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Yet Another Meaning of “P” in PHM

by Scott MacStravic

It seems almost as if authors have taken as a wordsmith challenge the creation of new and different meanings for the first word in the initials “PHM”.  The “HM” always means “health management”, but the “P” may stand for any one of the following adjectives:

  •     Performance – when HM is used to improve this among employees
  •     Personal – when HM is provided to self-paying consumers
  •     Personalized – when tailored to individuals vs. one-size-fits-all, or segment-differentiated
  •     Pervasive – when disease management becomes a continuous and deliberately intrusive, constant element in patients’ lives
  •     Population – when it is applied across populations such as insurance plan members or employees
  •     Predictive – when it focuses on altering predictions about individuals’ or populations’ health
  •     Pre-emptive – when it aims to replace sickness with health
  •     Preventive – when it employs primary, secondary or tertiary prevention methods
  •     Proactive – to distinguish it from reactive sickness care
  •     Productivity – when it aims to improve employee performance
  •     Prospective – when it is based on what is foreseen otherwise

This widely varied use of different adjectives to precede “Health Management” is not a serious problem, since the varied meanings are all embraced in what most of us think about and do when thinking about or applying PHM.  On my own part, I file articles under the generic initials “PHM” rather than worrying about what the “P” is said to stand for.  There are more similarities across all the different labels than differences.

And just to add to the list, it occurred to me this morning that there is still another “P” that can apply, though it would involve a number of specific elements that would distinguish it from a number of other PHM examples.  It would be called “Precision Health Management”, and would roughly correspond to “precision marketing” as defined and applied by a research and consulting firm. [“Precision Marketing Solutions” Aberdeen Consulting Group Aug 1, 2006 (www.mycustomerl.com)]

Precision health management would be like precision marketing in that it would rely on predictive modeling and analytics to identify and grade the risks of individual HM prospects, and particularly the different potential value of each to sponsors of PHM, as well as the idiosyncratic personality factors of each relative to selecting the most cost-effective PHM interventions.  Its use in marketing is a sound basis for application to PHM, since both aim to understand, predict, and influence consumer behavior.

Just as marketing is increasingly moving toward customization of relationships, interactions, transactions, and customer experiences in general with customers, so Precision HM would strive for a similar degree and kind of individualized approaches to managing individuals’ and populations’ health.  This would include, for example, choices to consciously avoid “acquiring” some consumers, and even “firing” some already acquired, when their predicted or actual value is less than their predicted or actual costs.

It would include precision choices of communications channels, frequency, and content, involving whatever mix of channels and messages is predicted to be most cost-effective.  It could easily involve the use of the same kinds of software (e.g. SSP and SAS) and contact center strategies currently used in marketing applications designed to improve customer lifetime value (CLV).  It would alter this common set of initials to “PLV” for participant lifetime value, but would otherwise involve similar content and analytic as well as communications technologies.

As with its marketing applications, users of precision HM could choose to adopt internal, on-demand, or outsourced analytic, process, and communications, in whatever mix over time proves most cost-effective.  And as with precision marketing, this approach to PHM would strive for, and should achieve similarly higher levels of ROI for its adopters.  The use of predictive metrics in rules-based application to individuals or segments, where appropriate, should ensure that the value proposition offered and delivered to each individual will optimize the value that both participants and PHM sponsors gain, in both the short and long run.

It is unfortunate that so far, the healthcare industry has been significantly behind the curve in terms of taking advantage of emerging and constantly innovating computer analytics and communications technologies.  Precision HM represents a challenge to all who are or might consider being involved in PHM to ride the “breaking wave” of such innovations in pursuit of the most mutually valuable results possible for all stakeholders concerned.

How Serious Is Medicare About “Preventable” Sickness Care?

by Scott MacStravic

When I wrote the blog piece posted on Aug 15 about “non-payment for non-performance”, little did I realize how prophetic it was.  In yesterday’s Times appeared an article - “Medicare Says It Won’t Cover Hospital Errors” - announcing that it will no longer treat the costs of preventable errors, injuries and infections that occur in hospitals.  This is expected to save the federal government millions of dollars, while also saving many lives as hospitals have that much more motivation to prevent such errors.

Imagine what could happen if Medicare, Medicaid, commercial insurers and consumers got together and decided not to pay for preventable sickness!  It has been estimated that roughly 75% of all sickness care could have been prevented by effective health management, immunizations, and other forms of proactive health care.  There has long been a category of “avoidable” hospital admissions and treatments, regularly estimated as a large portion of all such treatments, based on best practices in ambulatory care.

This could easily become a “blame game” of course.  Insurers, employers, and governments could blame either consumers for not adhering to healthy behaviors, or complying with medical recommendations and prescriptions, for example.  Or they could penalize providers for not following best practices in managing their patients’ health, or not getting their patients to behave better.

Patients could blame insurers and their employers for not offering proactive health management programs they could enroll in (unless, of course, they did so), or not covering preventive and proactive services (unless they do).  Providers could blame payors for not paying them enough or otherwise supporting them in proactive health care, e.g. not covering the amount of time and effort it takes in terms of “cognitive services” to get patients to behave themselves.  And providers could easily blame their patients for not following their advice, once it has been given.

Payors would clearly have the upper hand in the blame game if they denied all payment for preventable sickness, not merely preventable errors, nosocomial infections, etc.  They have a lot of practice in denying, or certainly dictating lower payment levels when they feel such is appropriate, as Medicare recently did in decreeing that ambulatory surgery centers should only get paid 65% as much as do hospitals for comparable procedures. [”Doc Group Says New ASC Rate Would be ‘Death Blow’” ModernHealthcare.com Aug 20, 2007]

Consumers, when they are payors for some or all the sickness care involved could also exert extreme pressure on providers, by denying them full payment of their charges for sickness care if they deem the sickness something their provider should have prevented.  Providers could be caught somewhere between the impossibility of surviving on payment only for non-preventable sickness, and what they could legally command, or negotiate as their share of the blame for preventable sickness.

Given the widespread number of examples of in-fighting among healthcare stakeholders, there may be some movement toward such a policy and practice combination.  After all, few insurers, employers, consumers, or governments have espoused a sense of responsibility for keeping the current sickness care system alive.  And denying payment, in whole or even in part, for sickness that a given payor deems to be preventable, would threaten the existence of almost all providers.

Wouldn’t it be far better for providers, payors, consumers, etc. to get together and set annual goals for reductions in preventable sickness, involving all of their efforts, with all sharing in accountability for preventable sickness that doesn’t get prevented.  Negotiating the relative share of accountability, in the form of lower payments by payors to providers, would be an interesting process to watch.  On the other hand, if a cooperative approach to common problem solving were tried, where providers and consumers, as well as payors defined and treated preventable sickness as a common problem, that might end up moving the current sickness-focused “healthcare system” in the right direction

Adapting Einstein’s Formula to Health Management

by Scott MacStravic

Albert Einstein used the formula E = MC2 to describe the conversion of mass into energy, later demonstrated with the atomic bomb.  A similar formula applies to health management (HM), whether applied to consumers paying for their own services, employees, commercial insurance plan members or government plan beneficiaries.  The difference is that the terms are different:

  •     “E” represents effectiveness/efficiency if HM programs
  •     “M” represents motivation in HM participants
  •     “C1” reflects participants’ capability and confidence, self-efficacy
  •     “C2” reflects participants’ consciousness of how/when to act

While a wide range of interventions have been used to promote HM participant “compliance” or “adherence” to medication and lifestyle regimens, they all can be categorized as aiming to achieve increases in motivation, capability or consciousness.  Many focus on just one of these, some on two, and a few on all three.  But experience has shown that the best results are achieved when all three are affected by HM programs, rather than relying on one or two.

For example, a recent report on a diabetes disease management program, used with significant effect by HealthMedia, Inc. of Ann Arbor, Michigan, identified nine keys to success in promoting diabetes patients’ adherence to medications:

  •     Improving patients’ depression and stress coping skills
  •     Fitting adherence into individual patients’ daily routines
  •     Understanding and addressing each’s adherence barriers
  •     Helping them feel accountable for adherence
  •     Strengthening their relationships with providers
  •     Bolstering their confidence in medications and themselves
  •     Moving them toward intrinsic vs. extrinsic motivations
  •     Focusing on their life quality benefits vs. sponsors’ gains
  •     Understanding and communicating with each as an individual

[K. Wildenhaus “Improving Medication Adherence: The Missing Link to Better Outcomes” HealthMedia.com Aug 16, 2007 (webinar + slides)]

All nine of these essentials deal with one or more of the “MC2” factors.  Improving coping skills, fitting adherence into daily routine, addressing barriers, bolstering their self-confidence – all relate to participants’ capabilities.  Fitting adherence into daily routines, strengthening relationships with providers (physicians, pharmacists, nurse coaches), and dealing with them as individuals — all relate to promoting their consciousness of what and when to act.  And helping them take ownership/accountability, strengthening provider relationships, moving them toward intrinsic motivations, and recognizing their unique personal benefits – all relate to promoting their motivations.

Addressing the changes in or reinforcements of participants’ personal and unique levels of motivation, capability and consciousness required for success is first a helpful basis for planning specific steps in an HM intervention.  It is also a useful focus for evaluating the immediate effects of intervention elements – are there noticeable changes in one or more of these three essentials as each reports them.  Unless one or more of these cognitive/emotional factors are increased, or at least reinforced by HM efforts, there is likely to be little if any effect.

By focusing on all three MC2 factors, HM sponsors can also create a “paper trail” that will enable or reinforce conclusions that their HM interventions are responsible for changes noted in participants’ health status, healthcare, disability and workers compensation insurance expenses, absences, productivity, performance, and overall economic impact.  If changes in one or more of these factors are noted after implementing efforts aimed at changing them, then are linked to changes in behavior, health status, and subsequently in desired economic impacts, sponsors can be much more confident that the HM interventions actually produced the impacts noted than if they only measured the impact per se.

By evaluating the particular impact that HM interventions have on motivation, capability and consciousness, sponsors and providers can also learn which of these three factors make how much difference in achieving necessary enrollment, participation, and completion of each intervention, and to each of the many dimensions of cost savings and performance improvement.  This will enable continuous “tweaking” of the HM interventions, themselves, and improvement of the predictive modeling methods used to identify and target prospects for particular kinds of interventions.

This is equally true with identifying the particular types of motivation, capability and consciousness dimensions, such as the nine examples identified by HealthMedia in its diabetes medication adherence program, that make the most difference to results.  Continuous improvement in our understanding of MC2 factors is needed to increase and maintain positive returns on investment from HM interventions in general, and to this key component of the solution of our healthcare cost crisis.

Self-Service in Health Care?

by Scott MacStravic

The very idea of people serving themselves instead of relying on professionals in healthcare has been parodied in a TV commercial where a physician in a hospital is advising a patient, in his home, over the phone, to “Make an incision between the fourth and fifth abdominal muscles.”  Clearly, most sickness care requires professional training and experience, and cannot be replicated by consumers in most cases.

On the other hand, “self-care” has long been the objective of 24/7 phone advice lines, offered by insurers, to enable consumers to determine if they could take care of their own or family members’ symptoms or signs in particular cases.  Self-care medical guides have long been published to offer similar advice entirely via self-service reading thereof.  After all, when self-care is appropriate, it is the most convenient and cheapest alternative for patients, as well as saving considerable money for payors.

Self-service is a growing element of chronic disease management, where patients check their own weight, blood pressure, glucose levels, and other clinical metrics that may indicate progress in getting them under control, or a problem that a professional should handle.  Devices that measure such indicators may be directly connected to professionals for review, as well as uploaded into patients’ records or personal web pages to enable both patient and provider to track progress and evaluate treatment.

A growing number of providers are making it possible for patients to make appointments, obtain health information, arrange prescription refills, etc. online, rather than taking the time of office staff.  Enabling patients to self-serve in terms of learning about the risks and benefits of alternative treatments or medications is a way to at least reduce the time professionals might otherwise have to spend educating them, though patient self-education can also end up costing providers time in explaining why something they may ask for, due to direct to consumer advertising or online information they have obtained, is not really the best choice for them.

But the greatest potential for self-service in healthcare may be in what is truly health, rather than sickness care.  The two biggest challenges in proactive health management (PHM) — whether paid for by consumers, employers, insurers or governments – is to make participation in specific interventions and behavior/lifestyle changes required as easy and inexpensive as possible.  Unless they are easy, convenient, fit participants’ work/life patterns, etc. such interventions rarely attract and retain enough participants.  And unless they are inexpensive enough, they will be rejected by potential and current investors therein.

Self-service in PHM is easily the least expensive approach possible, in most cases.  The question is always whether self-service will be effective enough to yield optimal ROI.  Making the costs to sponsors and participants as low as possible is a great way to minimize the cost denominator in ROI ratios.  But it is by no means always the best way to obtain the greatest ROI net gains.  And unfortunately, people differ dramatically in terms of how intensive, what kind, and how expensive efforts must be to get them to make the necessary behavior changes needed for PHM success.

Involving physicians and nurses, as “promoters” of PHM participation, as coaches and motivators of behavior change, and as sources of needed prescription drug support and lab tests or diagnostic scans needed to monitor clinical measures, has proven to improve results.  But it also greatly increase PHM costs, thereby threatening both ROI ratios and amounts.  Moreover, there are many self-service approaches to PHM that cost very little to make available, accessible and acceptable to consumers, in promoting health, preventing or reducing risk behaviors and conditions, or managing chronic conditions.

For example, a recent webinar sponsored by HealthMedia, Inc. of Ann Arbor, Michigan described how automated, self-service-based PHM programs can address a wide range of individual differences, across the spectrum of behavior change motivations and barriers.  Through automated analysis of online surveys that consumers take, behavior change motivation and barriers are identified and measured, with tailored e-mail or mailed communications aimed at individualizing coaching and support, while keeping costs highly affordable.

Compared to information-only efforts, where medications adherence levels averaged 57.7% when the same information is communicated to all participants in the same PHM program.  By contrast, the customized approach has been found to achieve 75.4% adherence, a 28% higher relative level, achieved at minimal added costs.  Even more positive was the fact that high levels of adherence were reached in as little as 30 days of PHM participation, and declined only a bit after its initial success. Participants’ confidence in their medications, perceived importance of adherence, and refill-on-time behavior actually increased from the 30 to 90 to 180 days participation. [K. Wildenhaus “Improve Medication Adherence: The Missing Link to Better Outcomes” HealthMedia.com Aug 16, 2007.

The use of “custom-tailored” communications is growing among most PHM providers, as they recognize the dramatically lower cost potential in automated communications systems and the potential for self-service inputs by participants to enable these systems inexpensively.  In addition to the reduced sickness costs that are typically achieved through better adherence, participants in the program who also reported an improvement in their health because of that adherence were found to yield productivity-cost savings of $1440 on average.

In order to achieve optimal participation in PHM, and thereby optimal economic value for sponsors, participants must also feel they are gaining something worthwhile, in return for the time and effort they must put into improving their health.  In the HealthMedia adherence study, participants reported an average 27% increased confidence in their ability to control their diabetes, a 15% increase in their ability to manage the emotional issues accompanying their condition, 83% reported being better able to communicate with their provider, and almost twice as many reported a good understanding of their condition.

It is certainly unfortunate that most of the negative press that Medicare disease management demonstration projects have received, thanks to the mixed results achieved therein so far, has come from interventions that were very much on the high side in terms of expense, costing literally from ten to one hundred times as much as automated customization systems may cost.  The full potential of self-service by PHM participants, together with automated communications that can be used as often as weekly, even daily when necessary, is yet to be learned, but the signs so far seem promising to say the least.

Healthcare Providers as Health Managers: Clock Issues

by Scott MacStravic

Okay, I admit that had I not begun with an obsessive commitment to “C” issues, the title of this piece would have been “timing” rather than clock issues.  But it is clear that deciding when the ‘clock starts running’ is a key element in health management (HM), for not only providers but all current and potential payors, as well as for consumers.  And generally speaking, nobody seems to start the clock early enough.

The total challenge of health management is to reduce the incidence and prevalence of disease and injury, in order to reduce sickness care costs, productivity and performance impairment, as well as move personal health and employee performance into “better than normal” range.  Different payors have different notions of what is the most important goal, and how best to achieve it, as well as when they should begin.

If it were up to healthcare providers, the time to begin is probably pre-pregnancy in preparing mothers for healthy pregnancies and having healthy babies.  During pregnancy has already been cited as a great point in time to prepare parents for promoting optimal health in their babies after they’re born, from healthy diet to immunizations to child development.[W. Boggs “Better Prenatal Education May Improve Childhood Immunization Rates” Medscape.com Aug 16, 2007]

Preventing childhood obesity is known to be vital for their future health, and preventing metabolic syndrome among children would avoid the fifteen times higher risk of heart disease that this risk condition creates for children. [“Metabolic Syndrome in Kids Ups Adult Heart Risk” Reuters.com Aug 7, 2007]  Teens are among the most susceptible to adopting unhealthy behaviors such as smoking, alcohol and drug abuse, which can condemn them to lifetime addiction.

Insurance plans are increasingly tailoring minimal health insurance coverage for young adults who already see themselves as invulnerable, but if they do not include coverage for risk prevention, at least, they are only adding to the likelihood that when they are older, they will also be sicker.  While capturing them early makes it easier to convert them to more complete and expensive coverage, it could also ensure that they will be more expensive members than is necessary, unless health promotion and risk prevention/reduction are lifetime pursuits.

For younger workers, often with minimal skills and low wages, their employers often deny coverage of health insurance of any kind, and certainly don’t invest in their long-term health.  But when these workers get older, they will likely be expensive risks and performance-impaired due to lack of health management by anyone.  And with older workers, Medicare should worry about what their health will be like when they retire and become eligible for government-paid coverage.

The great disadvantage this country has is the unsystematic plurality of efforts to manage health.  All kinds of different organizations, different providers, payors, and advocacy organizations approach their own narrow segments of the population, their diseases or risks, and their times of life, while there is not even a systematic, lifetime framework upon which they might coordinate their efforts for greater efficiency and effectiveness.  The free market is not capable of doing the job when there is no organized market for lifetime health management.

Clearly, all the stakeholders involved, from insurers to consumers to employers to governments and providers – could get together in an integrated effort to create a health management system.  And until we have the will, shared by enough of these to make enough difference, we can predict that the healthcare crisis will never be solved, and the potential of healthy children, workers, parents, and aging will never be realized.  The clock for health management ticks from even before birth, and continues until death, but we haven’t yet timed our health management efforts accordingly.

As far as I know, not even healthcare providers are organized around, nor do they have a lifetime health management structure to apply to the challenge. But at least they include among them specialists in every phase of the individual life cycle, so may have the best foundation for the job.  But it will take the cooperation of all the other stakeholders to make lifetime health management work, and so far, nobody seems to have even stepped up to the plate to take on the challenge.

Healthcare Providers as Health Managers: Convenience Issues

by Scott MacStravic

Traditional healthcare providers, including hospitals and physician practices have long had an “edifice complex”, expecting patients to come to them for necessary services, to rely on face visits for communications and interactions.  Even today, only a modest proportion of physicians permit online communications with their patients, for example.  Hospitals have relocated or added locations in suburbs rather than the old-fashioned “pill hill” centrality in major cities, but are still losing patients to more conveniently located ambulatory surgery centers and specialty hospitals that established convenient locations earlier.

Convenience of location, hours of availability, and communications is even more important in health management, whether aimed at providers’ own employees or the workforces of employers that are clients for revenue-generating HM programs.  The U.S. Preventive Medicine, Inc. models of “Centers for Preventive Medicine” rely on hospital locations for most of the services they offer, though participating physician “partners” increase the number of locations where patients can obtain services. (www.USPreventiveMedicine.com)

The many hospitals and a few physician practices that offer “executive health” HM programs, which are still the most common example of hospital ventures in this market, almost all offer their major program elements at their own sites, requiring a one-day or longer stay.  While this stay is usually in luxurious surroundings, with “concierge” services to help make it easier for executive and other affluent clients to wend their way through the program, it is still necessary to come to a single location in most cases.  Until recently, most clients had to manage their own lifestyle changes, perhaps with the help of their personal physician back home, though many programs now offer phone coaching follow-up between stays.

By contrast, employers that offer their own HM programs often make them available at the worksite, with a growing number of onsite health clinics that include HM along with traditional occupational health services.  Retail clinics, conveniently located in popular superstores and pharmacies, offer HM services where consumers often shop, and even enable customers to shop while waiting, until a pager notifies them that the provider is available.

HM vendors often offer convenient “kiosks”, where HM participants can have parameters such as weight, body fat and blood pressure checked, in retail stores or worksites, in order to track their progress and qualify for incentive rewards.  Virgin Life Care offers such kiosks (“HealthZone” – www.virginlifecare.com) as does IncentaHealth (www.incentahealth.com).  IncentaHealth also offers daily online coaching for weight loss and fitness improvement.

In the IncentaHealth example, its services are offered mainly through employer-sponsored programs, though it also offers consumer-paid coaching through the New West Physicians in Denver and its Physician Health Coach program.  Participants get physician health recommendations, then IncentaHealth coaching for only $20 per month while they participate.  While these programs are limited to weight management and physical activity, these represent two of the most common health challenges that consumers have.

Whether providers are sponsoring HM programs for their own employees (and dependents, perhaps), for other business clients and their employees, or both – the programs are generally free to participants.  This means that the convenience dimension, i.e. the time and effort required of participants is the major cost to them.  Making it as easy as possible for people to participate, at times and places they find most convenient to participate, with communications channels and timing that fits best into their normal routine, is often the major factor determining the extent of both their participation and success.

Traditional healthcare providers’ insistence on patients coming to their places of business, at limited days and times of access, and communications at providers’ convenience will simply not work in HM, nor can it compete with specialized HM vendors who have already recognized and responded to consumers’ expectations.  Providers wishing to engage as many employees or other consumers as possible, and to promote their continuous and enthusiastic participation, will have to adopt a host of non-traditional convenience tactics in order to compete in the HM market, or achieve optimal results with their own workforce.

As the “new consumerism” increases the power of individuals and their importance in healthcare in general, traditional healthcare providers are already recognizing and responding to increasing consumer demands for greater convenience, even in traditional sickness care.  Providers must be prepared to make even greater improvements in convenience if they hope to achieve optimal results for themselves and their clients in HM, as well.

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.

Healthcare Providers as Health Managers – Communications Issues

by Scott MacStravic

Communication is a major, some might argue the most important element of health management, whether for sickness care cost reduction or productivity/performance improvement, and for traditional healthcare providers own workforce, other employers’ employees, or insurance plan members and beneficiaries.  The chief challenge in PHM and EHM is to achieve behavior changes among individuals and populations, and communications is the major basis for doing so.

The type of communications used vary widely, but generally fall into three categories, depending on whether their purpose is to motivate, empower/enable, or remind/prompt people to initiate or maintain a given behavior.  Unfortunately, professionals in one kind of communication may stress of use only their own kind, rather than considering other applications/reasons for communicating, and other kinds of communication.

For example, professionals who favor education, or what has become recently known as “information therapy/prescriptions (Ix), may rely solely on objective information sent to or shared with targeted HM participants in classes or seminars.  By focusing solely on the motivational power of facts, and on rational edification, the educational approach may fail to engage targets emotionally, and have little effect on enrollment, participation, behavior change and perseverance, all of which are necessary to optimal HM success.

Motivational appeals, for example, have long been understood by marketers to work much better if they engage targets emotionally, which is often sufficient by itself to elicit the desired behavior.  Rational education is often useful in enabling people to change, such as pointing out where help, peer support groups, etc. might be found, and remind people of incentives and rewards available.  But reliance on extrinsic rewards both costs HM sponsors money, threatening their ROI, and can run into trouble in time as rewards become perceived as entitlements, and no longer motivate well.

The absence of reminders for desired behavior changes is frequently absent, when HM providers rely on motivation and capability alone as sufficient.  Unless people can remind themselves, or otherwise remember when desired behaviors are needed, they may simply forget, even when they have both the motivation and capacity to act “correctly”.   Simple reminders, of the problem being addressed, the outcomes that might be achieved, and of the precise behavior needed, to the right person at the right time and place, may suffice for many participants, and cost relatively little when automated phone reminders, e-mails, or wireless communications are employed.

While my bias is understandable, as a career marketer, I believe that the inclusiveness inherent in marketing communications concepts and models will work well in HM, far better than educational or informational models, alone.  Marketing routinely reminds prospects and customers of the benefits to be gained, how to gain them, and when/where to do so, for example, rather than relying on motivational messages alone.

Moreover, marketing, when used to promote and sustain continuous relationships, understands the importance of reminding customers what they have gained, but also what they can expect to gain by persisting as HM participants, and what they could lose if they stop participating in an HM program or persisting in a desired behavior.  The effects of anticipated participation and benefits, as well as anticipation loss have been found, by marketers, to often overpower even satisfaction with past participation and benefits, in determining the continuation of relationships.

At a minimum, HM communication should include and test for the best methods, messages and media for motivating, enabling, and reminding prospects and participants.  All three kinds of communication can be combined in the same interaction when appropriate and efficient, so they need not add to the costs of communication, but they can significantly add to its effects, and thereby to the success of HM investments.

Moreover, the reminding function of communication can help in reducing costs of HM interventions.  By reminding participants of the intrinsic benefits of health and life quality improvement that their HM behaviors and achievements have delivered to them, the need for extrinsic incentives and rewards, with their unavoidable costs, may be reduced, or even eliminated at about the time they lose their impact.  It has often been shown by psychologists that intrinsic rewards are more effective, particularly in the long run than are their extrinsic cousins, and they cost HM sponsors nothing extra.

Perhaps even more important as a communications challenge for healthcare providers is the reminding of their internal and external “clients”, i.e. those who must be convinced of the total economic benefit of HM investments made.  Reminding them of carefully measured and monitored progress achieved can be helpful in maintaining current investments, while reminding them of the total gains achieved can be the source of internal approvals for next years’ investments, and external client retention, and even for results-based payment increases.

Communications strategies adopted by healthcare providers of HM services should be planned, implemented, and evaluated to achieve all the outcomes that everyone involved is pursuing, plus recognition of all it has achieved, and is likely to achieve in future.  This will add significantly to the motivational impact of persuasive communications, as well as add confidence to the capability and empowerment effects of communications used for that purpose.