Large self-care study demonstrates significant positive results
Shows decrease in portion of emergency department visits
In what many observers consider the largest study of its kind, a program tracked the effect of a self-care booklet on members of a large network-based HMO for a random sample of 15,000 members who received the self-care guide. The findings: Distributing self-care guides to employees can lead to a statistically significant decline in emergency visits for conditions covered in the self-care guide.
The study by Blue Cross and Blue Shield of Massachusetts compared emergency department (ED) visits among 15,000 members who received the DecisionCare Guide, published by the American Institute for Preventive Medicine in Farmington Hills, MI, with those who did not. The group who received the guide accounted for 26.8% of visits due to self-care conditions compared with 30% before receiving the book. For members who did not receive the book, the proportion of visits stayed flat over the same period. (See charts illustrating study results, p. 27.)
How can these findings be translated into dollar savings? "The average cost for an ED visit is $350 if you are not admitted," notes Don R. Powell, president of the American Institute for Preventive Medicine. "So, you begin to see substantial savings when you look at the reductions [in the group using the guide]."
While also pleased with the numbers, the health promotion professionals at Blue Cross and Blue Shield who spearheaded the study urged caution, simply because it was virtually impossible to eliminate all possible variables or to say with certainty that the book alone was responsible for the positive results.
"We feel we did get some nice results that certainly show a value to the book," says Janet Edmunson, program manager for prevention and wellness at the Boston-based HMO. "Still, it’s probably a hard question to answer. The results could have been diluted because of other [wellness] initiatives, but we’ve seen enough to say that it has value, accomplishes a purpose. Yes, we found significant results, but we’re not sure we realized tremendous savings."
(Editor’s note: Blue Cross and Blue Shield of Massachusetts was simultaneously implementing a larger wellness initiative that targeted upper-respiratory and other common, self-limiting illnesses.)
Another benefit to the member
There was, Edmunson adds, an additional benefit of the program. "From the standpoint of Blue-Cross Blue Shield as an organization that cares for its members, we have determined anecdotally that the book becomes a touch’ to the member it shows we care."
Michele DiPalo, director of outcomes and program assessment, admits she tends to "see the glass as half-empty" when assessing study outcomes. "All I know is that there is an association between this book and a slight drop in emergency room visits," she observes. I can’t absolutely tell you the book did it, but I can’t think of other variables, and we do have a proportionate drop in ER visits."
Having said that, DiPalo adds, this was a large-scale study. "We can’t be faulted on that because we looked at a lot of data. Most previous studies of this type had been done in small HMOs, not a large network HMO like ours."
Powell maintains that self-care is "perfect" for the managed care environment, "in that you have a capitated system where financial benefits to the HMO are great if you can reduce unnecessary visits."
Given the fact that large network HMOs do not typically provide self-care initiatives, why was one considered in the first place? "There was enough research on self-care to show its potential," notes Edmunson. "We felt we needed to tell the organization whether it was valuable or not.
"We had a lot of inside champions who had been involved in previous studies suggesting that self-care not only holds down utilization, but it might also benefit members who would no longer be burdened with going to a doctor or an emergency room unnecessarily," she adds. "They avoid these inconveniences if they can handle the problem at home."
While a number of wellness initiatives were ongoing, she says, the self-care guide was chosen for its potential to yield meaningful results. "We knew who received the book, and we knew who did not," she explains. "It was our best shot at getting a quantitative picture."
When Blue Cross and Blue Shield of Massachusetts decided in 1995 to proceed with a self-care initiative, it first had to select a self-care guide. The network chose the DecisionCare Guide, says Edmunson, because "We looked at all our claims for the most common conditions [that might be addressed by self-care] and wanted to customized those topics for us; they already had them."
Also, she notes, the HMO wanted a smaller guide, not a big book. The guide they chose is a 64-page booklet, with a cost of $2.50.
The guide was then sent to a panel of providers, who commented and re-customized the product, assuring that it was focused on the most frequently used ICD-9 codes. Originally there were 25 different illnesses, but the study only covered 23; two behavioral health illnesses were eliminated so that the focus would be entirely on physical ailments.
Work with the clinical review team was completed in 1995, and the booklet was mailed in February 1996, accompanied by a cover letter from the medical director.
The HMO already had a basis to compare ED visits after the self-care guide with previous claims data. "We just needed to wait long enough for people to get the guide and wait and see what happened to claims," notes Edmunson. "We sent one guide per household to our insured population not the self-funded groups we work with." That will change in the future, Edmunson says.
A positive bottom line
Powell says that the study’s findings are highly significant for two reasons. "One is the large size of the study," he says. "I don’t think I’ve seen anything like that. Second, they did actually use a control group. Most self-care data in the literature are either self-reported or pre-post (one year before, one year after); not too many compare user groups with a control group using pre-post data."
"I think the drop in emergency room visits but the lack of a [large] drop in outpatient visits is pretty consistent to the book," adds Dipalo. "People may have moved utilization to a more appropriate setting in the physician’s office, where they are guaranteed a continuum of care."
Edmunson, who says her organization will continue to use the guide, agrees. "It does encourage members to see their primary care provider," she asserts. "It’s a good education tool and resource; it complements our nurseline, and self-care is an important part of how we do business as a managed care company.
"If we had found that it did nothing, we would probably be considering taking it off the budget. The fact that we did find some apparent savings means we’re still committed to it." (For another view on bottom-line impact of self-care guide, see story, p. 28.)
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