Archive for Prevention and Health Promotion
by Jody Dzuranin
September 9, 2008 at 10:32 pm · Filed under Prevention and Health Promotion, Wellness
I recently attended a forum of workplace wellness managers and they voiced similar frustrations of employees who were pushing back against taking the health risk assessment. The main reason cited is the fear that this personal health information will be used against them by their employer or their health insurance company. No matter how many incentives (or disincentives) were on the line, people do not want their employer dictating health behavior change. It led me to ponder our current structure. Why does it fall to the employers to try to convince their employees to lead a healthy lifestyle? It is not a comfortable position for the employer or employee. I really don’t think my boss needs to know what I weigh, but in small companies who are administering their own HRA, that is exactly what is happening. If I know my employer is going to see this information, I may not be honest in answering these personal questions. (I expect that the weight question and number of drinks per week are the 2 questions that are answered dishonestly most often). Something needs to shift in this model. On one hand, I think it is very important that the consumer (patient) has access to as much of their personal health information as possible, to become a good “self leader” as Dee Edington, PhD calls them. A good self leader will share their health information with their health professionals and take an active role in their own wellcare plan. On the flipside, who has more motivation than the employer who pays the expensive health insurance premiums, to make this helpful health information available to the employee? The right spot for it would be to come through the health professionals, but mostly people only see their doctor when they are ill. Who is responsible for wellcare? I think healthcare, health insurance and personal health information has become over-complicated to the point where the patient feels like an observer, rather than an active participant in the process. If we can streamline and simplify, we can bring the consumer back into the center of this unbalanced equation.
This post seems to raise more questions, than provide answers. Hopefully I will have more to share next week. I will be blogging at the 4th Annual Consumer Healthcare & Wellness Congress in Washington DC, September 15-17, 2008. I look forward to learning which corporate wellness, health prevention and promotion initiatives are gaining traction with employees and saving money. I am sure there will be lots of “healthy” conversation on this topic and more. I hope to see you there!
by Scott MacStravic
April 26, 2008 at 11:19 am · Filed under Prevention and Health Promotion, Business of Health, Marketing
Honesty is required by law in advertising of medical treatments and pharmaceuticals, though both are subject to some “overenthusiastic” promotion by physicians and drug companies, alike. On the other hand, there have been even more cases of overenthusiastic promotion by manufacturers of vitamins and food supplements, as well as providers of “alternative medicine” services whose methods have not been subject to scientific proof of safety and effectiveness before being advertised.
The regulation of treatments and products used in sickness care has long been a major effort in the interest of protecting patients from unscrupulous manufacturers, retailers, and providers who can easily take advantage of patients desperate for something that works, or those who rely too much on emotional vs. rational bases for making decisions about the care and providers they seek. There are certainly a large number of complementary and alternative medicine treatments that have solid evidence behind them. But in some ways, this makes it easier for unscrupulous sellers to make the case that their offering will work, by citing other examples where medicine has been wrong in concluding that previous CAM therapies were worthless.
The growing popularity of health management, of persons and populations (both deserving to be labeled “PHM”) has opened up a large new market for CAM therapies. Where CAM providers have achieved greater credibility among their patients for their approaches, and even greater success in terms of bang for the buck, thanks to their holistic approach to patient care, or their ability to enlist more enthusiastic collaboration among patients, they may be significantly more successful than are traditional physicians, at least in terms of benefits vs. costs.
Achieving a greater benefit/cost ratio is sure to make CAM providers more popular among payers, whether governments, commercial insurers, or employers. A growing number of insurers, for example, are offering, and employers as well as consumers selecting, lower-priced coverage plans that involve more use of CAM providers for health management of sickness care services. The generally lower prices they charge for their services, and lower overhead/operating costs for their practices, make CAM providers more likely to be able to compete on costs, at least.
The challenge in PHM is to promote honesty in advertising by its providers, whoever they are – specialty organizations that focus on PHM, traditional providers, or CAM alternatives – about what kind of results they are getting for what kinds of costs. If honesty in advertising were enforced in PHM, then unscrupulous or simply ineffective providers would be severely limited in their ability to attract payer clients, or even consumers, whether they pay out of their own pocket, or have a third party doing so.
There would be a significant number of current PHM providers who would probably be forced out of business if there were forced honesty in advertising, or even if there were the kind of comparative testing and reporting of outcomes and providers as is increasingly true with sickness care. Commercial insurance plans are already talking about developing and rating the performance of physician practices in terms of managing the health and costs of patients with chronic diseases. It would be relatively simple to do the same for practices engaged in protecting and improving their patients’ health, such as the MDVIP retainer medicine practices, now numbering over 200 in the US.
If honesty in advertising were required across the board in PHM as well as in sickness care, there would naturally be the same two effects as already noted with publication of comparative quality in sickness care. The lower-performing providers would strive and many succeed in improving their performance to make themselves more competitive with their higher-performing rivals. Or they would be forced out of business, as more consumers and payers would be able to “Buy Right” in PHM, as well as sickness care.
It will take a major improvement in the numbers of payer clients forcing and financing rigorous evaluation of the actual performance that PHM providers achieve. This will have to be done on a set of comparable outcome dimensions, rather than only those that individual PHM providers choose to measure or report. And there would have to be the kinds of rigorous analysis of the different results that different PHM providers get as has already been done in sickness care, and even in disease management D(M), though for the wrong reason.
Instead of rigorous scientific analysis of a number of different PHM providers and methods, there should be equally rigorous analysis of individual PHM providers’ results across their entire book of business. And instead of pursuing a ludicrous and futile answer to the general question of whether PHM works, as has characterized reviews in DM, these analyses should aim to develop comparable performance data on competing PHM providers to identify which do the job best.
This will speed up the ability of PHM sponsors and buyers to identify and selectively prefer those PHM providers who have been shown, in objective, accurate, and rigorous ways, to deliver the best outcomes. Ideally, these “best outcomes” should include both economic effects on payers, and personal health/life quality for those persons and populations that participate and invest their own time and effort, as well as their money in many cases, to achieve these outcomes.
The same amount of money already wasted on answering the unanswerable general question of whether it works could go a long way toward identifying which PHM methods work best. The general question is unanswerable because PHM, as is true for DM, is simply not one “treatment” that can be examined across different populations and problems to find out if it works. PHM and DM are a wide range of significantly different approaches, with highly varying costs and intensity, being applied to highly variable sets of problems and populations. The individual programs that do work should be the focus of analysis, not the collection of diverse programs, where some do and some don’t, virtually guaranteeing the almost always equivocal and uncertain results of studies addressing the general question.
Armed with comparative, rigorous, reliable and valid data on the performance of competing PHM methods and providers, the entire discipline and market of PHM could become dramatically more effective and efficient, and in a far faster time than is possible without such an effort. When the results of publishing such data are combined with regulated, honest advertising, PHM would have its best chance of succeeding, for its providers, its payers, and the populations that should be benefiting from such success.
by Fred Fortin
February 12, 2008 at 1:56 pm · Filed under Prevention and Health Promotion, International Health
Larry Brilliant writes in Slate about Google’s work to come to terms with the direction of its philanthropic giving. Google.org, the relatively new face of this effort, will be funded with 1 percent of Google’s equity and profits in some form, as well as employee time — thus its ‘hybrid’ nature. Brilliant says Google asked three broad questions: 1) Where can Google work to help the poorest and weakest of the world? 2) Is it a big enough idea? and 3) Did Google have particular expertise for each potential project?
Five initiatives were decided upon all with strong health implications. They are, according to Brilliant:
Predict and Prevent: We plan to identify hot spots where there is a high risk of emerging threats, such as infectious disease or climate risk, and enable a rapid, coordinated response.
Inform and Empower to Improve Public Services: Our goal is to use information to help spur citizens, communities, providers, and policymakers to improve the delivery of essential public services such as education, health, water, and sanitation.
Fuel the Growth of Small and Medium-Sized Enterprises: As described above, we want to increase the flow of risk capital to small and medium-sized businesses in the developing world.
Develop Renewable Energy Cheaper Than Coal (RE<C): Our goal is to create utility-scale electricity from clean renewable energy sources that is cheaper than electricity produced from coal.
Accelerate the Commercialization of Plug-In Vehicles (RechargeIT): We want to plant the seeds for innovation, demonstrate vehicle electrification and vehicle-to-grid technology, inform the policy debate, and stimulate market demand to foster mass commercialization of electric vehicles.
Google’s Predict and Prevent initiative, in particular, seeks to improve the “vulnerability mapping” of disease “hot spots” and create systems to detect threats better enabling early warning and a rapid response. The development of a wiki early warning capability for pandemics, a concept Brilliant has discussed before, is certainly a fantastic match for the resources and talent that Google can bring to the global health table.
The ‘hybrid’ flexibility embedded in these new philanthropic programs is a typically smart and innovative — as well as bold– Google move. Let’s hope that people like Brilliant can put this together in a way that has a real global impact on health care.
by Scott MacStravic
October 15, 2007 at 9:14 am · Filed under Insurance, Hospital and Health System CEOs, Prevention and Health Promotion, Business of Health, Employee Health Management
When I began my career in health marketing thirty-odd years ago, I was struck by the fact that hospitals and physicians were always open to become innovators, as long as they didn’t have to be the first to do so. When the concept of marketing in health care emerged in the 1970s, the American Hospital Association was one of the earlier organizations to embrace the idea, at least as far as sponsoring the first national conference on the subject in 1977. I recall spending a delightful time in Orlando with my wife at the conference, and meeting a number of people who later became friends as well as colleagues there.
By contrast, when the AHA came out with its report: “Healthy People Are the Foundation for a Productive America”, AHA TrendWatch Oct 2007, it was decidedly behind the early adopters of the idea, even among hospitals. It is an excellent report, compiling information from a wide range of resources (57 references are listed), and making sense out of an admittedly complex topic.
One of the more welcome aspects of the report it that it does not merely cite the productivity damage that employees’ and their families’ “unhealth” causes. It also cites the often dramatic improvements in productivity that have been achieved through protecting and improving employee health, as well as managing chronic diseases that affect the workforce. It notes that patients after heart surgery, for example, are significantly more likely to be working than they were able to do prior to surgery. Of course, this is a bit self-serving, since hospitals provide heart surgery.
But more important, and less self-serving, the report notes that promoting employee health and well-being, i.e. preventing them from getting sick in the first place can have even more dramatic effects on productivity, through reducing absenteeism, and particularly presenteeism. Often traditional medical treatments, such as prescription triptans for migraine headaches, or medications for allergies are cited as “solutions” that improve productivity. But promoting healthier behaviors and lifestyles, i.e. self management of disease and health are also mentioned favorably, even though an epidemic of wellness would certainly reduce revenue for hospitals.
A number of hospital-based health/wellness programs are cited, such as the Cleveland Clinic Employee Wellness Program. With hospitals already stressed by severe labor shortages, as well as high labor costs, any gains they can make in productivity of their workforces can only help on both counts. The Hospital for Joint Diseases Orthopaedic Institute Return to Work program includes efforts to prevent lower back pain and work-related disability, as well as expediting return to work among those where prevention failed.
Employees at Swedish American Health System in Rockford, Illinois lowered their blood pressure, cholesterol, and body fat after a 40-hour course on nutrition, physical activity, and risk factors for chronic disease. One interesting finding that the report mentioned was the fact that at least some employers believe that offering health insurance benefits to their employees is good for business, despite widespread declines in such benefits, and frequent calls for eliminating employer-based health insurance.
In one survey, the majority of small employers surveyed indicated that they believed covering health insurance helped with employee health, while almost as many agreed that it helped reduce absenteeism. And another survey indicated that four-tenths of employers felt that health benefits were “very” or “extremely” important in improving employee productivity. While many have suggested that insured employees are bound to be careless about their own health, and somewhat profligate in their use of sickness care when someone else pays the bill, this report cites findings that workers who can take paid time off to get medical attention are likely to take fewer sick days than those who cannot afford to. Those who have paid sick leave are less likely to come to work while ill, and thereby infect others, plus when they are at work, they will naturally be more productive.
While favoring the continuation of employer-based health insurance may also be self-serving for a hospital organization, favoring the reduction in the incidence and prevalence, as well as the negative productivity consequences of disease and injury is definitely not. Though many health promotion efforts, aimed at productivity impairment factors such as poor sleep habits and nutrition, inadequate physical activity and ineffective stress management, may not end up costing hospitals lost sickness care revenue, virtually all disease management efforts will.
The report stops short of advocating that all hospitals in the U.S. immediately undertake, or at least investigate the need and demand for health and productivity management, it doesn’t stop too far from it. As both a major element of hospitals’ missions, and to gain what is sure to be essential stretching of their labor resources and cost reductions available through improved productivity, hospitals will necessarily reduce their own, and perhaps their communities’ sickness and sickness care burdens. With all the attention that hospital associations have given to demonstrating the positive economic impact that hospitals have on their communities, it is a welcome addition that they are finally recognizing this potentially far greater positive impact that they might have.
The one item missing entirely from the report was any mention of hospitals that have already ventured into the health and productivity market on behalf of local, or as Mayo Clinic has done, on behalf of national employers. There are ample examples already that hospitals everywhere could emulate, though the potential for such ventures to end up reducing their sickness care revenues must give them pause. At least the AHA has recognized the larger reality that “healthy people are the foundation for a productive America”. If they can join with the many other stakeholders in identifying and implementing cooperative efforts in this direction, the report could truly be the start of something big.
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by Tony Chen
October 14, 2007 at 8:36 pm · Filed under Prevention and Health Promotion
I previously posted this same question on my own blog, but I want to pose it to this group - why is Minnesota so healthy? And what can we learn from them? They consistently rank among the healthiest states in the country.
While Minnesota may be known for its the health care businesses and organizations (Medtronic, Mayo, and MinuteClinic), I think the real difference is a strong, persistent culture of wellness and health. Sure, the government has done its part with a good state-run safety-net program. And yes, maybe there are a higher proportion of good jobs with good insurance (though many other states have higher income and poor health). There’s also a lot of lakes and a great outdoorsy mindset. Whatever it is - for some reason, living healthy is just ingrained into many Minnesota residents. Just google “healthy Minnesota” and compare those results with any other “healthy [pick your state]”. Very quickly, you’ll see that there is an usual amount of energy, out-of-the-box collaboration, and emphasis on staying healthy.
So, as we continue to debate health care reform, maybe we have too many conversations about policy & insurance & who’s going to pay for it. More thoughtful dialog is needed around how we can shift a national culture that is wired for over consumption.
by Scott MacStravic
October 10, 2007 at 10:03 pm · Filed under Hospital and Health System CEOs, Prevention and Health Promotion, Disease Management, Health Management
Predictive Modeling (PM) has many applications in healthcare. It can be used in market research for pharmaceuticals or healthcare providers, for example, to identify individuals or more likely segments in a population who are most likely to be interested in particular products or services. It can be used by health insurance plans to aid in making underwriting and pricing decisions about covering a particular population.
While predictions in the past were often made on fairly shaky grounds, relying solely on past trends or expert guesstimates, modern information and computer analysis technologies have improved our ability to predict at least some futures, though as Alan Greenspan recently noted, predicting the stock market is still a crapshoot. One of the newer applications is in health and disease management (HDM), where it can be used in a variety of ways to make investments safer and more likely to yield positive results.
MEDai, Inc. in Orlando, Florida, for example, has been producing predictions of the clinical and financial risks of populations for many years. Its “Risk Navigator” suite of three “solutions” for Clinical, Financial and Reporter functions enables a wide variety of clients to not only predict, but manage future developments in quality and costs of health care. These solutions are based on a complex mix of mathematical models and artificial intelligence, that enables predictions to be continuously updated as reality is compared to predictions.
Its solutions have been purchased by organizations such as HealthSTAT, Inc. for its onsite primary care and risk/disease management services for employers in over 200 facilities for 80 client organizations in 19 states. Health plans have used its PM solutions for managing care and diseases in their covered populations. They have been used to improve patient compliance with treatment regimens, and to improve underwriting accuracy by health insurers. (www.medai.com)
One of the most useful applications has been in stratifying members of populations at risk based on their past costs, predicted risks of future costs, and potential for positive impact or change. MEDai has both Acute and Chronic Impact indices for its Risk Navigator ClinicalTM application, enabling the prediction of the impact of improved patient compliance in disease management, for example. [“MEDai Addresses the Needs of Chronic Disease Management” News Release MEDai.com Sep 25, 2007]
As in the HealthSTAT example, its PM solutions also enable employers to achieve greater control over their healthcare costs, by giving employees better tools to both improve their own health and navigate the healthcare system when needed. PM can improve the selectivity of prospects for participation in HDM programs, increasing the proportions that will succeed and decreasing the proportions that will not. This can improve the ROI ratios and amounts of HDM investments significantly.
HealthMedia, Inc. Ann Arbor, Michigan uses its own PM solution, based on its HealthMedia® SucceedTM health risk assessment tool. This “configurable” (customizable) HRA enables similar careful selection of who should participate in HDM interventions based on a combination of the potential of individuals and segments for significant savings based on health improvement, and the probability that such potential will be realized.
The same HRA provides the basis for individually tailored feedback from the HRA results, and continuous coaching on whichever HDM intervention individuals participate in. Because the HRA includes assessment of productivity impairment, and factors that are linked to high levels thereof, it leads to interventions that go well beyond traditional “diseases”. Programs for sleep problems, depression, poor nutrition, physical inactivity, smoking cessation, stress management, etc. are either already in operation or in development.
HealthMedia also uses its HRA results to customize efforts to enroll eligible prospects in appropriate HDM interventions. The risk/reward potential of individuals can be reflected in whether or not incentives are offered for participation, and how large they are. The characteristics of individuals, such as their motivation, self-confidence, perceived barriers and stage of change are used to both predict risk/reward probability and tailor recruitment communications sent to individuals, as well as ongoing coaching communications.
Its “intelligent recruitment” communications can be delivered via e-mail, direct mail, or interactive voice response phone technology offered through Eliza Corporation, which partners with HealthMedia in this effort. Early results of this approach have shown that as many as 30% of eligible populations can be recruited to interventions without incentives, except for participation in the HRA, initially. [“HealthMedia’s Configurable HRA and Intelligent, Tailored Recruitment Revolutionize Risk Assessment and Increase Participation for Improved Outcomes” Press Release Oct 1, 2007 (www.HealthMedia.com)]
We are just beginning to scratch the surface of PM’s potential in HDM, just as we are doing the same for HDM, itself. The ability of PM to significantly improve the identification, selection, and prediction of financial as well as health outcomes for participants should help further increase the adoption and success of HDM strategies and interventions, with significant benefits for all concerned.
by Scott MacStravic
September 26, 2007 at 10:54 pm · Filed under Employer CEOs, Prevention and Health Promotion, Employee Health Management, Population health management, Health Management
Healthcare organizations (HCOs) , whether as employers seeking to enjoy the economic gains of employee health management (EHM), or as providers of EHM services to other employers, face the challenge of gaining enough participation among employees to make such services successful. One wellness program provider, Gordian Health Solutions, has reported that the purely voluntary participation rate among employees tends to be around only five percent. [A. vanDusen “Slimming Down the Workforce” Forbes.com Sep 4, 2007]
Voluntary engagement in EHM programs may be low, but the participants who participate may be more motivated than non-participants to manage their own health, and to reduce whatever risks they have, manage their chronic conditions, and thereby deliver benefit to their employers, as well as to themselves. But if only 5% of employees at risk participate, the potential gains will necessarily be low compared to the potential if high participation rates were achieved.
Gordian also reports that, with the right incentives, employers have achieved from 60-80% participation. It suggested that an increase of $30 per month in health insurance premium costs to non-participants could promote higher participation, as well. But while participation in EHM programs may be necessary to achieving the kinds of economic benefit employers seek, it is by no means sufficient. It is the “success” or “efficacy” rate that delivers the benefits — of lower healthcare, disability, absenteeism, presenteeism, and turnover costs, as well as quality, customer satisfaction, and new business revenue.
While participation may be increased dramatically through negative incentives, they may reduce the net benefits thereof. Employees who are punished for not participating, or rewarded for participating, may “participate” in whatever ways are used to measure such participation, in order to avoid personal financial costs or achieve financial rewards. But will they be truly “engaged”, and make the behavior and lifestyle changes that are necessary and sufficient to improve their health, and thereby benefit their employer?
Moreover, employees who feel “coerced” into participation by threatened punishments may become sullen and uncooperative at work, as well as in their participation. They may not improve their productivity or performance, due to a decline in their motivation, even if their health improves. [W. Lynch & H. Gardner “A Hierarchy of Aligned Incentives” Health as Human Capital Foundation 2006 (www.hhcf.org)]
And if that were not sufficient reason to be careful, positive incentives add to the costs of EHM programs, dollar per dollar. Moreover, their effective cost, relative to the benefits desired, is usually increased significantly because of limited efficacy or success rates among participants. In fact, participation incentives’ costs are multiplied directly compared to the benefits gained, based on these rates.
For example, participation in weight management programs may yield true “success” in as few as 5-10% of participants, in terms of losing weight and keeping it off for an extended period. Smoking cessation programs may only yield a 20% “quit rate”. If so, then incentives paid for participation will automatically be multiplied. To predict this effect, the participation costs per participant are divided by the efficacy rate.
For example, if participation incentives for weight management are $100 per participant, and only 10% lose weight, the effective costs per success are $100 divided by 10% equals $1000. In other words, it takes paying ten people $100 or $1000 in total, to get one to quit, or $1000 per quitter. With smoking, a $100 incentive with a 20% quit rate would mean a $100 divided by 20% equals $500 per success.
And these are not the only costs per participant, since the EHM program, itself, will cost something. If program costs per participant are as little as $100 each, these costs are also multiplied in the same way, depending on the efficacy rate of the program. This would mean the costs per success for the weight management program would be doubled to $2000 per success, and costs for smoking cessation to $1000 per success.
This would put a major burden on the EHM sponsor and provider alike, since both depend on achieving a positive, and ideally admirable return on investment (ROI) ratio, as well as net economic benefit. For them to simply break even, the overall economic benefit from weight management would have to be at least $2000 per success, or $1000 for smoking cessation. This may well be the case, but to achieve even a $2.00:1 ROI ratio, the overall economic benefit would have to be $4000 for weight management, and $2000 for smoking cessation.
This multiplier effect would be significantly less if the efficacy rate for EHM programs were higher. If the efficacy rate for a stress management program, for example, were 50%, the participation incentive of $100 per participant would only add $100 divided by 50% = $200 per success, as would the $100 in program costs, making total costs only $400. The benefit per success would only have to be $400 to break even, and $800 to achieve a $2.00:1 ROI ratio.
Moreover, offering an incentive for success, instead of for participation, may significantly increase the efficacy rate of the EHM program. It should even reduce the proportion of participants who participate just to avoid penalties of non-participation, or gain rewards for participation, and add to the success rate increase. In the case of weight management, or smoking cessation, for example, the employer could afford to offer a $1000 per success incentive for weight loss, and $500 for quitting smoking, rather than a $100 participation incentive, and still gain the same net economic benefit per success.
Since the costs of a success incentive are subject to no multiplication, they can be significantly more generous than the participation incentive, particularly when the efficacy rate for the EHM program involved is low or only modest. A large incentive offered for success may be enough to overcome the lack of an incentive for participation, by being significantly larger, and offering a reward that can be gained through behavior the participant can control, even enlist family and friends or co-workers to help the participant succeed.
Another approach that seems to have worked in EHM generally is to appeal to the competitive spirit of employees. As the vanDusen article reported, the Blue Cross/Blue Shield Association has found that team competitions in EHM help increase participation in its “Engaging Consumers @ Work” program. A team approach, where participants are grouped in teams with prospects of winning a success incentive based on the success rate within the team, could promote peer pressure and enlist peer support to each member, and raise success rates even more than individual success incentives do, while costing no more.
Since all costs that are incurred per participant “cascade” in a multiplied fashion to costs per success, while success incentives do not, HCOs might at least test the idea to see what improvements in their success rates and net economic benefit results.
by Scott MacStravic
September 24, 2007 at 9:06 am · Filed under Insurance, Employer CEOs, Health Plan/Payer CEOs, Hospital and Health System CEOs, Prevention and Health Promotion, Population health management, Health Management
The idea of using the altogether too loosely defined set of CAM solutions in treating the sick has been a contentious one for as long as I have been involved in health care. Our family was an osteopath when I was growing up, when even that was a kind of “alternative” approach to medicine, though it has been largely incorporated in traditional medicine today. I have on occasion tried acupuncture and chiropractic, without becoming a convert to CAM as “the” alternative.
With the growth of interest and investment in proactive health management (PHM) applied to individuals and populations, in private practice, worksites, retail clinics, employee and insured populations, is opening up a significant new opportunity for “complementary and alternative medicine”, however it is defined. Included among what some define as CAM are the use of “nutriceuticals” whose use has been scientifically supported, such as folic acid for pregnancy, along with stress management coaching, for example for general risk reduction.
The determination of whether and which CAM solutions will be covered by insurance, incorporated into traditional medical practice or “integrative medicine” programs, etc. has largely been a function of four different avenues: political, scientific, popular, and economic. As CAM penetrates the PHM market, it is likely that the economic and market avenues will dominate, though the political and scientific will continue to play a role.
The political route has been used by a number of CAM practitioners and their supporters, with noisy protests, effective lobbying, etc. leading to mandates for coverage in state legislatures, and by Medicare or Medicaid at the federal level as well. In a country where freedom of choice is such a mantra, it is difficult to argue against people having the right to choose CAM therapies and individual practitioners whose efficacy and safety may not yet have been proven. And when they cost less than traditional medicine, it becomes that much harder.
The scientific route is increasingly being used in recent years, as studies are finally being done in keeping with traditional standards of rigor, though many CAM therapies are difficult to compare to a meaningful “placebo”. What is the “inert” alternative to chiropractic, for example, or even acupuncture that would compare to the sugar pill that can be used in pharmaceutical trials? And Chinese medicine, for example, leans toward total customization for the individual patient, so there is no clear single alternative that can even be compared to a single placebo.
Moreover, there is the question as to whether the placebo effect should be discounted in CAM studies. Since this same affect often plays a significant part in pharmaceutical and medical care success, the overall effect should arguably be recognized, rather than just the demonstrable difference that the therapy makes alone. If this effect is stronger in CAM, as it seems to be in many cases, particularly in treating chronic pain, then why discount or ignore it?
The market has long been a major factor in promoting acceptance of CAM, particularly when few scientific studies were being performed. When more than 30 or 40% of consumers use CAM practitioners or treatments of some kind at least some of the time, the voice and wealth of consumers can support such solutions even if insurers and traditional medicine refuses to. And if physicians wish their patients to inform them about CAM solutions they are using, as part of coordinating care and avoiding contra-indicated mixing of the two, they must at least be willing to discuss the idea with patients.
As consumers have an increasing share of the healthcare burden imposed upon them, they may more frequently seek care from CAM providers whose prices tend to be significantly lower than those of physicians. The very transparency that is being espoused so reluctantly by traditional providers about their prices will tend to make it easier for consumers and payors alike to identify which are the most cost-effective providers of sickness care, and consumers may have different notions about which effects they think most important than do traditional providers.
The potential that CAM solutions and practitioners can protect and improve the health of consumers with as much success as do traditional providers seems very real. For one thing, most CAM providers do not command the same income as do physicians, so their services need not cost as much. For another, having been forced most of the time to live without any, or with limited insurance coverage, CAM practitioners often operate with nowhere near as high an overhead practice costs as do physicians.
And if employers, insurers, and government payors are persuaded that CAM strategies for protecting and improving the health of consumers can achieve the desired cost savings they not only wish for but feel are essential for survival, there should be a far more open mind about CAM in health management than there has been in sickness care. While arguments over the safety of some CAM therapies will no doubt continue, if they do no harm, and end up saving payors more money than traditional providers do, it seems likely that they will be even more widely accepted, by payors as well as consumers.
I expect to see some major disruptions in the health management market, as the four avenues are used simultaneously in the health as well as the sickness domain. It should be very interesting.
by Scott MacStravic
September 21, 2007 at 8:02 am · Filed under Insurance, Employer CEOs, Prevention and Health Promotion, Disease Management, Employee Health Management, Health Management
The ancient Greek philosopher’s division of people into “hedgehogs”, who rely on one big idea as their preferred solution to everything, vs. “foxes”, who prefer many varied approaches, has proven a good, if simplistic way of examining solutions. There are many hedgehog solutions to the entire “healthcare crisis”, for example, such as “market forces”, “single payer systems”, etc. And there has been a history of hedgehogs in the health management (HM) arena.
The great advantage to hedgehog solutions is that they can be refined over time in terms of both effectiveness and efficiency, making it possible for them to gain more customers and deliver more profit for their hedgehog HM providers. They also enable clear differentiation across competing providers, when each offers a particular solution to all HM problems, or at least the same basic approach.
One example of hedgehog approaches, used in disease rather than health or risk management, has been tried in Medicare-sponsored demonstration projects. In one such project, the costs of the DM interventions, addressing a number of different diseases, ranged from $80 to $440 per month! With built-in costs of over $5000 a year per participant, the interventions would clearly be limited to only the highest risk/reward-potential members of the population at risk. And generally speaking, these interventions have had limited success in terms of saving significant costs for Medicare, and returning results-based bonus payments to the DM providers.
The hedgehog approaches to HM include the physician-based “Chronic Care Model for disease management. The basic model remains essentially the same over a variety of chronic diseases. It can also be used for “pre-disease” risk conditions, whose reversal or at least control at no worse than its current status can deliver greater savings in many cases than managing the disease(s) for which they are risks. It is a model widely accepted and applied by physicians, and one that can be relatively efficient, adding only $104 per patient per year in one practice’s application to diabetes patients. [P. Mohler & N. Mohler “Improving Chronic Illness Care in a Private Practice” Family Practice Management 12:10 Nov/Dec 2005 50-56] Of course, if the usual medical care costs are included, along with the costs of the DM effort per se, the costs are much higher.
Another example of a physician-based DM effort was able to keep the total costs of care for diabetes patients to only $343 per patient per year, compared to the average costs of primary-physician care of $1591. Unfortunately, the Care South Carolina practices that achieved these savings received no reward for the accomplishment. [R. Chaufournier & K. Reims “Hidden Opportunities for Cost Savings in Disease Management” Healthcare Savings Chronicle (Coalition America, Inc.) Mar 10, 2005 (www.imakenews.com)]
Another common hedgehog approach is the phone coach, usually a nurse, supervised by a medical director, with applications based on standardized guidelines for different diseases or risk conditions. These tend to be in the mid-range of HM provider costs, depending on how many phone coaching sessions, lasting how long each, are required for each disease, condition, or individual patient. Phone coaching can be expensive, since sessions often last for a half hour or more.
Phone coaching is being used in a wide range of applications, from disease management to executive health risk condition follow-up. American Healthways, for example, initially depended mainly on phone coaching for its DM programs.
At the other end of the cost spectrum are HM providers that use automated, computer-generated online coaching, and web-based self-service interactions, which can often be delivered at costs as low as a dollar a month per participant, though some charges are as high as $20 per month. Thanks to the analytical and communications technology involved, costs can become highly affordable for HM sponsors or individual consumers, with results that are at least competitive with more expensive models. HealthMedia, Inc. for employees and insured populations, and incentaHEALTH for individual consumers, are examples of “hedgehogs” in this category.
But what has been happening, gradually to be sure, but frequently, if not yet universally, is that HM providers have moved toward the “fox” end of the solutions spectrum. Disease management providers have increased from one to a few to many different diseases, for example, and then to a broader range of expensive and risky conditions, as well as risk behavior interventions. American Healthways, which became Healthways, Inc. when it began marketing its services globally, has 10 “Health Support” programs for general health/wellness promotion, plus 21 “Care Support” programs for a wide range of chronic diseases, disorders, dysfunctions and syndromes. (www.healthways.com)
HealthMedia has been increasing the number and expanding the type of problems it addresses from chronic diseases to risk conditions, to health conditions and behaviors that mainly help employers reduce productivity and performance impairment among their workforces, including sleep disorders and emotional health problems. It serves employers and insurers, along with pharmaceutical firms and medical device manufacturers. While its basic interventions remain web-based, it can add phone coaching, onsite biometric screening, incentive programs and other HM elements through integrated partnerships with other providers. (www.healthmedia.com)
The move from hedgehogs to foxes is aimed at both increasing the sheer number of clients HM providers can serve and the number of different problems they can “solve”. It has often occurred through merger and acquisition in order to obtain the immediate capacity to offer something new, though internal developments have been equally common. The addition of new dimensions of client success, moving from healthcare cost reductions alone to patient compliance and pharmaceutical revenue, employee absence, turnover, and lost productivity reductions accompany the growth in the variety and range of solutions.
As insurers and employers increasingly look for lasting trust relationships with a few or even just one HM provider, in order to simplify their “outsourcing” efforts, the move from fox to hedgehog strategies among HM providers is sure to continue. There may be a few niches where hedgehog HM providers can focus on a narrow range of or a single disease, a single or limited number of solutions, and a narrow range of success dimensions, but the fox alternative has so much more to offer both providers and their customers, that it seems the better, if not the only way to go.
by Scott MacStravic
September 17, 2007 at 9:25 am · Filed under Health Plan/Payer CEOs, Prevention and Health Promotion, Proactive health management, Health Management
In low-cost health management (HM) interventions, mainly those that use computer-generated health risk feedback, online or web-based “self-service” coaching for all participants, it is generally the case that the more participants the better. In such cases, costs to HM providers are fixed, and fees to their clients are usually set on a flat fee/per population basis. So adding participants does not add to costs for clients, while adding to at least the potential for added benefits.
In such cases, the only basis for selecting HM participants is the match between a particular intervention and the targeted persons identified as potentially benefiting themselves and their employer or insurer by participating. Many may benefit from participating in more than one HM intervention, since the average person typically has more than one health risk, chronic condition, or productivity/performance factor affecting each.
But when costs to HM providers and charges to clients vary significantly by the number of participants in a given intervention, careful selection of targets and of the most cost-effective/efficient ways to secure their enrollment, participation, cooperation and completion of the intervention can be essential. If the intervention is the same across all participants, selection should focus on ensuring that as many of those targeted for participation as possible have predicted risk/reward levels greater then the costs they add to the intervention.
This is good practice for both HM providers and their clients. If costs increase per participant, the best way to ensure that the overall ROI ratio and net economic gain or ROI amount of each intervention are acceptable or admirable is to ensure that as many participants as possible have individual ROI ratios and amounts that are at least positive. This is true whether the type of intervention is the same for all participants or varies by their predicted risk/reward potential.
Individual customers of any business tend to include “most valuables” that generate great profit, “profitables” that at least contribute some profit, “marginals” that cover the fixed costs of serving them but no profit, and “losers” that detract from profits. Individual employees can be arrayed across a similar scale of value to their employers. And HM eligibles should be identifiable in terms of the same varying levels of risk/reward potential using predictive analytics.
When those eligible for particular HM interventions are identified through claims analysis or medical records, or through screening tests alone, the risk/reward potential is likely to be based solely on their past costs to insurers or employers. But if health risk assessments (HRAs) are used, they can add far more information about individuals’ probability of responding well to HM interventions, plus their potential for improving their value to employers, when they are employees.
The key is to identify existing and validated HRAs that determine individuals’ attitudes and perceptions, as well as risks and past and current costs or productivity/performance impairment levels. These may assessments should identify their levels of concern about and motivation to change their health behaviors and risks, or manage their chronic conditions and the behaviors that can accomplish that. They may also identify where people are in stages of readiness to change, in internal vs. external locus of control perceptions, perceived barriers to change, etc. – whatever individual characteristics have been shown to affect their probability of responding well to HM interventions.
The combination of individuals’ past and present costs and impairment levels with their probability of changing these in the immediate future will determine their risk/reward potential. This potential can then be used to:
- select targets for a one-size-fits-all intervention
- determine what sponsors or providers can afford to spend on incentives and efforts to promote their participation
- graduate interventions to match the risk/reward potential of different cohorts or individuals among those eligible
Since the efforts expended by HM providers or sponsors, as well as any incentives used to entice their participation, cooperation and completion of interventions add to the costs of such interventions, these costs have to be factored into both selection and graduation processes, to ensure that the risk/reward potential of participants exceeds their predicted costs. And when a combination of general health/wellness promotion, risk behavior, risk condition, and disease management interventions are planned, the potential per individual will vary widely across those eligible.
General health/wellness promotion tends to have the lowest potential in terms of healthcare/insurance costs, though it can reduce worker injuries, for example. And it can include focused efforts to reduce productivity/performance impairment factors, such as lack of sleep, hydration at work, poor nutrition, etc. that may also add to healthcare costs. And it can improve employee morale, energy levels and other health and motivation dimensions that may move participants into the range of “positive presenteeism”, where they go beyond expected and “normal” productivity/performance levels and value to employers.
One of the challenges in this type of intervention, aimed at preventing people from getting any risks, or increasing the numbers they already have, is that there is no change to use as the basis for predicting risk/return benefits. Only the non-emergence of risks represents the source of benefit and ROI. Fortunately, there is plenty of experience with populations and their tendency to add risks if left “unattended”. The value of keeping people from moving to a higher risk category should always be added to the value of reducing them to a lower risk category.
For example, in one study, the proportion of people in a low-risk category (having 0-2 risks) who moved to the medium-risk (3-4 risks) level in the following year was 13.7%, while 2.2% moved to high risk (5+ risks). The added cost of moving from low to medium risk was an increase of 26% in healthcare costs alone, while the added cost of moving to high risk was a 65% increase. Moving from medium to high risk meant an increase of 31%, adjusted for inflation in overall costs. [D. Eddington & S. Musich “The Case for Low-Risk Maintenance” Absolute Advantage 2:5 2003 22-25 (www.welcoa.com)
The benefit of reducing risks from a high to a low level was a 37% reduction in healthcare costs, while remaining at high risks meant a 21% increase. So the total benefit of reducing a person’s risk from high to low amounted to avoiding an 88% increase in costs altogether, counting inflation of costs. The University of Michigan Health Management Research Center is an excellent source of information on the financial benefits of reducing health risks in employed populations. (www.hmrc.umich.edu)
This Center has also examined the productivity impact of risk reduction and increase. In one of its studies, it found that the addition or reduction of a single risk was an average of 1.9% loss or gain in productivity due to presenteeism, or impairment among those at work. [W. Burton, et al. “The Association Between Health Risk Change and Presenteeism Change” JOEM 48:3 2006 252-263] By multiplying such an effect by the average annual compensation of workers, roughly $50,000 nationally among employers who engage in health management, HM providers and clients can gauge the value, e.g. 1.9% of $50,000 = $950.
The value of disease management varies dramatically by the disease in question, in addition to across the individuals who have such a disease. Congestive heart failure patients, for example, can often have their healthcare costs alone reduced by 30-50%, while diabetes patients may save only 5-10%. People with depression rarely save on healthcare costs, but can save dramatically in reduced productivity/performance impairment, from 10-25% in many cases. This kind of potential value can often cover DM costs of hundreds of dollars a month, since 25% of $50,000 = $12,500 a year.
Careful selection of individuals to target for HM interventions, together with prediction of the risk/reward potential of each can make a dramatic difference in the ROI ratios and amounts achieved by such interventions. The prediction of such potential should be an inherent feature of HM strategies and programs, though it is most important when the costs of such programs vary significantly by the number of participants. Such prediction also enables informed decisions on incentives and graduated interventions, to make ROI even more likely to be gained.
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