The range of interventions that DIY payers and PHM suppliers have adopted in seeking desired behavior, health status, healthcare/WC/disability cost reductions, and improvements in productivity or performance is vast – as is the range of costs and charges for such interventions.  The least intense, expensive, and unfortunately effective method of which I am aware, used by a vast number of single-problem suppliers, and ranging on costs from free to a few dollars per month per participant, is the automated, standardized e-mail prompt/invited website visit combination.

Since visits to websites cost sponsors little or nothing, and online e-mails reminding participant to make such visits add only a little more, these types of interventions can be marketed to consumers for self-paid efforts.  I don’t know if any payers use them, though there is one fitness/weight loss intervention I know of that is sold to employer and insurer clients, for undisclosed fees. It is also marketed to consumers through their primary physicians, for as little as $19.95 per month.

At the opposite end of the spectrum are PHM interventions that rely on face visits for screening assessments and coaching interactions, which often include biometric measurements to track how well the participant is progressing, and supply evidence for incentives that are based on biometric improvements, such as weight, blood pressure, sugar, cholesterol, etc.  Such visits can also be used to verify smoking, drugs or alcohol abstinence by checking for traces in the blood or urine.

The cost to participants in time to make visits to individual practitioners, or for practitioners to go to worksites for interactions, tends to make this method the most expensive.

When physician-practice-based interventions were used in one Medicare disease management demonstration project, they came with costs that ranged from $80 to $444 per month for each participant = $960 to $5328 per year!  It is little wonder that out of the fifteen providers participating in this project, only two have been able thus far to produce results meeting Medicare expectations, and warranting a bonus to the providers for their efforts. [R. Brown, et al. “The Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years” Mathematica Policy Research, Inc. 2007.

This example is likely to be an “outlier” in PHM generally, particularly for employers, since it reflects only medical care cost reductions, and high-cost elderly chronic disease patients.  Another physician practice has reported offering diabetes DM services that only added $104 in costs to normal patient visits, for example, though it lost money by doing so, because only a minority of patients had insurance plans that paid anything at all for the services. [P. Mohler & N. Mohler “Improving Chronic Illness Care in a Private Practice” Family Practice Management, 12:10 Nov/Dec 2005 50-56]

Visit-based PHM programs are not necessarily the most expensive, however.  In many cases, visits to physicians’ offices or retail medical clinics for other purposes can substitute for special trips for PHM interactions.  And some retail clinics offer PHM services, at either low fee-for-service prices each, or in relatively low-priced (< $100) packages to patients who use them for sickness care as well, or may even come exclusively for PHM services. Kiosks used to monitor biometrics such as weight, blood pressure/glucose and cholesterol can be offered in retail clinics, enabling practitioners to monitor progress and coach at modest costs.

Many PHM suppliers rely on phone coaching, but both the frequency and duration of interactions can vary, as will the costs, as is the case for visit-based interactions.  Phone coaches have to rely on participant self-measurement and reporting when tracking cooperation, behavior change, and biometric improvements, of course, unless participants have remote monitoring devices that automatically upload measures to practitioners, or medications adherence devices that monitor when and how often participants take them.  And such devices are expensive in themselves, and normally only used in high-risk chronic disease(s) management.

Pretty close to the low-end website-based interventions are the wide range (ten at last count) of interventions offered by HealthMedia, Inc. (Ann Arbor, Michigan).  It offers each of the ten at separate costs per population, but the costs tend to be quite low, particularly for large employers with thousands of employees.  It also offers “book of business” data on as many as half a million employees who have participated in one or more of these interventions, so payers can get an idea of what results have been achieved in the past over a very large population.  It collects only productivity data, combining absenteeism and presenteeism, but individual employers can supply or analyze their direct costs as well to complete savings calculations.

Its intervention relies on online or paper health risk assessments, which include risk/reward psychographics and productivity impairment questions.  The answers to its 30-50-question assessments enable virtually total individualization of both the HRA analysis and feedback to HRA participants, and ongoing communications to each one that chooses to enroll in one of their intervention programs.  And since even a question with only two possible answers, when there are 50 questions in the assessment, yield a possible 250 = 1 quintillion (fifteen zeros) possible combinations, so it is unlikely that many if any individual participants get the same communications.

The PHM market, generally, is moving away from the one-size fits all approach, toward customization in both content and cost of interventions.  Graduating prospective participants into low, medium, and high risk/reward categories is common, with accompanying graduation in the intensity and costs of interventions tailored to each.  Formerly high-end suppliers have merged with or acquired lower-cost suppliers, or developed their own lower-cost options, in order to compete effectively with the vast number of rival choices available.  Lower-cost suppliers may create or buy capabilities that have better results, but require more intensive and costly interventions to achieve, to accompany their basic methods.

There is no way of saying what is the best choice for any payer newly entering the PHM market, since the problems and potential for each will likely be unique, as well the economic impact of particular solutions with their populations.  The plethora of choices available is reflected in a generally dispersed market, where no one supplier is dominant, particularly since many employers and insurers are in the DIY category. In a recent study of employer-sponsored EHM efforts, for example, out of 96 employers who were investing in such efforts, no one supplier had been selected by more than three of the employers, counting those who were operating their own programs. [Wellness: Saving Lives and Money” 2007 Willis Survey (Willis America Employee Benefits North America)]

But the wide range of choices relative to how PHM services are delivered probably adds the most to the enormous variation in PHM choices, when all seven elements are combined.