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The Name of the Game in PHM Is Variability: Part 5 - Recruitment

by Scott MacStravic

Once members of the population have been targeted for participation in particular PHM interventions, the next step is to recruit as many as possible, or at least as many as will contributable value per participant, to each intervention.  Such recruitment may actually be part of the assessment process, when members of the population have to be persuaded to engage in a health risk assessment or biometric screening process, for example.  In any case, this element is yet another in which there is wide variability across the methods used by different DIY payers or the suppliers they hire.

One of the simplest is the “opt-out” strategy, in which every member of the population targeted is automatically enrolled without their involvement, once the targeting process is complete.  They are usually individually notified of their enrollment, and invited to take whatever the first step in actual participation is.  In some cases, they are automatically assigned a coach who will call them, or are automatically sent online or mailed information that is part of the intervention process.

This method often results in 90-95% enrollment, since only those who explicitly opt out are deemed non-participants.  But the significance of their being enrolled lies in their active participation, cooperation, and changes in behavior, and the rates of each may be quite a bit lower than when other enrollment strategies are followed.  The major two options with “opt-in” interventions are: 1) targeting each for a particular intervention based on the identified most promising PHM intervention for each; or less common 2) asking each target to choose among a number of options based on recommendations customized to each.

The enrollment process has to balance two considerations: 1) which intervention promises the greatest return to the investor; and 2) which has the greatest likelihood of delivering on that promise.   The opt-out approach probably is strongest on the first criterion, and weakest on the second.  Inviting targets to enroll in an intervention pre-selected for each is probably medium on the first and on the second criteria.  The “self-determination” approach would probably be weakest on the first and strongest on the second.  So it is a balancing act to select the best approach, and one or two may be tried before the best is identified in each case.

The “style” of the intervention and enrollment effort may also make a major difference to the numbers who enroll, participate effectively, and succeed.  Early PHM interventions were mostly “one-size-fits-all designed and implemented by the sponsor or supplier.  Increasingly, however, interventions are either partly or totally individualized, by either the person who contacts the target, or the automated online/mail communications based on analysis of assessment information.  And the customized approaches tend to work far better.

Enrollment is also influenced by whether or not financial or other incentives are offered – for enrollment, participation, or success.  Incentives paid for enrollment should achieve the highest enrollment, but not necessarily the highest levels of enthusiastic participation.  Incentives paid for participation in or completion of an intervention may achieve high levels of participation, but not necessarily of success.  Incentives paid for success may promote both enrollment and participation, particularly among those with the greatest confidence in their probability of succeeding.

Of course, people often delude themselves.  Repeated studies have found, for example, that those with the highest levels of capabilities tend to underrate themselves, while those with the lowest levels overrate themselves.  If the assessment process identifies targets based on predicted probability of success, it should be safer to pay incentives for participation, since those with low probability, despite confidence therein, would not be targeted.  Those with high probability, but perhaps less confidence, would be encouraged to participate by the incentive, where they might not be as encouraged by a reward only for success.

Since incentives add to the costs incurred by insurers or employers, they have to be used carefully.  PHM suppliers or peers who have used incentives, if they share their experience, may provide a basis for choosing which type and amount of incentive may work best, though each population is likely to be unique enough to make actual experience with it the best guide in the long run.  The combination of customization and the right incentives is likely to work best, judging by experience in PHM so far.


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