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A call to action on health management of populations

For years, most DM programs have worked by first identifying the members of a population at the highest risk and then deploying interventions aimed at keeping complications—and health utilization—in check.

However, some health policymakers are now turning that model on its head, arguing that the greatest opportunity for controlling healthcare costs lies in identifying people who are low risk and intervening in a way that will keep them from transitioning into higher-risk groups.

This was a recurring theme during the National Managed Health Care Congress (NMHCC) meeting in Atlanta in March.

There were plenty of opinions to go around during the gathering of experts from healthcare, academia, and the business community, but there was wide agreement that the practice of shifting cost increases on to members or employees has been pushed to its limit and that payers need to rethink the way they have traditionally managed populations.

Offer something for everyone

Noting that there is consensus among employers/payers that they cannot sustain their businesses if healthcare costs continue to escalate, Dee Edington, PhD, directorof the Health ManagementResearch Center at the University of Michigan in Ann Arbor, emphasized that key players need to collaborate on new ways to implement health management.

“The old system hasn’t worked,” he said. “We identify the high-risk people, and then we go after them and try to get them to change. How successful [are] we? We [aren’t] successful at all, so the only solution here is to stop the upward flow.”

That upward flow is the transition of people at low risk into higher-risk categories, which inevitably results in higher costs. In the current environment, most health management programs offer nothing to members or employees in low-risk groups, preferring to target programming or interventions at people who have already been identified as having chronic diseases or other health risks, he noted.

Although he acknowledged that people with chronic diseases or acute problems need intervention, Edington suggested that it is a flawed strategy to focus on such groups to the exclusion of individuals who maintain active, healthy lifestyles—people he referred to as champions. “Whenever you do your benefits, whatever you think about a population, you need to have something for everyone,” he said, noting that people at all levels of risk should have access to coaching and that everyone should receive outreach contacts. “There are no negative aspects of health management. You decrease costs and you increase productivity.” The type of comprehensive health management approach that Edington described is a tall order, including the administration of regular health risk assessments (HRA) and positive reinforcement of health in the worksite environment. In addition, he said effective population management should include the following:

  • Risk-reduction strategies
  • Traditional DM programs
  • Low-risk maintenance activities
  • Web resources
  • Incentives for participation
  • Outcomes measurement

    Most organizations cannot put together this type of model without help from partners, Edington acknowledged, noting that a critical aspect is getting employees or members involved with the process. “You don’t have to teach weight loss or exercise,” he said. “Just teach them to be self-leaders.”

    Psychology and timing affect results

    Although it is clear that reducing risks should dampen spiraling costs, the data to support the kind of model Edington proposed are limited. Nonetheless, some companies attempting to go down that road have achieved success. For example, Hannaford Brothers, a supermarket chain based in Portland, ME, has implemented a range of initiatives aimed at educating employees about their risks and arming them with resources they can use to better manage their health.

    One component of this approach involves placing a wellness professional—either a registered nurse or a health educator—at all 159 of the company’s store locations. At first, the wellness professionals mainly provided health education to company employees, but they are now expected to take a much more proactive role. “We have evolved that [position so that the wellness professionals] now advocate for better care, help employees prepare for their physician visits, and coach people along the behavior change continuum,” said Ellie Udeh, manager of wellness initiatives for Hannaford Brothers. “We are noticing that this has had a significant [effect] on the culture of the store and on the attitudes in the store.”

    The wellness professionals have learned that, in many cases, you have to take the time to get to know someone before you can begin to suggest changes in lifestyle, Udeh said. She also noted that timing is important. “It is really important to take a psychological approach with people that piggybacks on anything else that is going on. In January, people are making New Year’s resolutions, so we better have stuff at the store level to capitalize on that,” she said. “In the summer, people care more about their weight because they are wearing shorts and bathing suits, so it is another great time to piggyback and make sure we are ready with a walking program.”

    Financial incentives get results

    In addition to having wellness professionals on-site part-time, the company has implemented financial incentives for employees who agree to complete an HRA once a year, are tobacco free or participating in a smoking cessation program, and agree to actively participate in DM coaching offered through the health plan if they receive an outreach call. “It used to be that all employees had to do was take the call and receive education, but now we are requiring them to set goals,” said Udeh, noting that the goals can range from needed lifestyle changes to procedures or screening tests they need to have done by their PCPs. “This has been a very provocative [move], but it has definitely influenced employees to take action.”

    The company has also begun offering a smaller incentive for smokers who are at least willing to participate in the process. “We felt if we could at least get them to take the HRA and participate in DM outreach, this would be another way of reaching them and, hopefully, getting them to make some changes in their lives,” said Udeh.

    The incentives have enabled the company to boost HRA completion rates to 90% in 2006—up from 60% when there were no incentives in place. Further, the people who opt out of the HRA process, and thereby bypass the financial incentives, essentially pay for the individuals who do participate, Udeh noted.

    Where opportunities exist, Hannaford is trying to partner with community resources to offer healthy programming. One example involves a diabetic program the company has put together with a local hospital. Also, as part of a new initiative, the company is working with data supplied by the state of Maine to identify best providers and centers of health excellence. This approach has been controversial, and it is not yet clear whether people are making use of the information, Udeh said. But the company is exploring the idea as a way to help employees access good, quality care, she added.

    Costs are under control

    Some aspects of the program have been difficult for Hannaford. For example, coming up with exercise programs and other activities is challenging because of the widely varying shifts that supermarket employees typically work. The company has had some success with a virtual walking program, but providing large-scale access to these kinds of activities remains difficult. And although the company would like to leverage the Internet to deploy HRAs and decision-support tools, the employee population—much of which is located in rural areas—is reluctant to do anything online, said Udeh.

    However, financial data show that although the company hasn’t eliminated healthcare cost increases, the costs aren’t rising to the degree that national trends suggest other companies are experiencing. “If we were where the national trends are, then we would be spending $121 million more over three years than we are,” said Udeh.