Those are the findings of a study led by Judith Hibbard, a professor emerita in the Department of Planning, Public Policy and Management at the University of Oregon. Hibbard and co-authors found that patients with the lowest level of "activation" -- that is, those most lacking in the skills and confidence to be actively engaged in their health care -- had average costs that were from 8 percent to 21 percent higher compared to patients with the highest level of activation. The study was the basis for two papers appearing in the February issue of Health Affairs.

"The study highlights the important role that patients play in determining outcomes," said Hibbard, who recently appeared as a featured expert on health care reform at a White House health care summit at Stanford University. "We found that patients who were more knowledgeable, skilled and confident about managing their day-to-day health and health care -- also called patient activation -- had health care costs that were substantially lower than patients who lacked this type of confidence and skill."

Hibbard and her team adjusted for patient differences, such as demographic factors and severity of illnesses. Even among patients with the same chronic illness, they found those who were more "activated" had lower overall health care costs than patients who were less so. An earlier study by the same authors had already established that more activated patients also had better health outcomes.

Using a Patient Activation Measure that assesses beliefs, knowledge and confidence in managing health-related tasks, the researchers found that patient scores on a questionnaire that ranks patient activation showed that patients' responses in effect predicted their overall care costs -- even when adjusted by the severity of patients' health conditions, age, sex and income. The researchers recommend that health delivery systems consider assessing these patient activation scores and supporting patients to become more engaged in their health and health care, as a way to both improve patient outcomes and lower costs.

Hibbard's two papers were co-authored by Jessica Greene, a professor and director of research at the George Washington University School of Nursing and a former associate professor at the UO. In the paper "Patients With Lower Activation Associated With Higher Costs; Delivery Systems Should Know Their Patients' 'Scores'" they examined the relationship between patient activation levels and billed care costs by analyzing 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota.

They found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels. Patient activation was a significant predictor of cost even after adjusting for a commonly used "risk score" specifically designed to predict future costs.

"Using patient activation levels to more effectively and appropriately support patients appears to be a potentially important way for delivery systems to improve outcomes and lower costs," researchers concluded.

The paper "What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Less Data on Costs," serves as a literature review of a broad array of research on patient activation. Hibbard and Greene examined the larger body of research in order to draw conclusions and point out areas in need of further study. They call for a systematic approach in encouraging patients to play a more active role in their health care and determine that policies and interventions aimed at strengthening patients' roles in managing their health care can contribute to improved outcomes.

"The emerging evidence suggests a potentially new quality goal," they conclude. "Increasing patient activation as an intermediate outcome of care that is measurable and linked with improved outcomes."

At a time when many unknowns surround the implementation of the Affordable Care Act, the study provides data that may inform the health care reform movement. The Patient Activation Measure (PAM) system that Hibbard and her colleagues at the UO developed is the industry-leading standard. It the basis for the self-assessment surveys licensed by the Oregon firm Insignia Health, which contracts with The Mayo Health Plan, Johns Hopkins Healthcare systems and other plans across the country. New health care reform measures emphasize self-management as a means of improving patient health and controlling health care costs.

"This study and the assessment system that Dr. Hibbard and her team developed are coming to the fore at a key moment in the evolution of our nation's health care system," said Kimberly Andrews Espy, vice president for research and innovation and dean of the graduate school. "Research conducted at the University of Oregon is giving rise to new tools and entrepreneurial technologies and creating intelligent solutions to tomorrow's problems today."The Commonwealth Fund supported Hibbard's research.