch College, CityRe-Endorsement of CBE ID 2483
June 14, 2024
Partnership for Quality Measurement
ATTN: Re-Endorsement of CBE ID 2483: Gains in Patient Activation (PAM) Scores at 12 Months
RE: Public Comments to the Partnership for Quality Measurement (PQM) regarding re-endorsement of CBE ID 2483: Gains in Patient Activation (PAM) Scores at 12 Months.
The National Partnership for Women & Families is providing the following comments to the PQM on behalf of the Patient Activation Measure (PAM). The National Partnership has long championed the multifaceted impact of patient and family engagement – such as better patient-reported outcomes and identification of more patient safety errors and adverse events. The PAM is a critical, reliable, and tested way to facilitate and enhance engagement with patients and family caregivers. We urge the Workgroup to re-endorse the PAM as a Patient Reported Outcome Performance Measure (PRO-PM).
We believe a system centered on patients and families performs better across several factors, including quality, safety, and patient experience. Unfortunately, the actual experiences of many people are far from person-centered. Women often report not being listened to, feeling ignored or overlooked, or having their pain not taken seriously by health care providers. Likewise, many childbearing people have reported being ignored, having their concerns dismissed, being denied choices in care, and otherwise being disempowered and mistreated during pregnancy, childbirth, and the post-partum period. Women of color are even more likely to feel ignored or mistreated, with clear negative effects. For example, higher rates of maternal mortality and morbidity are often anecdotally linked to Black women’s concerns and pain not being taken seriously.
Measures of patient engagement and activation are critical to advancing equity and improving outcomes. Active engagement improves the likelihood patients will share important information with care providers and makes it more likely a patient will ask a provider for valuable information that can influence the success of a care plan. Engagement in decision-making is the most determinative factor in positive patient experience.
The PAM leverages a brief survey that helps providers understand patients’ ability to manage their own health care by measuring their knowledge, skills, and confidence. Patients are then grouped into one of four activation levels that provide insight into health-related characteristics, including attitudes, motivators, and behaviors. The PAM helps a care team to understand and meet patients where they are by providing tailored communication, care planning and support. The validity, reliability and impact of the PAM is clear:
- - The PAM serves as the only Consensus-based Entity-endorsed patient activation measure and has been widely studied and used over the course of nearly two decades.
- - Over 300 health care organizations in nearly a dozen countries are using it. The PAM-PM is also already in use in one Center for Medicare and Medicaid Innovation Center (CMMI) model programs: the Kidney Care Choices (KCC) model. Within the KCC program, one large provider group has seen a decrease in hospital admissions and readmissions which they attribute largely to increases in patient activation. Most recently, the PAM-PM was finalized for inclusion in MIPS in the CY 2024 Physician Fee Schedule. Specifically, the PAM-PM was finalized for addition in five MVPs and 18 specialty measure sets.
- - Providers who have utilized the PAM in practice have expressed that they find the PAM beneficial and speak to its value helping patients pursue health and wellness goals.
NPWF encourages the PQM advisory group to consider the vital importance of increasing utilization of actionable tools that are proven to make a difference in achieving key goals and to re-endorse the PAM.
We appreciate the opportunity to provide these comments. If I can provide additional information, please contact me at [email protected].
Sincerely,
Erin MackayOrganizationNational Partnership for Women & Families
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CBE #2483 Staff Assessment
Importance
ImportanceStrengths:
- The developer cites several systematic reviews that have demonstrated an association between patient activation and material outcomes such as avoidable ED use and Health Related Quality of Life.
Limitations:
- The empirical data provided was somewhat limited (N=32) and demonstrated only a modest potential for improvement at the benchmark (likely under 10%)
Rationale:
- Overall, use of the measure informed entity and person decision-making, and has modest potential for improvement
Feasibility Acceptance
Feasibility AcceptanceStrengths:
- Data are collected using a relatively low burden survey instrument.
Limitations:
- Data collection requires both a baseline and a follow-up no less than six months and not more than 12 months.
Rationale:
- Overall, the measure has been used for many years in multiple settings.
Scientific Acceptability
Scientific Acceptability ReliabilityStrengths:
- The measure is clear and well defined.
Entity-level reliability is conducted on three datasets from 2022-2023 using the beta-binomial method (the measure is not risk-adjusted).
- Average entity-level reliability is >0.6 for all entity-size deciles for Dataset 1 which contains 13 entities. (The estimated reliability for the first decile is 0.93.)
- Average entity-level reliability is >0.6 for all entity-size deciles for Dataset 2 which contains 45 entities. (The estimated reliability for the first decile is 0.8.)
- Average entity-level reliability is >0.6 for most entity-size deciles for Dataset 3 which contains 32 entities. (The estimated reliability for the first decile is 0.56.)
Limitations:
- Low number of entities in reliability calculations.
Approximately 10-15% of entities below 0.6 reliability for Dataset 3.
Rationale:
- The measure is well defined. Reliability was assessed at the entity level. Reliability statistics are above the established thresholds for all but a few entities.
Scientific Acceptability ValidityStrengths:
- The developer cites systematic reviews of evidence demonstrating mechanisms (interventions) responsible for increasing the likelihood of patient activation.
The baseline score accounts for differences among populations in the "starting point" for activation.
Limitations:
- The developer supports the claim that the explicit mechanisms are responsible for the better or worse entity performance with an association study using a measure of patient satisfaction (promoter score).
However, the overlap between the mechanisms for the measure of interest and the promoter are not explicated stated and may be limited.
Therefore, the association study does not rule out other competing or confounding mechanisms that may be response for better or worse entity performance.
Rationale:
- Overall, based on the strength of the body of clinical study evidence, the measure has a strong demonstration of the association between the entity and the measure focus.
Equity
EquityStrengths:
- Empirical data suggest that factors such as education, income, ethnicity, and gender account for less than 10% of the variance in PAM scores.
Limitations:
- One might expect that these factors would be association with variation in baseline scores (which is the argument used for not risk adjusting).
Rationale:
- Overall there does not appear to be detectible differences in performance scores across subgroups, and some reason to claim that increasing patient activation would reduce disparities.
Use and Usability
Use and UsabilityStrengths:
- Measure is currently in use.
The developer reference studies that demonstrate approaches to overcoming barriers to increasing patient activation in challenging populations (e.g. chronic conditions).
The survey instrument is available in 30 languages.
Limitations:
- None identified, other than those common to patient reported measures.
Rationale:
- The measure is used in a structured quality improvement program.
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Support
Importance
ImportanceI concur with the assessment made by the staff.
Feasibility Acceptance
Feasibility AcceptanceI concur with the assessment made by the staff.
Scientific Acceptability
Scientific Acceptability ReliabilityI concur with the assessment made by the staff.
Scientific Acceptability ValidityI concur with the assessment made by the staff.
Equity
EquityI concur with the assessment made by the staff.
Use and Usability
Use and UsabilityI concur with the assessment made by the staff.
Summary
This is a very important measure, one that helps clinicians assess baseline knowledge, skill, and confidence to create appropriate solutions and engage patients in self-management. It improves their self-efficacy and empowers patients with knowledge, tools, and resources. This is a critical step in managing chronic diseases because up to 80% of chronic diseases can be managed by improving lifestyle behaviors. I fully support this measure, which has been in use for many years in many settings, is available in 30 languages, and has the potential to reduce healthcare disparities by increasing health literacy.
Supportive of measure but additional information is needed
Importance
ImportancePatient activation is important and measuring it will be helpful to understand where patients are at.
Feasibility Acceptance
Feasibility AcceptanceThere was data provided from different clinics about survey completion. It is not clear how many patients were at these clinics. A question would be among patients with 2 or more visits in 1 year, how many patients complete 2 surveys in whch to provide data for this measure? How many patients were approached and declined to complete a survey. Are patients who complete the survey different than those who complete the 2 surveys and included in the data analysis. In addition, I suspect survey completion may be more difficult at Federally Qualified Health Centers where there are fewer resources to try to obtain the survey.
Scientific Acceptability
Scientific Acceptability ReliabilityData was provided supporting reliability
Scientific Acceptability ValidityThere have been many publications about the PAM highlighting valdity
Equity
EquityWhile there is data on whether PAM varies by socioeconomic characteristics, it would be helpful to see data on PAM scores at lower resource clinics or Federally Qualified Health Centers as well as potentially from different parts of the country.
Use and Usability
Use and UsabilityThe PAM is currently in use. However, it is not clear what specific interventions can be done to individual patients for a given PAM score. In addition, what about clinics with limited resources, will they have the same ability to improve PAM scores?Data collection could be an issue if the PAM score is obtained via paper. Will clinics have the capacity to transfer this info to the EHR?
Summary
In principle, the PAM is important and would be helpful to use in routine clinical care. It is not clear the specific interventions tha are helpful to improve PAM scores and whether there are specific resources to help clinics with that. It seems like implementation of such a measure can have unintended consequences for lower resource settings/clincis that may not have the infrastructure/capacity to get the data and once wit the data, be able to intervene to increase PAM scores
Support Re- Endorsement pending additional information
Importance
ImportanceAgree with committee, supportive evidence exists.
Feasibility Acceptance
Feasibility AcceptanceThere is limited data on implementation in clinical practice and how PAM-tailored interventions can be integrated into clinical practice. Additional information on the feasibility of the care team implementing and supporting completion of the PAM would be helpful.
Scientific Acceptability
Scientific Acceptability ReliabilityIn MIPS, this measure can be reported at the eligible-clinician level, only clinician group level analysis was submitted. Is there data available to distinguish performance between individual eligible clinicians? There is indication that there were small differences in measure performance amongst older age groups, specifically the 65+ age group and that with care -team support, PAM scores can improve. Should older adults be considered separately, should the measure stratify or risk-adjust based on age if a clinician or clinician group has primarily elderly (>65) patient population?
Scientific Acceptability ValidityThere is supportive evidence demonstrating mechanisms (interventions) responsible for increasing the likelihood of patient activation.
The developer indicated that the PAM-PM was not tested with denominator exclusions/exceptions. The data is only at the clinician-group level and not individual eligible clinician level. How do individual clinician interventions for patients with low PAM scores improve the quality of care?
Equity
EquityMostly agree with staff assessment; however, there is notation of contradictory results and no mention of specific Medicare population testing to assess the >65 age population and the impact of exclusion criteria on this subgroup of patients.
Use and Usability
Use and UsabilityMeasure is currently in use with supportive evidence.
Would be interested if small practices also find the measure useful as uptake increases in the future.
Summary
Overall, the PAM tool itself is reliable, valid and useful. Increased scores on the tool have proven to correlate with improvement in patient satisfaction and perceived quality of care. However, further information about how PAM-tailored clinician-patient interventions can be integrated into clinical practice (especially small groups or individual clinician level) and guide the patient-clinician interaction in ways that improve the quality of patient care would be beneficial when implemented in value-based care programs. Specific interventions that are needed for clinicians and clinician group practices to implement in order to improve PAM scores and whether there are specific resources to help clinicians improve patient scores is unclear, which would impact practice's ability to report and do well on such quality measure.
PAM Assessment
Importance
ImportancePatient activation and patient behavior, utilization, and health outcomes are highly correlated. The instrument also captures important information that clinicians can leverage in the day-to-day management of their patients. For example, if a patient demonstrates a low activation level with no improvement at follow up, the clinician can attempt to directly address areas of low activation (e.g., patient does not know what each of their prescribed medications do).
Feasibility Acceptance
Feasibility AcceptanceAll of the feasibility data from Datasets 1 through 4 were limited to nephrology-related practices/settings focused on patients with ESRD. Providing feasibility data across all clinical practice sites (i.e., types of accountable entities) would assist the reviewer in ensuring that the Feasibility requirements are met. Also, the submitted documentation for review would benefit from additional information on the licensing process for PAM with Insignia Health, licensing fees, etc.
Scientific Acceptability
Scientific Acceptability ReliabilityAll of the reliability data from Datasets 1 through 3 were limited to nephrology-related practices/settings focused on patients with ESRD. Providing feasibility data across all clinical practice sites (i.e., types of accountable entities) would assist the reviewer in ensuring that the Reliability requirements are met. For the data provided, the mean beta-binomial is greater than 0.8 for all 3 data sets, indicating that the instrument is reasonably reliable at the clinician group level across the 3 data sources. For accountable entity-level reliability testing results, all entities met or exceeded a score of 0.8 in Dataset 1. All but 1 entity met or exceeded 0.8 in Dataset 2, but 13 out of 32 entities (or 40.6%) in Dataset 3 did not meet a mean beta-binomial score of 0.8. However, the 13 entities account for only 1,279 out of 11,367 (or 11.3%) patient encounters/episodes. Although the instrument as a whole appears reliable across the practice mix in the 3 data sets (with the noted comments related to Dataset 3), reliability data are provided at the PAM instrument level and not the individual item level. The reliability of some of the individual items comprising the instrument are questionable given their subjective nature. Providing reliability data on each of the individual PAM items (i.e., 10 or 13 items depending on the version) would address this area.
Scientific Acceptability ValidityAs with the other assessments, the concern here is that all of the data provided for the reviewer appears to be derived from settings serving ESRD patients. It would be beneficial to the reviewer to provide data across the entire spectrum of potential accountable entity care settings. Also, the reviewer would benefit from additional details regarding how the Net Promoter score was captured. The data provided in Figure 2 of the supplement (NPS as a function of PAM performance score) are not compelling and the removal of outliers would result in little to no substantive correlation between NPS and PAM performance measure.
Equity
EquityThe developer cites general information about the evaluation of patient demographic characteristics, but the data provided are limited to only age, gender, and patient income (with 17+% of patient income missing). No assessment of race/ethnicity is provided.
Use and Usability
Use and UsabilityThe PAM instrument is currently in use as part of MIPS. It is proven useful in numerous studies.
Summary
The importance and use/usability of the PAM instrument are established. For purposes of this review, it would have been helpful to be provided with data across a broader array of practice/accountable-entity types. It would have also been helpful to be provided more information on the licensing process with Insignia Health and the associated cost (included any information on ROI when implemented at the practice level). Validity data at the individual survey item level would have been helpful. Additionally, the validity assessment leveraging the Net Promoter Score was not compelling. Removing of outliers would result in little to no substantive correlation between NPS and PAM scores. It also would have been helpful to have been provided information on mode effects. The risk adjustment discussion in the supplement was quite general, but the approach was lacking. Limited patient-level covariates and no facility-level covariates were evaluated. A formal equity assessment was not performed leveraging patient race/ethnicity data. Overall, re-endorsement should be contingent on addressing the items mentioned above and throughout the review.
PAM: Recommend Contingent Re-endorsement with Conditions
Importance
ImportancePatient activation and patient behavior, utilization, and health outcomes are highly correlated. The instrument also captures important information that clinicians can leverage in the day-to-day management of their patients. For example, if a patient demonstrates a low activation level with no improvement at follow up, the clinician can attempt to directly address areas of low activation (e.g., patient does not know what each of their prescribed medications do).
Feasibility Acceptance
Feasibility AcceptanceAll of the feasibility data from Datasets 1 through 4 were limited to nephrology-related practices/settings focused on patients with ESRD. Providing feasibility data across all clinical practice sites (i.e., types of accountable entities) would assist the reviewer in ensuring that the Feasibility requirements are met. Also, the submitted documentation for review would benefit from additional information on the licensing process for PAM with Insignia Health, licensing fees, etc.
Scientific Acceptability
Scientific Acceptability ReliabilityAll of the reliability data from Datasets 1 through 3 were limited to nephrology-related practices/settings focused on patients with ESRD. Providing feasibility data across all clinical practice sites (i.e., types of accountable entities) would assist the reviewer in ensuring that the Reliability requirements are met. For the data provided, the mean beta-binomial is greater than 0.8 for all 3 data sets, indicating that the instrument is reasonably reliable at the clinician group level across the 3 data sources. For accountable entity-level reliability testing results, all entities met or exceeded a score of 0.8 in Dataset 1 and all but 1 entity met or exceeded 0.8 in Dataset 2, but 13 out of 32 entities (or 40.6%) in Dataset 3 did not meet a mean beta-binomial score of 0.8. However, the 13 entities account for only 1,279 out of 11,367 (or 11.3%) patient encounters/episodes. Although the instrument as a whole is reliable across the practice mix in the 3 data sets, the reliability of some of the individual items comprising the 10 and 13 items is questionable. Data (whether it be from these practices or prior testing) demonstrating reliability across each item would be helpful to the reviewer.
Scientific Acceptability ValidityAs with the other assessments, the concern here is that all of the data provided for the reviewer appears to be derived from settings serving ESRD patients. It would be beneficial to the reviewer to provide data across the entire spectrum of potential accountable entity care settings. Also, the reviewer would benefit from additional details regarding how the Net Promoter Score (NPS) was captured. The data provided in Figure 2 of the supplement (NPS as a function of PAM performance score) are not compelling and the removal of outliers would result in little to no substantive correlation between NPS and PAM performance measure.
Equity
EquityThe developer cites general information about the evaluation of patient demographic characteristics, but the data provided are limited to only age, gender, and patient income (with 17+% of patient income missing). No assessment of race/ethnicity is provided.
Use and Usability
Use and UsabilityThe PAM instrument is currently in use as part of MIPS. It has also been used as part of numerous studies.
Summary
The importance and use/usability of the PAM instrument are established. For purposes of this review, it would have been helpful to be provided with data across a broader array of practice/accountable-entity types. It would have also been helpful to be provided more information on the licensing process with Insignia Health and the associated cost (included any information on ROI when implemented at the practice level). Validity data at the individual survey item level would have been helpful. Additionally, the validity assessment leveraging the Net Promoter Score was not compelling. Removing of outliers would result in little to no substantive correlation between NPS and PAM scores. It also would have been helpful to have been provided information on mode effects. The risk adjustment discussion in the supplement was quite general, but the approach was lacking. Limited patient-level covariates and no facility-level covariates were evaluated. A formal equity assessment was not performed leveraging patient race/ethnicity data. Overall, re-endorsement should be contingent on addressing the items mentioned above and throughout the review.
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May 20, 2024
Partnership for Quality Measurement
ATTN: Re-Endorsement of CBE ID 2483: Gains in Patient Activation (PAM) Scores at 12 Months
RE: Public Comments to the Partnership for Quality Measurement (PQM) regarding re-endorsement of CBE ID 2483: Gains in Patient Activation (PAM) Scores at 12 Months.
Submitted electronically
Dear PQM Workgroup,
I am writing to provide comments to the PQM on behalf of the Patient Activation Measure (PAM) as you consider measures for endorsement this year. I am a family physician with 42 years of practice experience and retired as a full Clinical Professor from Stanford at the end of 2016. I currently work as an Adjunct Professor in the School of Medicine at the Clinical Excellence Research Center where I co-direct the High Value Health Care Incubator, working with federally qualified health centers and do research. I began utilizing PAM as an important clinical tool starting from 2008, and created Stanford Coordinated Care, a program for patients living with complex medical and social needs that utilized PAM both as a clinical tool and as an outcome measure that clearly predicted health, utilization and cost. I also served as a lead faculty for the Intensive Outpatient Care Program, a CMMI-funded 3-year $19 million collaborative that included 23 medical groups in 5 states that utilized PAM. My research and practice have shown that patient activation helps patients to become more empowered and engaged in their care. Activated patients are more likely to adhere to treatment plans, adopt healthy behaviors and engage in self-management, leading to improved outcomes and reduced costs. As you review measures for endorsement, I respectfully urge you to re-endorse the PAM as a Patient Reported Outcome Performance Measure (PRO-PM).
As you know, the PAM leverages a brief survey that helps providers understand patients’ ability to manage their own health care by measuring their knowledge, skills, and confidence. With this data, patients are grouped into one of four activation levels that provide insight into health-related characteristics, including attitudes, motivators, and behaviors. The PAM has been used in various settings, across diverse populations to understand risk, support care and disease management, allocate resources to low activated patients and, improve equity. 800 peer reviewed studies have been published over the course of nearly two decades proving PAM’s clinical validity and reliability. Over 300 health care organizations in nearly a dozen countries are using it. Despite its broad applicability, PAM is truly a unique measure and is currently the only Consensus-based Entity-endorsed patient activation measure.
The PAM-PM is currently in use in one Center for Medicare and Medicaid Innovation Center (CMMI)
model programs: the Kidney Care Choices (KCC) model. Within the KCC program, one large provider
group has seen a decrease in hospital admissions and readmissions which they attribute largely to
increases in patient activation. Most recently, the PAM-PM was finalized for inclusion in MIPS in the CY 2024 Physician Fee Schedule. Specifically, the PAM-PM was finalized for addition in five MVPs and 18 specialty measure sets.
As a researcher, who has experience with the PAM measure, I have seen this tool contribute to the improvement of health outcomes firsthand and can speak to the reliability and validity I have observed in my work over time. As a researcher and a clinician, who has direct experience with the PAM performance measure, I have seen this tool contribute to the improvement of health outcomes firsthand and can speak to the predictive value of the PAM performance measure as well as the reliability and validity I have observed in my work over time. My research on PAM in a published peer-reviewed paper that I conceptualized and co-authored in 2018 showed a statistically significant relationship between increases in PAM and lowered utilization and cost in 2155 high risk Medicare beneficiaries over a 3-year period (Patient Activation Changes as a Potential Signal for Changes in Health Care Costs: Cohort Study of US High-Cost Patients. J Gen Intern Med DOI: 10.1007/s11606-018-4657-6).
I encourage the PQM advisory group to consider the benefits of the PAM that I have mentioned and urge you to re-endorse the measure. To successfully achieve patient-centeredness through value-based care, patients should feel enabled and armed with the tools to be more active in their care and develop healthy behaviors. In the long term, this will also reduce burden to the system and help lower health care costs. I appreciate the opportunity to provide these comments and share my positive experience with the PAM. If I can provide additional information, please contact me at [email protected].
Sincerely,
Alan Glaseroff MD
Co-Founder, Stanford Coorinated Care
Co-Director, CERC High Value Health Care Incubator
Clinical Excellence Research Center
Center for Academic Medicine
Stanford School of Medicine
453 Quarry St - MC 5657
Palo Alto CA 94304