Given the large number of PHM suppliers already available, and growing numbers of hospitals, physicians, and other suppliers joining still, the number of options across the seven elements of PHM is enormous.  If there were as few as five options available for each element, to say nothing of different mixes of elements for the same purpose, there would be 75 = 16,807 different mixes of the options to consider. In practice, of course, insurers and employers, like consumers when faced with too many choices, first strive to limit the number to a manageable few, perhaps no more than five sets.

This may be accomplished by looking for particular vendors, as outsource suppliers or at least basic models for a DIY option.  ON the other hand, some PHM investors have divided up the strategy, and even particular interventions among multiple suppliers, using one for the assessment element, and others for interventions, or one for interventions, and another for evaluation.  If each different supplier offers different options for each element, that could greatly increase the mix of options available, even if only a few suppliers are considered.  Moreover, suppliers are increasingly adding numbers and types of interventions, in order to be able to offer options graduated in cost and effectiveness to the risk/reward potential of different programs and participants.

One development should reduce the difficulty of making choices in this “overstocked” world.  Predictive modeling is improving in its accuracy all the time relative to the risk/reward issue.   And since different element options, as well as different suppliers, bring with them different charges and typical costs for their clients, these may more accurately be compared to the risk/reward of the population under consideration, and for targeting prospective participants, thereby improving the chances of investments turning out well.

But the biggest boon to payers will come only when sufficient studies are made of the relative cost and returns on investment of the methods available in the market.  It may take decades to do this for each option in each element, but it should not take more than a few years of concerted effort to compare different suppliers, along with more successful DIY efforts.  The key is to retain a focus on results and returns, rather than be satisfied with thinking that investing in PHM is a good idea for its own sake.

Employers are probably somewhat more averse to “rigorous evaluation”, when it adds significantly to costs, than are insurers, at least as regards PHM investments.  Managers spend relatively little time measuring things, as long as the key items in their balanced scorecard are going well.  And if they are not going well, they may have to conserve their funds anyway, so would be unable to invest in measurement.  Insurance, with its core competencies of underwriting and risk management, are at least more engaged in measuring things.

One study, for example, has found that only a small minority of employers even measure employee absences, much less presenteeism, despite the fact that both cost them a lot and can be reduced, with presenteeism many times more expensive and potentially rewarding than health-related absence alone. [W. Lynch & H. Gardner “Our People Are Our Greatest Asset… But No, We Don’t Track Their Performance or Attendance” Health as Human Capital, Dec 17, 2006]

Another found that only 38% of employers surveyed in 2007 measured the ROI at all from their PHM investments, though this was up from 23% in 2006.  Many seem satisfied that it is an inherently good thing to do, or are confident that it is yielding a positive ROI, at least in the long run, and don’t wish to waste money proving it. [Wellness: Saving Lives and Money” 2007 Willis Survey (Willis America Employee Benefits North America (request: willisebsurvey@willis.com)]

Investing on faith alone will certainly not last long.  Finance executives and governing bodies are sure to begin questioning at least any large investment in PHM, so CEOs and whoever else champions PHM should be prepared to prove the business case.  In all the cases where efforts have been applied, the business case has been proven, and usually based on the most conservative figures, such as not including full productivity and performance benefits, or not including healthcare cost reductions. [S. Nicholson, et al.  “How to Present The Business Case for Health Care Quality to Employers” Applied Health Economics and Health Policy, 4:4 2005 209-218]

Many results have no doubt seriously understated the full economic value of their PHM efforts because they neither counted productivity impairment or its “non-disease/risk” causes nor invested in interventions related thereto.  There is ample evidence, for example, that conditions rarely included in disease management programs, including emotional disorders, allergies, arthritis, and chronic pain cause far more productivity impairment than to the most managed diseases.  Moreover, poor nutrition, fitness/activity levels, stress, lack of sleep, poor hydration, for example, have been found to be far more valuable when corrected to productivity benefits than to reduced disease and healthcare costs.

We have a long way to go, and far too many choices of how to get there at the moment.  What is needed is a concerted and coordinated effort — funded by governments, insurers, and employers – to evaluate the hundreds of options available, or at least screen for the most probably good ones, then rigorously evaluate these to identify and publish information on what are truly best practices.  This may begin with what is already being done in sickness care, measuring and reporting who is best, or least bad in this far too expensive side of “health care”.  It would make far more sense for it to be done where health can be improved, along with the quality of life for all people, as well as money can be saved by everyone who now pays for sickness care.

And one thing that is certainly clear, given the enormous variations in how PHM is designed, delivered, and evaluated, is that there is no way on earth to determine scientifically if “PHM works”.  The definitions and applications of “PHM” are so variable, and of “works” equally so, making any attempt to arrive at a single conclusion about it ridiculous and impossible to begin with.  The same has always been true of its separate components – disease management, health/wellness promotion, risk behavior and condition prevention and correction – in addition to whatever combination of these is included in PHM.  It may be understandable that academic institutions and governments strive to “test the hypothesis” of whether PHM works, but any such attempt is doomed by the extreme degree of variation in what “PHM” is, and how “works” is measured.