by Fred Fortin
June 5, 2008 at 2:15 pm · Filed under Uncategorized
Mark C. Taylor’s intriguing book, The Moment of Complexity: Emerging Network Culture, is one of those brilliant boiling pot examinations of social theories and philosophy which forces one to think and re-think where we are heading in this new flat world. Of course, when confronted with such intellectual challenges, my initial thoughts are always to line up the questions good authors generate and put them to the test in health care — my personal anchor to all things real and important.
The processes of globalization and proliferation of information technology, according to Taylor, is “creating a new network culture whose complex logic and dynamics we are only beginning to understand.”
Falling between order and chaos, the moment of complexity is the point at which self-organizing systems emerge to create new patterns of coherence and structures of relations.
Poised between too much and too little order, the moment of complexity is the medium in which network culture is emerging.
Taylor is studying that site between chaos and catastrophe, where boundaries are shifting, power relationships are becoming quite shaky, but order has not been overthrown - at least not just yet. And in theory it is never quite eliminated because “separation is always incomplete, for we remain entangled with that from which we struggle to escape” as Taylor puts it.
So a question that this theoretical assault raises for health care could be this: Will there be a “moment of complexity” where the ‘grid’ that structures health care — the systems, hierarchies, roles, science, authority and the rest of it — gets, well . . . torqued. As he describes,
Whereas walls divide and seclude in an effort to impose order and control, webs link and relate, entangling everyone in multiple, mutating, and mutually defining connections in which nobody is really in control. As connections proliferate, change accelerates, bringing everything to the edge of chaos.
One could argue that the brewing excitement in US health care — the crisis of health care costs, the catastrophe often proffered by futurists and economists, the explosion of health 2.0 and beyond, the perplexity of the public will — all speak to our hapless entry into this unnerving social space: health care’s very own ‘moment of complexity.’ The future may well indeed already be here.
One of the problems of being in this space, says Taylor, is the issue of whether the noise, the information glut, and the “confusion and debilitating sense of vertigo” it engenders will overwhelm the controls. For health care, that possibility could have both liberating and devastating consequences.
One response is to simplify and strengthen the stranglehold of the authority structures that govern and control medical practice and information distribution. Yet, if complexity is inevitable, then these attempts although well intentioned, will be more or less futile. No, the question really revolves around focusing our intellectual attention to this changing landscape, its “fluid dynamics” and how we adapt to its effects.
Taylor argues that education is the currency of the realm in network culture. If that is the case, then how we train our physicians, nurses, allied health professionals, technicians and the rest will be of critical importance in confronting this emerging challenge.
by Fred Fortin
May 29, 2008 at 8:07 pm · Filed under Policy Makers, International Best Practices, Business of Health, International Health
Fareed Zakaria argues in his new book “The Post-American World“, that the problem America faces in the new emerging international sphere is not so much domestic decline, but rather more “the rise of the rest.” By this he means that countries all over the world “have been experiencing rates of economic growth that were once unthinkable.” This is resulting in shifting of the balance of power, the movement from a unipower world with America at the center, to a world of “many actors, state and non-state” where there is no center. The challenge in such a world, according to Zakaria, is “how to stop the forces of global growth from turning into the forces of global disorder and disintegration.”
In this new “Post-American World”, Zakaria asks “will international life be substantially different in a world in which the non-Western powers have enormous weight?” Will Washington be able to “adjust and adapt to a world in which others have moved up?” And can we thrive in a world we cannot dominate? In America, “new thinking about the world is sorely lacking” and our isolationism has left us quite unaware of the world beyond our borders.
We also suffer from a “dysfunctional politics”, Zakaria writes, one characterized by gridlock and partisanship, which prevents us from beginning “a generous effort to engage the world.” The future is already here.
The task for today is to construct a new approach for a new era, one that responds to a global system in which power is far more diffuse than ever before and in which everyone feels empowered.
And organizing coalitions has become a primary form of power. Real solutions require,
creating a much broader coalition that includes the private sector, nongovernmental groups, cities and localities, and the media. In a globalized, democratized, and decentralized world, we need to get individuals to alter their behavior.
Now here is where health care begins to enter into the “Post-American” picture.
While Zakaria complains that health care costs “have risen to point that there is a significant competitive disadvantage to hiring American workers,” — and will not be an easy fix — he strongly believes that “America will remain a vital, vibrant economy, at the forefront of the next revolution in science, technology and industry — as long as it can embrace and adjust to the challenges confronting it.” The United States “has been and can be the world’s most important continuing source of new ideas, big and small, technical and creative, economic and political.”
In fact two of the industries he cites as examples are nanotechnology and biotechnology.
So where does Zakaria’s analysis leave those of us in health care. Here are a few thoughts.
- Health care reform in the US is not just a domestic priority but an international one as well. It is both part of the problem and part of the solution to America’s future position in international affairs.
- As I have argued a number of times before( here, here, and here ) American health care can become a stronger component of our international ’soft power’ because it is a valuable and desired center around which international coalitions can be formed.
- The world (and the US) has yet to full advantage of the emergence and development of Health 2.0. What an opportunity for a technology which emphasizes social networks to bring the world a bit closer together around a major concern of all countries– health care.
- The time to bring America’s involvement in world health care to the next level is now.
Health care can help to renew America’s legitimacy to act, in Zakaria’s words as an “honest broker’ in world affairs. It is time for US health activists to think global and take leadership in this important challenge.
by Fred Fortin
May 16, 2008 at 8:50 pm · Filed under Policy Makers, Regulators, Health IT, Transparency/Public Disclosure, Ethics
Lawrence Lessig wrote in Free Culture, that “privacy was assured because of the inefficient architecture for gathering data and hence a market constraint (cost) on anyone who wanted that data.” Privacy was guaranteed to us by a kind of economic “friction” and system inertia. Today that friction has all but disappeared and the privacy protection it once offered along with it.
Given that health care is a late bloomer to new media and the Web 2.0, some of the friction Lessig talks about may still be helping to secure private health information. Since this confidential information predominately resides today in slow moving, conservative institutions that dominate health care delivery, there is still time to consider the threats to privacy that Jonathan Zittrain outlines in his new book, The Future of the Internet (and how to stop it). He writes:
Cheap sensors generatively wired to cheap networks with cheap processors are transforming the nature of privacy. . .
The heart of the next-generation privacy problem arises from the similar but uncoordinated actions of individuals that can be combined in new ways thanks to the generative Net. Indeed, the Net enables individuals to compromise privacy more thoroughly than the government and commercial institutions traditionally targeted for scrutiny and regulation. . .
The essence of Privacy 2.0 is that government or corporations or other intermediaries need not be the source of the surveillance. Peer-to-peer technologies can eliminate points of control and gatekeeping from the transfer of personal data and information just as they can for movies and music. . .
Peer-leveraging technologies are overstepping the boundaries that laws and norms have defined as public and private, even as they are also facilitating beneficial innovation. . .
The slippery slope that privacy now sits upon is coming to health care.
Most of the privacy debate we see now in health care is focused on what Zittrain would call Privacy 1.0: how to impose rules and sanctions regarding things like disclosure, notice, encryption etc. upon recognized institutions and professional groups and medical workers. And while we hear calls for a new national privacy framework that will apply to the information technology industry (Google, Microsoft) it centers on the protection and control of electronic or personal health records. Again the emphasis is on formal records and institutions.
Privacy 1.0 is still a necessary front to secure if we are to modernize the health care system. But it does not get at the threats to privacy that Zittrain contemplates.The recently touted Congressional bill S 1693, the “Wired for Quality Health Care Act’ may, if passed, provide various forums for discussion of Privacy 2.0, but the bill itself seems oblivious to the implications of these kinds of issues.
So how do we manage ‘consent’ when it comes to private health information in this social media environment? This is one hell of a key question that needs to be addressed, and one that many are afraid to ask less it result in some draconian measures applied to all social media.
Do we have to accept a diminished private space to gain the benefits of social media? Will confidential health information become the entertainment for the ‘monitorial citizen’, part of the banal collective din of spectators who are fast becoming the new surveillance force in contemporary society? The values that are “animating our concern for privacy” are changing according to Zittrain, noting the age gap between those who use social media and those who shun it.
Zittrain does pose some ideas at least on how to signal the ‘intent’ of patients when it comes to their health information through tags, and embedded codes. But they pale in comparison to the zero-tolerance controls now demanded by US laws and regulations.
Nicholas Carr argues in The Big Switch, that contrary to popular sentiment, the technologies that make up the Internet are not those of emancipation, but are at core “technologies of control.” As social media begins to invade health care we will be able to test the capability and nature of that control. So hang on.
by Scott MacStravic
May 15, 2008 at 2:40 pm · Filed under Employer CEOs, Employee Health Management, Health Management
In the early years of employee health management (EHM), beginning in the 1970s, employers understandably used a management approach to their efforts to improve the health of their workforces. Initially, employer-sponsored efforts almost always involved health promotion or wellness initiatives, aimed at improving overall health and fitness, with specific initiatives aimed at weight loss, smoking cessation, diet/nutrition, and physical activity. When insurance plans became involved, somewhat later, they focused mainly on disease management for a few common and expensive diseases.
Both employers and insurers offered these EHM programs at no cost to employees, but mainly offered no incentives for participation in them. Their primary, if not sole purpose, was to improve the health of the workforce as a good thing in itself, while reducing the trend in annual health insurance premium increases. Insurers focused on the minority of their members who had one of the common chronic diseases, such as asthma, diabetes, heart and lung ailments, based on their prevalence and impact on health insurance costs. Employers involved the minority of their employees who were motivated to improve or maintain their overall health.
Disease management has had an often checkered history in terms of delivering desired results. The costs of interventions intended to improve control of the targeted conditions, and reduce the crises, complications, and worsening thereof, were often fairly high, relative to the cost savings achieved. Medicare-sponsored examples seem to generally yield equivocal or disappointing results, except with the most expensive and remediable conditions, such as congestive heart failure, and often increase health care costs by promoting greater adherence to and expenses related to prescription drugs needed to control diseases such as diabetes or asthma.
Wellness programs offered by employers often attracted those already committed to personal health and fitness, while those most needing to improve these dimensions ignored the opportunity. They made it easier to engage in healthy activities, by offering healthier food and exercise opportunities at the worksite, for example, but typically involved only a small minority of workers, as was true for disease management initiatives.
Once insurers and employers realized that the greatest returns on their investments (ROI) depended on getting more of their members and employees to participate in EHM programs, they began using more of a marketing approach. The sponsor considered, and occasionally even asked prospective participants what they wanted or hoped for in an EHM program, and what it would take to get them to participate, conducting, in effect, market research to help guide their efforts.
The use of incentives became common, once it was learned that EHM programs without incentives often attracted only 10-30% of workers as participants, while with incentives, participation rates of as high as 95% were possible. Executives and managers began serving as examples, while fellow employees supplied testimonials and case histories that could be used in promoting participation and supplement the effect of incentives, by describing the intrinsic benefits to participants, including dependents, along with extrinsic incentives.
EHM programs in this mode are typically one-size-fits-all “products”, though some are graduated to be high, medium, or low-cost alternatives for sponsors to selectively offer to high, medium, and low risk prospects. Instead of focusing solely on healthcare and disability claims costs, the programs in this mode look also at absenteeism and presenteeism reduction as desired outcomes. As a result, they look at employees who have “productivity impairment” behaviors and conditions, including emotional/behavioral problems, inadequate sleep, stress, and similar debilitating factors, as well as diseases and health risks.
Results from this mode have generally been far more positive than earlier EHM investments that focused just on healthcare cost reduction. Productivity “recovery” often increases total economic benefit to employers by two to five times, compared to healthcare cost reduction alone. Dramatically improved financial benefits have enabled employees to cover the added costs of “marketing” EHM through incentives and internal “advertising”, where healthcare cost reductions, alone, often could not. Of course, insurers could not gain anything but lower healthcare costs, themselves, but pleasing their employer clients has led an increasing number of health plans to offer EHM strategies and programs to attract and retain such clients.
Only in the past few years has an additional option been explored, that of empowering employees to select or design their own EHM goals and initiatives. Since it is the employees’ own personal efforts that make EHM successful or not, and empowerment approach might engage more of them at a higher level of commitment and personal investment if they have more choices in the matter. Moreover, since individual employees rarely have only one health risk, productivity impairment, or other health behavior “problem, empowering them to focus holistically on their overall health, rather than marketing a single-focus “product” might lead them to do more about more things, and yield better results.
In order to make sure they still gain a positive ROI from an empowerment strategy, employers can adopt at least two approaches in this mode. First, they can let the inherent attractiveness of enabling employees to choose their own goals and initiatives to substitute for reduced incentives, as compared to the marketing mode. Second, they can graduate the type and costs of the support they offer to employees in their self-directed efforts to the predicted risk/reward potential of the goals each selects to pursue.
Those whose current health, risk, and impairment levels are on the low side, whose goals are less relevant to and likely to yield less ROI for employers, and whose personality profile, motivation and self-efficacy are lower, can be allocated fewer resources for their personal EHM quests. Those at higher levels of many or all of these factors, can be allocated significantly more resources, e.g. personal phone coaching vs. automated e-mail efforts, in order to match resources and costs to the economic benefit predicted for each.
By more consciously matching resources and sponsor investments to the predicted economic benefit of individual participants or particular segments of the employee population, the empowerment mode can do a better job of achieving desired results. By automatically doing a better job of matching the focus of EHM efforts to each individual’s personal goals and values, and enabling them to choose what to invest their own time and effort on, it can also lead to greater commitment and persistence in such efforts, and thereby greater success for participants, as well as for the employer or insurer sponsor.
Individual employers or insurers can follow this development history, in the same way that individual organisms repeat the history of their species in their own development. (“Ontogeny replicates phylogeny” in Darwinian evolution.) Starting small, while maintaining total control over their EHM investment, may be an appealing option to sponsors getting their first experiences. Or they may choose to leapfrog over the slow, gradual successes of their peers by learning from their example and experiences, and selecting the best mix of the three modes to improve their chances of initial, as well as eventual success.
by Scott MacStravic
May 12, 2008 at 12:42 pm · Filed under Employee Health Management, Health Management
In the early days of health management (HM), whether for employees (EHM) or insured populations (PHM), insurers were among early adopters of the outsourcing approach thereto. Since insurance plans had plenty of work to do in marketing their offerings, paying claims, and managing utilization of care, they were quite willing to outsource HM to the growing number of specialized vendors of disease management (DM) or health & wellness programs (HW).
But there are increasing signs that insurance plans are reconsidering this decision, and “in-sourcing” HM as a major strategy and revenue-generating addition to their insurance offerings. For one thing, they have the large populations that can create the kinds of economies and qualities of scale that enable HM to be effective and efficient. For another, they are faced with employer clients who want, even insist on HM as a key element in their relationships with insurance plans.
Both CIGNA and Aetna, for example, have long offered their own in-house HM programs, beginning with DM, and adding on HW and risk behavior/condition management efforts over time. The majority of employers, according to one survey, look to their insurance plan to provide HM services, and employers typically prefer to deal with only one supplier of such services, rather than having to juggle many. [L. Butcher “Wellness Programs: No Longer Just an Add-On” Managed Care Magazine, Feb 2008]
Wellpoint’s president of its Health Management subsidiary considers “health optimization” to be the future of the health insurance industry, according to this article. Employers are making HM a key consideration when they select which insurers to do business with, and any plans that lack a commitment to and capability for HM, with its full effects on healthcare costs but worker productivity and performance even more important, will be at a competitive disadvantage.
Employers often develop their own internal HM programs, but many prefer to outsource this function. For one thing, many are not large enough to have sufficient numbers of employees with similar health issues to enable internal programs to be cost-effective. And for another, employers are barred from knowing as much about their employees’ health, as individuals, which makes it that much more difficult to match their programs to individual risk/reward potential.
This matching challenge is perhaps the key to successful HM strategies and interventions. Unless HM providers can match interventions to the personal characteristics, preferences, and risk-reward potential of individual employees, they are essentially “flying blind” when it comes to ensuring positive and competitive levels of investment returns for their employer clients. And employers are legally prohibited from knowing much of the information needed for such matching.
Wellpoint, for example, has 1500 staff already in its Health Management subsidiary, and has spent millions developing its “360o Health” program. It is intended as a holistic health optimization strategy for employers, and Wellpoint envisions adding another 599 staff to meet growing demand for this service among its employer clients. Health plans are even offering their HM services to employers who are not clients, though this may also be an effective strategy for gaining additional health insurance clients, once these HM services have proven effective.
As one sign of the times, Blue Cross/Blue Shield of Minnesota just announced that it is dropping its contract with Healthways, Inc. Nashville, Tennessee, as it readies its own internal program for rollout next year. The intent is to offer a similar nurse-based phone coaching program, but aimed at not just DM participants, but at employees who are medically at risk, but not yet ill. It will be able to use the BC/BS claims database to identify patients at risk of non-compliance, for example, and intervene immediately to identify and address the reasons therefor.
As in other examples of insurers taking over the HM function, BC/BS will compete with their former HM supplier for its own employer clients, and potentially for other employers as well. While Healthways is large enough to easily absorb the loss of the direct contract, if the trend persists, all HM specialty suppliers may find competition from insurers a major challenge. [S. Alexander “Blue Cross Dropping its Contract with Healthways” StarTribune.com, May 8, 2008]
Like all HM suppliers, of course, insurance plans are faced with the challenge of delivering and demonstrating significant and consistent positive ROI for their employer clients. Employers initially adopted HM investment as a worthwhile idea in its own right, and formal evaluation of financial returns has yet to become universally adopted. But it is clearly headed in that direction, and proving results will increasingly become essential to survival in the HM market.
The HM market is, at present, filled with hundreds if not thousands of different models and techniques for each of its elements, as discussed in the already posted series of articles on “The Name of the Game in EHM is Variability”. But it is certain that there will be intense efforts, by individual employers, consortiums thereof, and institutes developing for the purpose, to determine which are the best practices, and to publish this information for all to see. Then we will learn how well insurance plans compete with both specialized HM suppliers and employers, themselves, some of whom are already marketing their services to their peers. [“Employer Cooperation in EHM” May 5, 2008]
by Scott MacStravic
May 12, 2008 at 11:49 am · Filed under Disease Management, Population health management
Conventional wisdom in PHM has long adhered to the notion made famous by Willy Sutton, the famous robber, who explained his predilection for robbing banks by noting that they are where the money is. Translated into PHM terms, it leads to identifying those people – members of health plans and employees – who cost the most money. This logic became the major reason for the growth of the disease management (DM) industry, once it was realized that people with chronic disease account for roughly 75% of all health care costs.
This was the original logic that prompted investments in DM, and it persists today, despite the fact that federal government studies persist in finding, at best, equivocal or uncertain evidence as to the return on investment delivered by DM providers in practice. An article just last month, for example, noted that “Health plans are not effectively reaching the sickest Americans…” according to the latest Silverlink Healthcomm Behavior Index. It concluded that one recommendation for improving health and reducing costs is to “…focus on those who are most unhealthy. [L. Masterson “Getting Personal Engages Members” HealthPlans.HCPro.com, Apr 30, 2008]
While the idea may seem self-evidently true, or at least logically justified, it is more often blessed with the appearance than the reality of how disease and health management can be best applied. Even in the narrow context of PHM applied to health insurance plan members, selecting the sickest members has not turned out that well for DM providers, at least not in the Medicare demonstration projects that persist in yielding equivocal or disappointing results.
The basis for selecting targets for PHM interventions should be the economic and other value that can be obtained thereby, not simply the severity of the problem individuals may have. In the Medicare examples, often the problems addressed were simply too severe for the solution to fit well with, given the cost of the solution compared to the benefits it delivered. It is the benefit to cost relationship that should determine who will make the best prospects and participants for PHM.
Moreover, the relationship should be benefits minus costs, more than benefits divided by costs. The ROI ratio available from any single prospect or participant, or from a given PHM intervention relative to a population, should only be an indicator of value, not its calculation. The highest ROI ratios, almost automatically, will tend to arise from the lowest cost interventions, merely because their denominator is low. But if we rely on the ratio, alone, it is too easy to miss far greater opportunities for ROI amounts that require a bit more investment to achieve, and deliver lower ratios as a result.
The best prospects for PHM success will be the individuals and health problems that contain the greatest potential for delivering value, not merely reflect the worst problems. Smoking, for example, is often cited as a catastrophic risk factor, considering the great many diseases to which it can be connected. But smokers are often the toughest people to “reform”, and deliver only low economic benefit to payers per participant in smoking cessation initiatives, because so few quit and remain abstinent long enough to deliver significant benefit.
By contrast, some “minor” health problems, such as sleep deprivation or lack of physical fitness may have far higher success rates in PHM efforts to reform them, and deliver far greater benefit faster, with slightly higher costs per participant. Self-service methods such as visiting web sites and support communities may be so inexpensive as to enable practically all members of a population to be directed to use them. This may yield a high ratio based on modest improvement for even more modest cost, but fall far short of a more intensive approach aimed at another problem, or the same problem.
Since employers are not permitted to know much about the health of their employees, only medical care and PHM providers can normally select who are the best prospects among individuals. But populations and problems should be selected based on the overall ROI amounts available thereby, as long as the ROI ratios for the interventions available represent an attractive rate of interest on the money involved. Targeting based on severity of the healthcare costs or productivity/performance impairment levels alone will only yield the best choices by chance, not because they are the worst problems around
by Scott MacStravic
May 12, 2008 at 11:08 am · Filed under Employer CEOs, Health Plan/Payer CEOs, Business of Health, Variability in PHM Series
Given the large number of PHM suppliers already available, and growing numbers of hospitals, physicians, and other suppliers joining still, the number of options across the seven elements of PHM is enormous. If there were as few as five options available for each element, to say nothing of different mixes of elements for the same purpose, there would be 75 = 16,807 different mixes of the options to consider. In practice, of course, insurers and employers, like consumers when faced with too many choices, first strive to limit the number to a manageable few, perhaps no more than five sets.
This may be accomplished by looking for particular vendors, as outsource suppliers or at least basic models for a DIY option. ON the other hand, some PHM investors have divided up the strategy, and even particular interventions among multiple suppliers, using one for the assessment element, and others for interventions, or one for interventions, and another for evaluation. If each different supplier offers different options for each element, that could greatly increase the mix of options available, even if only a few suppliers are considered. Moreover, suppliers are increasingly adding numbers and types of interventions, in order to be able to offer options graduated in cost and effectiveness to the risk/reward potential of different programs and participants.
One development should reduce the difficulty of making choices in this “overstocked” world. Predictive modeling is improving in its accuracy all the time relative to the risk/reward issue. And since different element options, as well as different suppliers, bring with them different charges and typical costs for their clients, these may more accurately be compared to the risk/reward of the population under consideration, and for targeting prospective participants, thereby improving the chances of investments turning out well.
But the biggest boon to payers will come only when sufficient studies are made of the relative cost and returns on investment of the methods available in the market. It may take decades to do this for each option in each element, but it should not take more than a few years of concerted effort to compare different suppliers, along with more successful DIY efforts. The key is to retain a focus on results and returns, rather than be satisfied with thinking that investing in PHM is a good idea for its own sake.
Employers are probably somewhat more averse to “rigorous evaluation”, when it adds significantly to costs, than are insurers, at least as regards PHM investments. Managers spend relatively little time measuring things, as long as the key items in their balanced scorecard are going well. And if they are not going well, they may have to conserve their funds anyway, so would be unable to invest in measurement. Insurance, with its core competencies of underwriting and risk management, are at least more engaged in measuring things.
One study, for example, has found that only a small minority of employers even measure employee absences, much less presenteeism, despite the fact that both cost them a lot and can be reduced, with presenteeism many times more expensive and potentially rewarding than health-related absence alone. [W. Lynch & H. Gardner “Our People Are Our Greatest Asset… But No, We Don’t Track Their Performance or Attendance” Health as Human Capital, Dec 17, 2006]
Another found that only 38% of employers surveyed in 2007 measured the ROI at all from their PHM investments, though this was up from 23% in 2006. Many seem satisfied that it is an inherently good thing to do, or are confident that it is yielding a positive ROI, at least in the long run, and don’t wish to waste money proving it. [Wellness: Saving Lives and Money” 2007 Willis Survey (Willis America Employee Benefits North America (request: willisebsurvey@willis.com)]
Investing on faith alone will certainly not last long. Finance executives and governing bodies are sure to begin questioning at least any large investment in PHM, so CEOs and whoever else champions PHM should be prepared to prove the business case. In all the cases where efforts have been applied, the business case has been proven, and usually based on the most conservative figures, such as not including full productivity and performance benefits, or not including healthcare cost reductions. [S. Nicholson, et al. “How to Present The Business Case for Health Care Quality to Employers” Applied Health Economics and Health Policy, 4:4 2005 209-218]
Many results have no doubt seriously understated the full economic value of their PHM efforts because they neither counted productivity impairment or its “non-disease/risk” causes nor invested in interventions related thereto. There is ample evidence, for example, that conditions rarely included in disease management programs, including emotional disorders, allergies, arthritis, and chronic pain cause far more productivity impairment than to the most managed diseases. Moreover, poor nutrition, fitness/activity levels, stress, lack of sleep, poor hydration, for example, have been found to be far more valuable when corrected to productivity benefits than to reduced disease and healthcare costs.
We have a long way to go, and far too many choices of how to get there at the moment. What is needed is a concerted and coordinated effort — funded by governments, insurers, and employers – to evaluate the hundreds of options available, or at least screen for the most probably good ones, then rigorously evaluate these to identify and publish information on what are truly best practices. This may begin with what is already being done in sickness care, measuring and reporting who is best, or least bad in this far too expensive side of “health care”. It would make far more sense for it to be done where health can be improved, along with the quality of life for all people, as well as money can be saved by everyone who now pays for sickness care.
And one thing that is certainly clear, given the enormous variations in how PHM is designed, delivered, and evaluated, is that there is no way on earth to determine scientifically if “PHM works”. The definitions and applications of “PHM” are so variable, and of “works” equally so, making any attempt to arrive at a single conclusion about it ridiculous and impossible to begin with. The same has always been true of its separate components – disease management, health/wellness promotion, risk behavior and condition prevention and correction – in addition to whatever combination of these is included in PHM. It may be understandable that academic institutions and governments strive to “test the hypothesis” of whether PHM works, but any such attempt is doomed by the extreme degree of variation in what “PHM” is, and how “works” is measured.
by Scott MacStravic
May 12, 2008 at 11:06 am · Filed under Business of Health, Variability in PHM Series
To a great degree, the evaluation element in PHM comprises repetition of one or more of the assessments done for the initial baseline analysis. Ideally, this repetition, whenever it is repeated, will identify the changes of concern to payers, at least, while any added tracking of results used to sustain participants in their efforts and changes will do the same for the changes of interest to participants. But saying this, there will inevitably be the complication of making a “business case” that credibly demonstrates that the PHM strategy overall, and its individual interventions, have been the causes of the changes discovered.
Because the value dimensions addressed in EHM efforts and evaluations are major concerns of insurers and employers all the time, it is likely that they are doing something else to reduce costs or improve productivity and performance, beyond the effects of PHM interventions. And rarely would insurers, much less employers be willing to devote an entire year’s financial performance to the effects of a PHM investment alone. So generally speaking, the PHM evaluation should include some effort, at least, to separate out what changes in the evaluation dimensions it addresses that were probably affected by other efforts as well.
One of the best ways to track the effects of PHM is to analyze the tracking data that connects PHM efforts, such as HRA, screenings, and other information that was shared with individual participants in the HRA, coaching interventions used with participants in particular PHM interventions, and participant-reported behavior changes, health status biometrics of self-reports, etc. If this “value chain” of causes and effects can be shown to be connected as expected, that will make a strong case for attributing much at least of measured improvements to the PHM effort rather than “extraneous” causes.
Results such as “yes/no” behavior changes, (smoking, alcohol/drug abuse cessation) or “degree” changes, (increased physical activity, improved nutrition, longer average time slept per night, lower stress, etc.) should correlate with the amount and intensity of interventions, together with participant participation measures. In other words, the more the inputs by coaches and participants, the more the outputs in terms of behavior change, either a higher rate of yes/no changes, or a greater degree of change in continuous metrics.
In turn, the more the changes or progress achieved in behavior, the greater should be the improvements in biometrics, risk/impairment factor status, etc. that are supposed to be affected by each. This should also appear as a correlation between the different kinds of measures. And the measured biometrics, health/risk/impairment factor status should be well correlated with changes in healthcare cost, disability, and workers compensation costs, plus productivity and performance metrics or estimates.
The higher the degree of correlation across these changes, the more likely and credible the causal connection between them is. Only randomized and limited intervention clinical trials will meet academic standards, but demonstrated correlation should provide stronger evidence than simply records of changes in the outcome value, and certainly be better than the most popular approach, which among employers, at least, is not to measure ROI at all.
To determine ROI, of course, it is essential to factor in all costs as well as financial gains discovered in the evaluation. These will include all internal costs for payers who do it themselves, and is likely to include internal costs – for staff efforts, incentives paid, internal promotion of participation, team contests, etc.—as well. The costs imposed in the form of PHM supplier charges should be the easiest to identify, since they involve direct payments. When all financial benefits are compared to all costs, the ROI ratios and net earnings can be calculated.
There is a further complication in PHM, however, because, as is the case with some marketing expenditures, some portion of PHM costs should probably be treated as longer-term investments, rather than this year’s costs. While the published cases of long-term PHM results are few, they strongly suggest that when most of the participants in one year’s PHM efforts remain beneficiaries, members, or employees, the second-year results tend to be better than the first, and the third better than the second. The only case I know of where results were tracked for longer than three years found the fourth-year results essentially flat compared to the third.
This case, however, involved a cohort of employees, roughly 6000, who were continually employed and continuously participating in the PHM program for all four years. The pattern they produced, which was savings of $233 per participant in the first year, $375 in the second, $944 in the third, and $950 in the fourth, counted both medical care and disability/workers compensation expense savings, but not the productivity losses most likely associated. [G. Stave, et al. “Quantifiable Impact of the Contract for Health and Wellness” JOEM, 45:2 2003 109-117]
But chances are, when there are high turnover rates among health plan members or employees, the degree of improvement in that case would not be replicated. “Veteran” participants would too often be gone, instead of in their third or fourth year of improvement. And “novice” participants would have to replicate lower first-year results when it is their first year, even if the fifth or tenth for the payer in terms of PHM program investment. But as long as there is less than 100% turnover in the participant population, there seems likely to be improvement in annual results for successive years, at least up to three or four.
Improvements usually occur both because it takes time for participants to gain confidence in the own abilities. It also may take time for health status effects to occur. Fortunately for employers, many improvements in productivity occur quickly, so this should bolster clients’ confidence. One of the factors that take time is the influence that successful participants have on their peers who chose not to participate when first offered. The examples of successful peers, and the word-of-mouth reports spread by them, can be the most effective, and certainly least expensive approach to promoting future participation and improved results.
In general, it may be the third or fourth year until positive or at least desired ROI levels are achieved. Marathon Health, for example, a PHM supplier in Vermont, guarantees a 2:1 ROI, and often achieves 3:1, though not until the third year. The huge increase in the third year cited above may have meant no significant ROI was achBy contrast, HealthMedia is willing to guarantee the results it measures, though not ROI, for whatever period it uses in measuring them should its clients desire (per e-mail from Ted Dacko, CEO). HealthMedia only has two years* history with any of its results, and less than that for interventions introduced more recently, has not yet reported long-term results, but it makes employers who want quick results happy.
Whatever method for evaluation is used, it should meet at least standards for accuracy, reliability and validity, and avoid at least the most common errors due to self-selection bias and regression to the mean. Measuring ROI is clearly superior to pure credence that PHM works, or even relying on results others evaluate and report. The huge variety of methods currently in use, particularly in what is measured, together with the unavoidable costs of measuring many important sources of value from PHM investments, as well as the need to be able to take a long-term view of such investments, makes choosing an approach difficult, but definitely worthwhile.
by Scott MacStravic
May 7, 2008 at 8:46 pm · Filed under Hospital and Health System CEOs, Business of Health
In a previous article on the move toward increasing the places where health care is delivered, I noted a wide variety of additional locations where health care organizations (HCOs) are making care available. But the trend is even greater than I indicated. As reported in another earlier article by George van Antwerp, at least one new organization is offering health care at anyplace a person desiring it happens to be at the time.
American Well functions as a “broker” of physician services, once consumers have signed up as clients with their health history and payment information, and physicians have signed up to offer care in the form of online consultations. It offers consumers information on the qualifications of physicians relevant to the problems they describe, along with ratings of patient satisfaction among consumers who have consulted with them previously through this online service.
This means that consumers can obtain consultations at their home or workplace, or thanks to wireless communications devices, anywhere they and their devices happen to be. Phone communications can be arranged to accompany the online interactions, adding live audio communications to real time online transactions. American Well advertises itself as creating the same “transaction” opportunities as online shopping services such as Amazon.com and Expedia.com in the retail and travel realms.
It also notes that the care consumers get in this manner can be integrated into other sources that consumers use, including their personal physician, where they have one. Extensive records of the online transaction patients have had with American Well can be communicated to such physicians, with the patient’s permission, of course, as soon as the consultation is completed.
This service also includes information on the prices that will be charged by physicians offering the service, and enables such physicians to link their fees to the level of quality and past patient satisfaction they can demonstrate. Physicians can log on to the service when they wish to be available for consultations, and log off when they do not, meaning they control the amount as well as timing of their availability, based on their personal preferences.
Dr. Robert Shoenberg, co-founder of American Well has noted that current health care web sites offer consumers information, but not any opportunity to turn what they learn into transactions, i.e. actually obtaining care. By signing up both consumers and physicians, and enabling consumers to identify who is available to serve them online at a time and place they wish a consultation, American Well enables them to carry out a transaction in essentially the same way they buy from online retail or travel sites.
Consumers who log on to the American well site are walked through a process of indicating their problem or concern, identifying who is available to serve them, getting advise on how they can get the most benefit from their discussion, select a physician meeting their recorded preferences regarding age, gender, languages spoken, etc. They can access “five-star” ratings of each physician available based on previous consumer ratings of each, and determine the price of the transaction set by each physician.
Physicians can determine what topic(s) the consumer wishes to discuss, and offer the option of seeking care from a different specialist. Patients can see the responding physician online, and augment the online consultation with phone contact through the same computer, while enabling the physician to access an online medical record previously created. Each transaction is followed immediately by a feedback survey of the patient, and clicking a button to send the record of the transaction to the patient’s personal physician, including any needs concerns not addressed during the transaction that the personal physician can take care of at the next face visit.
Insurers can exert some control over use of the service by varying co-payment requirements according to the volume of use for individual plan members. In practice, the ready availability of physician online consultations wherever and whenever members wish them should reduce the unnecessary use of emergency rooms and face visits of other kinds. As such, the online service adds to retail clinics as alternative sources of care that can be coordinated with patients’ regular source of care. Nurses at retail clinics could use the online service as an immediate source of consultation when patients present with a problem where physician input is desirable.
This same service can easily become part of a more consumer-driven approach to health management, where consumers lack resources and programs offered by their employer, insurer, or physician. Ideally, insurance plans will come to appreciate the advantages of online health management consultations, in addition to sickness care transactions, and include coverage for them where they prove to be cost effective. [L. Dunbrach & R. Shoenberg “Health 2.0 – The Transformation to Online Care,” HealthIndustryInsights.com Webinar]
In any case, this is one example of a method for consumers obtaining care and physicians delivering it that falls into what is normally espoused as the “new consumerism”. Consumers have far more control over when and where they get care, while able to select physicians with considerable transparency as to qualifications and performance, as well as price. Dr. Shoenberg considers it to be a truly disruptive innovation. The rest of us will have to wait and see.
by Scott MacStravic
May 6, 2008 at 8:14 am · Filed under Business of Health, Variability in PHM Series
Once targets are enrolled, i.e. as many choose to opt in or fail to opt out, there remains the next challenge of sustaining their participation, in terms of frequency and duration of interactions, cooperation in pursuing the intervention goal, and making behavior changes – and completing or continuing in the intervention, depending on which applies. There may also be a separate challenge to sustain the changes in behavior, health status, and economic benefit delivered, since relapses relative to the behavior change targeted, or “slipping” into risk levels of some other behavior or condition is common.
PHM suppliers and sponsors seem generally to rely on the same approaches for sustaining participation and behavior changes as they do in achieving them. Of course, the least expensive course may be simply to ignore those who succeed, and even those who do not, rather than attempt to enroll them in the same intervention again. Re-enrollment efforts may help for those who failed to succeed or still have plenty of room for improvement, or they may be offered a different intervention, linked by assessment to a comparable or at least appreciable level of risk/reward potential.
For those who have succeeded already, some kind of “maintenance” intervention may work, with a lower intensity and cost to sponsors. Or, since almost every member of the population is likely to have many more than one cost factor present, those who succeed in one may be invited to enroll in another, assuming there remains plenty of room for reducing one or more of the costs involved. It may easily be possible to enroll “succeeders” in both one maintenance-level and one new intervention, without reducing the effects of either.
The most powerful approach to promoting sustained and continuous participation, however, is likely to be paying significant attention to what the participant has gained through past and current efforts. When the PHM intervention involves personal coaching, by phone or in person, it should be an automatically included part of each interaction to check what progress each participant has made in changing behavior, improving health status, reducing healthcare use, or improving productivity/performance, as each perceives such changes.
Their perceptions, at a minimum, can be used to reinforce their confidence in success, and thereby their motivation to persist. If, in addition, an effort is made, such as by asking participants to track for themselves, the health-related quality of life, and perhaps “life asset” impact of their participation so far, and their success once achieved, this should reinforce their persistence even more. Progress and success in changing behavior, health status, and productivity or performance, for example, when participants have their recognition of these prompted or reinforced, should add to their self-esteem as well as self-confidence.
Moreover, such changes may well have measurable impact on their life asset of “wealth” as well as “health”. Quitting smoking can save literally thousands of dollars a year in costs of tobacco, for example. Enabling and reminding participants to track how much they are “wasting” while they still smoke, and “earning” while they remain abstinent, can reinforce their commitment. It has been difficult to get smokers to recognize how much their productivity and performance have been impaired by their addiction, but measured improvement in both can add to their sense of “talent” or performance asset as well. And if productivity/performance improvements have come with increased compensation, reminding them of that should help as well.
Participants, themselves, are most likely to be at least potentially aware of many life benefits they are gaining through participation, if they are asked about them, or encouraged to record them in a personal health log or diary. This may be kept private for the participant’s personal use, or shared with the PHM supplier, as each participant chooses. Those that the supplier knows about can be used to provide periodic summaries to participants, to remind them of their achievements.
For PHM suppliers or programs that include frequent assessments, and I know of one that performs assessments at 30, 90 and 180 days, for example, for some clients, at least, can use these assessments to provide reinforcement effects to sustain participation, if it is intended to be longer than 30 or 90 days for example, or sustain change if repeated again after a year. Having three opportunities for participants to report their progress means they will be reminding themselves every time they are asked. If they also keep a shared log of results, the supplier can add its own summaries to these reminders.
Others, including incentaHEALTH and Virgin Health, use self-service kiosks that employees can use to “check in” with weight and other biometric measures whenever they choose. Each participant registers a confidential ID when using the kiosk, so that each’s efforts and biometrics can be tracked, making periodic reporting of progress and achievement easy for PHM providers.
Of course, like so many of the elements of PHM, supplying extra reminders, even asking separately about participant progress and achievement, may add some costs, so balancing the positive effects or sustaining efforts with their costs will be necessary. I know of no PHM supplier that has separated out such costs and effects, so there is no experience that I know of to look at. But research has clearly indicated that the prospect of future benefits is an even more powerful stimulant for continuing relationships than is recognition of past benefits, so reinforcing both seems likely to help. [K. Lemon et al. “Dynamic Customer Relationship Management: Incorporating Future Considerations into the Service Retention Decision” Journal of Marketing, 66:1 Jan 2002 1-14]
With so little known about how suppliers and clients have sustained participation and success in the past, it is difficult to say how much variations in this element add to the overall variability of PHM strategies and interventions. But when efforts are used, or even if they become only gradually added to PHM efforts, they will likely add to the overall variability, since there is no evidence at all, as far as I know, of which methods work best.
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