Physicians and hospitals have put their toes in the water of proactive health management (PHM) for either their own workforce, to save money, or other employers, to gain profitable revenue.  Except for a rare few physicians, PHM is a sideline for these providers, while sickness care revenue is either still a major source of revenue, or the chief source.  The general class of “paraprofessionals”, including nurses, physicians assistants, dieticians/nutritionists, psychologists/counselors, etc. are much more likely to have put a lot more of themselves into PHM, and even to be solely devoted to it.

For example, there are at least hundreds, and more probably thousands of paraprofessionals, mostly nurses, who are engaged solely in providing case, care and disease management programs on behalf of insurers, all aimed at saving insurers money while improving health outcomes for patients.  Many more are solely engaged in other PHM coaching related to risk behaviors and conditions, working for the new class of healthcare organization usually called “vendors”.

In addition, there are the NPs and PAs that are working in the rapidly increasing number of “retail clinics” springing up all over the country.  In most cases, their PHM efforts are limited to routine physical exams and history taking, plus flu shots and perhaps simple testing or screening.  But in a few cases, these clinics combine making patients better to helping them become healthier.  The RediClinic chain of clinics, for example, combines a host of different PHM services as the “Stay Well” counterpart to their “Get Well” services. (www.rediclinic.com)

These extra services, also charged for based on posted fees for service, include educating patients on self-management counseling and monitoring for diseases (such as asthma and diabetes), and for risk conditions, such as high cholesterol and blood pressure, overweight and obesity.  These clinics create either a general or comprehensive health profile for patients wishing to manage their health, rather than merely be treated for existing problems.   The healthcare reformer Stephen Case is one of the owners of this chain, and it fits well into the kind of consumerism that is already affecting the healthcare system. [“Health Care Reform Should Address ‘Content, Coverage and Care”, Steve Case Writes” Kaiser Daily Health Report Oct 24, 2005 (www.kaisernetwork.org)

A few nurse practitioners, at least, have gone into PHM as the sole focus of their independent practices.  While some writing of prescriptions may be useful in PHM, and medications are major elements in disease management initiatives, most other risk issues and health goals can be addressed with no more than “cognitive services” by providers, and enthusiastic cooperation by patients.  This saves on malpractice insurance costs, for example, and enables independent practitioners to choose whether to rely on third-party payors willingness to pay, or charge patients directly, and thereby keep practice costs even lower.

Because paraprofessionals are generally paid dramatically less than physicians, and are usually far better educated and trained in health maintenance and improvement than are physicians, they make ideal providers of PHM, whether on their own, working for payors, for physician practices, or hospitals.  Of course, with a growing shortage of many kinds of paraprofessionals, having them engaged, partially or wholly, in PHM reduces the labor supply available for sickness care.  But since PHM reduces the incidence and prevalence of sickness, this should not be a serious drawback, and healthier employees, patients, or insurance beneficiaries generally benefit everyone more than do sicker ones, with the exception of providers dependent on sickness care.

In many cases, new kinds of professionals, with far less clinical education and training make good health and fitness coaches, for example, though clinicians are probably best for disease and even some risk condition management challenges, especially where prescription drugs may be used.  Organizations such as WellCoaches.com in Wellesley, MA are busy training large numbers of non-clinician coaches that can add to the number of qualified people working in PHM without reducing those engaged in sickness care.

Altogether, it is likely that there are and will continue to be far more paraprofessionals involved in PHM than there are physicians or hospitals, though both physicians and hospitals may become major employers of PHM paraprofessionals as they decide to “go over to the enemy” and invest in PHM programs that serve all the other stakeholders in our “healthcare system”.  If the large numbers of “Preventive Medicine Centers” offering consumers the PHM they will pay for, plus employers Prevention Plans that they will pay for envisioned by U.S. Preventive Medicine, Inc. is realized, there will be plenty more hospitals and physicians involved in PHM.