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Healthcare Providers as Health Managers – Choice Issues

by Scott MacStravic

“Customization” of both the HM “customer experiences” that PHM and EHM clients and participants have, and the communications between them and HM providers, is recommended for successful health management.  But the question remains as to which of the parties involved actually does the customization, i.e. who decides what will be customized and how it will be done.

In the vast majority of cases, any tailoring of the HM goals — to external clients and participants, or to providers’ own employees and dependents – is done by the HM provider.  Providers select which health dimensions, risk behaviors and conditions, or chronic diseases will be addressed, and what goals will be pursued.  These goals are by no means solely those of the provider or client involved, since participants must perceive that they will achieve something worthwhile, as well, if high levels of participation are to be achieved.

Decisions regarding the process to be used for different participants are also normally made by the HM provider or client that is paying for the program.  Targets for participation may be risk/reward-stratified into three or more levels for differentiated levels of attention and intensity/cost of interventions, in order to gear the HM investments to the reward potential of different segments.  And processes employed will naturally be differentiated somewhat depending on the specific behavior changes that are needed to make the HM program succeed.

Customization to individual participants may be achieved entirely by the HM provider.  HealthMedia, Inc. and Thomson Healthcare, both in Ann Arbor, Michigan, have capabilities for tailoring communications to individuals via automated computer analysis and generation of mail or online messages to HM participants.  Healthways, Inc. in Nashville, uses nurse health coaches who customize their phone interactions with participants as a natural element in identifying and addressing participants’ concerns at the time of contact.

While HM specialized suppliers have often been accused of using “one-size-fits-all” interventions in their programs, the move has been toward some degree of customization, mainly in communications, based on the health risk assessment (HRA) input that individual participants provide when completing these surveys.  And all suppliers are capable of customization to the particular wishes of their employer or insurer clients, based on the goals and costs each indicates a preference for.

What is rare, indeed, however, is customization of HM goals to the participants in HM programs.  The one example of tailoring the very nature of the HM intervention to individuals of which I am aware is that offered by Duke University Health to employees and dependents who are covered by its self-insured health plans.  Its “Duke Prospective Health” program initiates the HM process by asking (while guiding) participants to create their own personal health vision/mission statement, and select their own specific goals.

Since such goals can vary widely in terms of their significance to Duke, compared to meaning for participants, Duke further tailors the kinds of support it offers to participants based on its own likely benefits.  While all participants are eligible for group education and communications, more intensive interventions such as case management and personal coaching, can be reserved for cases where the employer will gain along with the employee or dependent involved.  Initially, these gains are only sought in terms of reduced healthcare expenditures, though productivity and performance gains may be added in future. (www.dukeprospectivehealth.org)

It is generally the case that the greater the customization, the greater the HM success will be, as is true in consumer marketing in general, and HM, after all, involves “marketing” behavior changes in much the same way that marketing seeks consumer purchases.  But customization also tends to add significantly to costs, though with current computer and online communications technologies, tailored communications can add little to nothing as far as communications costs are concerned.

It is the customization of HM processes and goals to individual preferences that is unusual, and adds the most to both the costs and the variability of reward potential for HM sponsors.  When consumers pay their own way, as with the MDVIP physician practices’ “retainer medicine” approaches to HM, the payments they make can cover a significant degree of individualization, where in payor-sponsored HM programs, most payors might be reluctant to pay the added costs.

Like so many of the decisions involved in planning and implementing HM programs, decisions regarding the type and degree of customization, of the particpant choices permitted and responded to, involve trade-offs between effectiveness and efficiency.  With relatively little published evidence regarding the relative cost-efficacy of different degrees and kinds of customization, and given the wide variations across populations involved in HM programs, as well as payors who sponsor and suppliers or healthcare providers that deliver them, chances are trade-offs, themselves, will end up being customized to individual applications.

The values and challenges that each sponsoring insurance plan or employer is guided by, the preferences of both supplier/provider and client, as well as those of participants will all play a part in customization.  This makes the trade-off challenge that much more complex, though HM decisions that do not at least consider customization options will miss out on the significant opportunities that incorporating some degree of choice in HM program design and execution offer.

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