Study reveals health plan concerns about behavioral health programs
Cost impact unclear’; lack of significant research cited
While the final verdict is still years away, early returns on the impact of managed care on disease prevention/health promotion efforts have been disappointing. Now a study from the Washington, DC-based Center for the Advancement of Health (CAH) both underscores the lack of participation by most managed care organizations and shines a spotlight on some of the major sources of their reluctance.
The study, "Health Behavior Change in Managed Care: A Status Report," notes that "while most health plans offer some services to help members better manage chronic conditions or modify health risk behaviors, the majority of these efforts consist of handing out brochures or pamphlets."
The report is based on a 1999 survey of HMO medical directors in five states and the District of Columbia, interviews with public and private health care purchasers, and an extensive review of the scientific literature on behavior change interventions in medical settings.
HMO respondents said they were reluctant to incorporate behavior change interventions into their systems of care, in part because the cost impact of doing so is unclear. They also noted a difficulty in distinguishing effective behavior change approaches from unproven ones.
CAH executive director Jessie Gruman, PhD, says the survey clearly underscores some of the main reasons that managed care has not lived up to its billing in the area of health promotion. "But I think we should frame those findings relative to a very important point," she notes. "Under the old fee-for-service model, none of these services was available. The fact that it is not yet state-of-the-art is absolutely understandable."
Not a simple sell’
In the HMOs’ defense, says Gruman, the current job market makes things even more difficult. "At a time when employee turnover is around 18%, the average amount of time an employee spends in any managed care group is about 18 months — not a long period of time [to demonstrate results]," she points out. "So it’s not a simple sell from the cost perspective — even if we had excellent, excellent programs."
As for scientific evidence, "Actually, a number of really credible studies on the economic impact of health promotion show in fact that short-term health care costs go up. We just can’t say absolutely that it saves money, and if so, over what period of time?"
Gruman’s group is especially interested in what the research says. "What CAH is really concerned about is the translation of research on health behavior change into real-world policy and practical solutions, and the translation of the needs of policy-makers back into researchable questions, so we can improve the ways in which we do we research," she explains. "Otherwise, it’s an endless cycle."
That, of course, is why CAH undertook the study as part of its mission. "One of the wonderful things about managed care is that for the first time there are structures into which we can build protocols, guidelines, and procedures that will allow for systematic delivery of interventions to prevent disease and manage chronic conditions," says Gruman. "It presents a wonderful opportunity. And since prevention is part of the managed care rhetoric, we thought we’d see what was actually going on."
The answer, apparently, is "not as much as we had hoped." Nico Pronk, PhD, senior director, Center for Health Promotion, at HealthPartners in Minneapolis, takes a different tack. "One of the more interesting findings is that in general, HMOs or managed care very much recognize the role of behavior in health enhancement activities. But at the same time, when you look under the hood, how often does it happen that a purchaser is willing to pay for it? The medical directors know about the science and they’re not opposed to it — it’s not like they want to withhold it — but if you want to provide it, you need a customer."
Lacking cost data
The cost side, Pronk concedes, is another matter. While the medical directors recognize the impact of behavior on health, on the cost side there is hardly any data. "There are some concerns about gaps in the literature," he asserts.
Pronk, who is a member of the CAH Health Behavior Change in Managed Care Advisory Committee, would like to see "well-controlled, cost-effect studies. You can’t do a randomized, controlled study in the work site because you would need equity for all employees. But you need reproducible methods for strong analysis; you have to get around basic assumptions.
"Having said that, when you look across the literature, particularly in work site health promotion, and you start accumulating all the available reports, you do find that the research has become more and more sophisticated, and the results are all in the same direction," he continues. "So there is a body of literature that is strongly suggestive that this is a good investment."
D’Ann Whitehead, PsyD, manager, health and productivity at the Chevron Corp. in San Ramon, CA, has a different take.
"Part of the frustration purchasers feel is that when you really try to work with managed care plans and you ask them why they don’t have more in-depth plans, they talk about turnover and lag time between programming and results," notes Whitehead, who also sits on the CAH advisory committee. "But I think that’s a bogus argument. If they would all pool together, like the Pacific Business Group on Health, they’d overcome some of those problems."
She concedes that the research being done in the work site "doesn’t necessarily translate into the clinical setting." She adds, however, that there are a lot of unpublished studies that show the cost-effectiveness of health promotion. "We won the Koop Award two years ago, and that award was based on showing a positive return on investment," she notes.
Potential is great
What keeps the interest high in this area, despite the obvious obstacles, is that the potential for progress is so great — and that wellness professionals and managed care professionals both have different — and complementary — skills and services to bring to the table.
"The real value of health behavior change is identifying everyone in a population who is at risk and making sure that they have access to tailored information that meets their current needs and preferences," notes Gruman. "One of the things managed care offers is the ability to identify a population and track it over time. Also, managed organizations all have guidelines, and guidelines for delivery of care can be included in behavioral interventions."
Pronk agrees. "The unique contribution a health plan can make is the idea that there is a link back into the clinical care setting; you can’t do certain things in the work site setting," he notes. "Also, in the work site setting you have a limited opportunity to work with people because of the need for anonymity. With a health plan you can literally integrate the disease management approach into your overall health management study. You can carve out, say, all your diabetes patients, some of whom you otherwise may not have been able to find because of confidentiality concerns."
Under the managed care model, Pronk explains, the health plan can find out who has diabetes, link the employee’s treatment back to the clinic, check with physicians, and make sure regular blood sugar and other checks and performed. "It’s a proactive approach to best care."
HealthPartners has put this approach into action, and it was won them a Koop Award, notes Pronk. "We work with a variety of companies and basically look across the entire spectrum of health and see how the employees align, and what’s available for them [in terms of intervention]," he explains. "When something comes up that would be outside the normal set of benefits, we want to do them as strategically as possible so we both reap the benefits. We conduct a thorough assessment, see where the risks and the costs are, pick a couple of programs and do them well. We cost-share 50/50 with the employer."
Over the years, says Pronk, his organization has grown to rely on in-house wellness specialists, "because we need someone to work with. We tell employers, if you want us to implement a program, you have to provide us the on-site people. We have a team of people who focus on work site health promotion, but I will not hold my staff responsible for programming at a work site where we have no support."
Collaboration is the key
Whitehead insists that collaboration among plans and employers is the key to success. "For example, I’d try to get them to collaborate in jointly funding some smoking cessation programs," she suggests.
"I almost think that when you deal with behavior-based programs as a health plan, it’s hard to put your arms around it, which makes it difficult to implement," she continues. "For example, physicians are not really well-trained to deal with them. These behavior-based interventions go on for a long time and have strong psychological issues — which are more difficult to address.
"Also, from the health plan side, you have a lot of competing priorities. Health promotion can fall to the bottom of the list, even if the plan has a great health promotion staff — and many of them do."
Gruman says that self-care represents another opportunity for cooperation between health plans and wellness professionals.
"We asked in the survey about community linkages for delivery of self-management and preventive services, and found that the health plans were not closely linked to their communities," she says. "To the extent that companies offer internal self-management programs, if the health plan can refer people back to the employer for those services that would be a really valuable asset."
Despite the disappointment to date, Gruman believes the future will show significant progress. "The people who make these decisions are thoughtful, careful, and recognize the critical importance of health behavior," she notes.
She also says that employers must bear some of the responsibility for the lack of progress to date. "We found that even large employers took seriously the HMO claim that they were going to deliver health maintenance programming — and that included a soup-to-nuts buffet — all things that dealt with maintaining health and delivering health care. But they decided not pay for health promotion twice, and since employees were then paying for health promotion through the health care plan, they stopped offering internal wellness programs."
A potential win-win
Nevertheless, says Gruman, "I see a cooperative situation developing. To the extent that wellness programs inside of companies can let health plans know there are already certain services available, it’s a potential win-win situation.
The object of the game for internal wellness programs, notes Gruman, is to make sure employees get the richest range of health behavior change services possible.
She is confident that we can look for an increasing uptake of those services on the part of health plans "because it’s undeniable that behavioral medicine is a critical issue that needs to be addressed. There’s now a lot of curiosity in Washington, in places like the National Institutes of Health."
Whitehead sees potential for progress, if health plans pursue a strategy of collaboration. "I admit it’s difficult," she says. "Out here we have more network models — if you have a staff model like Kaiser, it’s easier to do. If a physician has 15 different HMOs he sees patients from, it’s not really realistic for them to conform with each plan, but what I’m hopeful for is that technology will be able to make a huge difference."
Future looks bright
Technology, Whitehead says, will give health plans a greater opportunity to align with each other. "If you could pull up a patient’s information electronically and see what plans he’s on and what programs are being offered, it would help tremendously."
So Whitehead is not entirely negative as she looks toward the future. "We did a study with our health plans three or four years ago," she recalls. "We found for the most part their programs were pretty poor and mostly window dressing, but where we did find they did a pretty good job was in the area of disease management — which you’d expect. I’m not seeing this pattern go away, but I do see very slow but continued improved performance; the promise is there. Also, I believe technology will help in the future, and thirdly, if there’s a way that we could get consumers to be behind these kinds of things and request them more often, there’s more potential for change."
Whitehead outlines what she considers her "takeaway" from the study: "How do I create a need in employees’ minds for these services? It’s hard; I don’t want to talk it up if the service does not exist, so the thing to do is where they do exist to push employees on our end to take advantage of that availability, and to keep communications going. Consumers can drive huge change."
"There is an openness and an attempt to make progress," notes Gruman, "And wellness professionals should feel encouraged. Most managed care professionals are really interested in this, and it’s just a matter of moment."
The ultimate goal, says Gruman, should be to do things right as opposed to just doing the right thing. "Efficacy means doing things right; effectiveness is doing the right thing," she explains. "We’re concerned not only in having health interventions done right but in addition, going past that by matching the intervention to the target population, and having those interventions delivered by people who are competent and trained in things we know will work." n
• Jessie Gruman, Executive Director, Center for the Advancement of Health, 2000 Florida Ave. N.W., Suite 210, Washington, DC 20009-1231. Telephone: (202) 387-2829. Fax: (202) 387-2857. Web site: www.cfah. org.
• Nico Pronk, Senior Director, Center for Health Promotion, HealthPartners, 8100 34th Ave. S., P.O. Box 1309, Minneapolis, MN 55440. Telephone: (952) 883-6729.
• D’Ann Whitehead, Manager, Health and Productivity, Chevron Corp., P.O. Box 6024, Room E 1058, San Ramon, CA 94583-0724. Telephone: (415) 894-7700.
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