In the early days of health management (HM), whether for employees (EHM) or insured populations (PHM), insurers were among early adopters of the outsourcing approach thereto.  Since insurance plans had plenty of work to do in marketing their offerings, paying claims, and managing utilization of care, they were quite willing to outsource HM to the growing number of specialized vendors of disease management (DM) or health & wellness programs (HW).

But there are increasing signs that insurance plans are reconsidering this decision, and “in-sourcing” HM as a major strategy and revenue-generating addition to their insurance offerings.  For one thing, they have the large populations that can create the kinds of economies and qualities of scale that enable HM to be effective and efficient.  For another, they are faced with employer clients who want, even insist on HM as a key element in their relationships with insurance plans.

Both CIGNA and Aetna, for example, have long offered their own in-house HM programs, beginning with DM, and adding on HW and risk behavior/condition management efforts over time.  The majority of employers, according to one survey, look to their insurance plan to provide HM services, and employers typically prefer to deal with only one supplier of such services, rather than having to juggle many.  [L. Butcher “Wellness Programs: No Longer Just an Add-On” Managed Care Magazine, Feb 2008]

Wellpoint’s president of its Health Management subsidiary considers “health optimization” to be the future of the health insurance industry, according to this article.  Employers are making HM a key consideration when they select which insurers to do business with, and any plans that lack a commitment to and capability for HM, with its full effects on healthcare costs but worker productivity and performance even more important, will be at a competitive disadvantage.

Employers often develop their own internal HM programs, but many prefer to outsource this function.  For one thing, many are not large enough to have sufficient numbers of employees with similar health issues to enable internal programs to be cost-effective.  And for another, employers are barred from knowing as much about their employees’ health, as individuals, which makes it that much more difficult to match their programs to individual risk/reward potential.

This matching challenge is perhaps the key to successful HM strategies and interventions.  Unless HM providers can match interventions to the personal characteristics, preferences, and risk-reward potential of individual employees, they are essentially “flying blind” when it comes to ensuring positive and competitive levels of investment returns for their employer clients.  And employers are legally prohibited from knowing much of the information needed for such matching.

Wellpoint, for example, has 1500 staff already in its Health Management subsidiary, and has spent millions developing its “360o Health” program.  It is intended as a holistic health optimization strategy for employers, and Wellpoint envisions adding another 599 staff to meet growing demand for this service among its employer clients.  Health plans are even offering their HM services to employers who are not clients, though this may also be an effective strategy for gaining additional health insurance clients, once these HM services have proven effective.

As one sign of the times, Blue Cross/Blue Shield of Minnesota just announced that it is dropping its contract with Healthways, Inc. Nashville, Tennessee, as it readies its own internal program for rollout next year.  The intent is to offer a similar nurse-based phone coaching program, but aimed at not just DM participants, but at employees who are medically at risk, but not yet ill.  It will be able to use the BC/BS claims database to identify patients at risk of non-compliance, for example, and intervene immediately to identify and address the reasons therefor.

As in other examples of insurers taking over the HM function, BC/BS will compete with their former HM supplier for its own employer clients, and potentially for other employers as well.  While Healthways is large enough to easily absorb the loss of the direct contract, if the trend persists, all HM specialty suppliers may find competition from insurers a major challenge. [S. Alexander “Blue Cross Dropping its Contract with Healthways” StarTribune.com, May 8, 2008]

Like all HM suppliers, of course, insurance plans are faced with the challenge of delivering and demonstrating significant and consistent positive ROI for their employer clients.  Employers initially adopted HM investment as a worthwhile idea in its own right, and formal evaluation of financial returns has yet to become universally adopted.  But it is clearly headed in that direction, and proving results will increasingly become essential to survival in the HM market.

The HM market is, at present, filled with hundreds if not thousands of different models and techniques for each of its elements, as discussed in the already posted series of articles on “The Name of the Game in EHM is Variability”.  But it is certain that there will be intense efforts, by individual employers, consortiums thereof, and institutes developing for the purpose, to determine which are the best practices, and to publish this information for all to see.  Then we will learn how well insurance plans compete with both specialized HM suppliers and employers, themselves, some of whom are already marketing their services to their peers. [“Employer Cooperation in EHM” May 5, 2008]