Making Sense of “Consumer Engagement” Initiatives to Improve Health and Health Care: A Conceptual Framework to Guide Policy and Practice

The ongoing pursuit of policies and programs to engage individuals in their health and health care is in large part based on their conceptual appeal. This is both the philosophical argument that individuals should have more say in their care (e.g., patient centeredness) and the performance-based argument that if obstacles to being engaged are removed (e.g., lack of information or motivation), then these active consumers will make informed decisions to behave in ways, such as selecting high-quality providers or helping design a care plan to follow, that improve the quality of their health care, their health, and their well-being and also may help contain their health care costs (e.g., Arnold 2007; DHHS 2008; Duggan et al. 2006; Epstein and Street 2011). Some people are skeptical about the power of this pathway to achieve all these desired results, especially system transformation (e.g., Berenson 2005; Hurley et al. 2009; Nichols et al. 2004), as the existing evidence for successful interventions is still limited and mixed, especially for efforts to stimulate behavior change in large numbers of consumers (e.g., Haynes et al. 2008; Ketelaar et al. 2011). When one community leader was asked about his community's efforts to improve consumer engagement, he said, “I think consumer engagement is the wild card. On the one hand, I think a lot of people are hopeful and see it as the missing link [to improving quality and controlling costs]. … On the other hand, I think it's a new enough topic that there's probably a fair amount of skepticism. I'll tell you [there is] skepticism; [colleagues ask,] ‘Is that even possible? Why should we be spending our time on that?’” (Alexander et al. 2009). This debate suggests the need for additional research into consumer engagement and for an evaluation of consumer engagement initiatives. Meanwhile, public and private entities continue to experiment with consumer engagement initiatives. For example, the 2010 Patient Protection and Affordable Care Act (ACA) included multiple provisions to support consumer engagement, such as increasing the availability of information and assistance to consumers for decision making and resources for wellness and self-management programs (DHHS 2012). Private purchasers’ efforts, such as offering personal health coaching or consumer-directed health plans, also continue to grow: from 11 percent and 13 percent in 2008 to 27 percent and 23 percent in 2011, respectively (KFF-HRET 2008, 2011). The $300-million Aligning Forces for Quality (AF4Q) initiative, supported by the Robert Wood Johnson Foundation, is another large national program whose goal is to improve the quality of health and health care for individuals (12.5% of the U.S. population) residing in sixteen communities nationwide by, in part, implementing community-based interventions to improve consumer engagement (AF4Q 2012; Painter and Lavizzo-Mourey 2008). We are part of the independent team hired by the Robert Wood Johnson Foundation to evaluate the AF4Q initiative, which began in 2006 (Scanlon et al. 2012). Our early efforts to “make sense of” the AF4Q communities’ varied consumer engagement activities revealed that consumer engagement is multidimensional and that these dimensions need to be made explicit and to be distinguished from one another in order to describe and compare them. We needed a framework to systematically characterize the diverse and evolving array of interventions that the AF4Q communities were piloting. While there were a range of thoughtful and useful conceptual models addressing important elements of consumer engagement in the literature, none on its own could be used to characterize the diversity of strategies reflected in the current consumer engagement initiatives. The need for such a framework was revealed in our in-depth interviews with AF4Q participants, who suggested that “everyone comes at [consumer engagement] differently,” which contributed to difficulties to “thinking through … and bring[ing] some cohesion to [the consumer engagement piece]” (Alexander et al. 2009). In this article we present a conceptual framework that distills the multifaceted concept of consumer engagement in health and health care into the critical analytic components that characterize community-based efforts to improve consumer engagement and help stimulate productive discussions about advancing health and health care through consumer engagement initiatives. After a brief discussion of our data and methods, we examine the meaning of the term “consumer engagement” and related concepts; offer a conceptual framework to typify and differentiate initiatives and to serve as a foundation for broad thinking and debate about the consumer engagement universe; and apply the framework to one community's consumer engagement initiative.