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Promoting Wellness­­What Works in Managed Care (aka Prevention)

B1011. K.E. Warner. All that is gold does not glitter: The economics of health education and health promotion. Keynote address to the National Conference on Health Promotion and Health Education, Washington, DC., April 26, 1996.

• Summary. "In this increasingly stingy age," prevention advocates need to demonstrate that there are sound economic reasons to support their interventions, i.e., "golden nuggets of benefits that do not glisten." One problem is that the costs of prevention are immediate and tangible while the benefits of prevention in terms of cost savings rarely begin to emerge prior to several years after the event and are subject to interpretation. Another problem is that prevention may be cheaper than clinical interventions to achieving the desired end of improved health, but may not be cheaper than doing nothing. Cost enters into the equation as a factor in deciding between alternatives to achieve a noneconomic purpose.

  Prevention is held to a higher standard of benefit than other procedures. A surgical procedure is supported if found to be safe; a clinical procedure is supported when found to be safe and cost effective; prevention is allowed only when found to be safe, effective, and capable of saving money over doing nothing. If offered a medical procedure that reduces risk of heart attack in high-risk patient by 15%, insurers will allow it even absent reduced overall health costs. They won't allow membership in an aerobic exercise program, although the literature is clear that the reduction in risk is the same or higher.

  Warner cited a British Lancet article that documents that two minutes of annual physician counseling doubles the average number of adult smokers who quit from 5% to 10% and asked why such findings don't result in more use of physician counseling. Despite results, doctors don't counsel because they haven't been trained, counseling isn't interesting, they won't get reimbursed, they view it as ineffective (because 90% of the smokers they advise continue to smoke), and they don't wish to alienate the patients. Patients don't push for physician counseling because they don't want to be embarrassed, they want an approach that allows passive health improvement, and they don't want to pay for it.

  In traditional insurance, health education is not an insurable event. Insurable events: (a) involve major costs; (b) are relatively infrequent; and (c) have an incidence that is not affected by the purchase of insurance (e.g., cancer incidence does not increase when insurance is available). Preventive health encounters (a) do not involve major costs, (b) should be relatively frequent; and (c) have an incidence affected by the purchase of insurance (i.e., health education is more likely to occur when patient is insured). Conclusion: what we are seeking in the economics of prevention is SUBSIDY and not merely inclusion in insurance.

Comments: Kenneth Warner, an economist who holds the Remington Chair at the University Michigan School of Public Health. His main point was that no health care—clinical or preventive—is cheaper than doing nothing; the problem for prevention is making sure that prevention costs and benefits are appropriately compared to the cost and benefits of doing something else to achieve client satisfaction.

B1012. H. Garrison, G. Rodgers, K.S. Hoyt, and C. Soderstrom. The Role of Health Care Providers in Injury Prevention. Presented to the Fourth National Injury Control Conference, Washington, D.C., November 20, 1997.

• Summary. Dr. George Rodgers, president of the American Association of Poison Control Centers, described the Centers as threatened under managed care because they generally are funded by the host facility—usually a hospital. The 75 remaining centers received requests for help on 2.1 million toxic exposures last year, of which 1.4 were for children under 18 years old. Telephone charges account for about 10% of the Center operating costs; average cost saving is $7 (mostly avoidance of admission) for every $1 expended. Other preventive activities of the Centers include telephone teaching (follow-up of earlier calls) quarterly newsletters featuring seasonal toxic risks, school programs. CDC, HRSA, and the Poison Control Centers have been working for two years on designing improvements in the system, including a unified 1-800 telephone number, standardized toxic exposure education curriculum, and an electronic network for information exchange. Rodgers also mentioned prevention activities of the American Academy of Pediatricians, including the TIPP program that advises pediatricians on how to screen and offer counseling on sensitive adolescent health topics.

Comments. The Poison Control Centers are particularly relevant to reducing clinical costs of behavioral health problems such as suicide attempts and drug overdose. Because the Centers are funded by hospital facilities rather than by health systems and because their benefits are distributed among enrollees of all systems and the uninsured, they are seen as a financial burden when the hospitals are acquired by new owners. Managed care and the public sector need to work together for a solution so that no one health plan is stuck with the bill for a resource that serves the entire community.

B1013. M.J. Stoil (1997) Why managed care needs counselors. The Counselor 15(5):30-31.

• Summary. Most substance abuse counselors maintain that their work is inherently different from any other form of health care. An alternative view suggests that substance abuse counselors need to emphasize the usefulness of their counseling and education skills to the other members of the managed care team. The ideal managed care enrollee population consists of people who care about their health and have the motivation, skills, and knowledge to avoid risky behavior and to practice effective self-care. Such enrollees are less likely to need expensive clinical treatment and therefore are less costly to the managed healthcare system. Substance abuse counselors are experts in providing and reinforce the motivation, skills, and knowledge that enable the client to avoid drug-seeking behavior and to practice effective self-care. In effect, substance abuse counselors are unique among clinicians because their work consists of the services needed to change the behavior of their clients.

Comments. Substance abuse counselors, like many other clinical specialties, often feel that they have nothing to offer managed care. This brief analysis shows that their skills and services, rather than their narrow clinical specialty, are potentially very valuable to managed care.

B1014. M.J. Ludwig. The Aim of Anti-Drug Public Service Announcements: A Target Group's Interpretation. Presented to the 125th Annual Meeting of the American Public Health Association, Indianapolis, November 12, 1997.

• Summary. This study used a series of seven focus groups to explore the interpretation of anti-drug broadcast public service announcements (PSAs) among young adolescents in South Carolina. The adolescents understood the obvious anti-drug messages but questioned the accuracy of content because the ads appeared on television. They also criticized the ads as too stereotyped in portraying drug users as African-American and male, and raised questions about the depiction of drug use as a solitary behavior rather than in its peer- to-peer social context.

Comments. Interesting idea: we invest in teaching adolescents media literacy, avoidance of stereotypes, and skepticism about The Box, and then spend hundreds of millions of dollars in expectation that they will be influenced by stereotype-ridden TV ads against drugs. At least, we need to recognize that the health care system and other credible sources must reinforce PSA content.

B1015. K. Bonnington. Value Based Purchaser Initiatives: The Benefits of Collaboration for Substance Abuse Prevention. Presented to the 125th Annual Meeting of the American Public Health Association, Indianapolis, November 13, 1997.

• Summary. Greater Detroit Area Health Council (GDAHC) consists of multiple health purchaser coalitions: Southeast Michigan Council of Governments Health Alliance, Southeast Michigan Employer Coalition, etc. Together, they represent over 350,000 lives. Their Value Based Purchasing Initiative is developing a common Request for Information to HMOs, benchmarks for performance, and purchaser evaluation. In addition, the Purchasing Initiative and Healthy Detroit are collaborating on the Healthy Village campaign to reduce alcohol, tobacco, and drug use in the Detroit area. Participating MCOs (HealthPlus, Blue Care Network, M Care, OmniCare, SelectCare, Total Health Care, etc.) increase their prevention activities, participating employers agree to restrict or prohibit smoking and establish more effective substance abuse policies, and everyone (including enrollees) support neighborhood prevention activities. Call 313 963 4990 for details.

Comments. The purchasing group represents about 3% of the total lives of Michigan but has enough leverage to recruit eight HMOs for a joint purchaser/provider initiative. One contributing factor: the Purchasing Initiative has
 an explicit goal of expanding HMO penetration.

B1016. J. Vondras. Local and Statewide Response to ATOD Prevention and Managed Care by the Cambridge Prevention Coalition. Presented to the 125th Annual Meeting of the American Public Health Association, Indianapolis, November 13, 1997.

• Summary. The Cambridge (Mass.) Prevention Coalition is a private sector/public sector/ school system coalition that has found multiple ways to assist managed care...and to stay solvent. These include marketing parent workshops for Health Centers, systematic I&R training for healthcare staff, development of dual purpose sports physicals/ATOD education sessions, and conducting annual student health surveys to identify primary care needs. Goals are to become a subcontractor for prevention services (nearing fruition with one Provider sponsored MCO), continuing to be a trusted source of accurate data on children's health needs in the community, and marketing training products.

Comments: This unusual case points to the advantages of thinking in terms of services rather than programs, of considering the MCO's needs, and moving outside of the narrow confines of substance abuse prevention to examine the full range of adolescent prevention needs. It will be interesting to see if the Coalition becomes more or less attractive to other MCOs after it contracts with the Provider sponsored group.

B1017. C.J. McLachlan, K. Hull, G. Reinhart. Families Report: A Study on Managed Care and Children With Special Health Care Needs. Presented to the 125th Annual Meeting of the American Public Health Association, Indianapolis, November 13, 1997.

• Summary. The Child Health Survey c1996 is a two year longitudinal panel survey designed to measure the impact of managed care, welfare reform, and other changes on families with children with special health needs. Most prevalent conditions were developmental disability or delay, ADD or other learning issue, severe asthma, and vision impairment. First year results indicate that families were generally satisfied with clinical care, including those in private MCOs and Healthy Options (Medicaid's managed care plan). About half, however, were either dissatisfied or very dissatisfied with the health plan that provided the care. Reasons for dissatisfaction included lack of information on how to use the plan (26%), clinic hours that required loss of time in school and at work (25%), poor telephone communication with physician office (25%), lack of care for siblings while child is at clinic (23%), and problems in obtaining nonphysician therapy for chronic conditions (20%). Parents also wanted more information about parenting their special needs child, handling the child's behavior, and getting more time for themselves. Choice of doctors, waiting times, and copayments were not frequently cited issues.

Comments. Consumers focus on nonmedical aspects of care, including understanding how to access services, convenient hours, and aspects of chronic care that do not depend on physicians. Effective outreach and patient education, and respite services for parents with special needs children, are behavioral health interventions that could make a major difference in the satisfaction of these enrollees.

B1018. M.J. Ludwig. The Aim of Anti Drug Public Service Announcements: A Target Group's Interpretation. Presented to the 125th Annual Meeting of the American Public Health Association, Indianapolis, November 12, 1997.

• Summary. This study used seven focus groups to explore the interpretation of antidrug broadcast public service announcements (PSAs) among young adolescents in South Carolina. The adolescents understood the obvious antidrug messages but questioned the accuracy of content because the ads appeared on television. They also critiqued the ads as stereotyped in portraying drug users as African American and male, and raised questions about depiction of drug use as a solitary behavior rather than in its peer to peer social context.

Comments. Interesting idea: we invest in teaching adolescents media literacy, avoidance of stereotypes, and skepticism about The Box, and then spend hundreds of millions of dollars in expectation that they will be influenced by stereotype ridden TV ads against drugs. At least, we need to recognize that the health care system and other credible sources must reinforce PSA content.

B1019. Center for Health Care Strategies. Proceedings of Health Literacy, A National Conference. Washington, D.C., June 3, 1997.

• Summary. Conference explored causes, implications, and potential solutions of the problem of functionally illiterate Americans enrolled in health plans that assume more patient responsibility for care of chronic conditions. In an Atlanta sample, more than 80% of the patients over age 60 could not read forms and pill instructions. Other studies found:

  • literacy levels dramatically affect patient knowledge of their diagnosis immediately after seeing the doctor (Mark Williams of Emory University)
  • low literacy patients are twice as likely as similar patients to report poor health and experience three times the rehospitalization rate (David Baker of Case Western)
  • most patient education materials can be comprehended by 20% of American adults

  (Terry Davis of Louisiana State University). The Prudential Center for Health Care Research reported on a study in progress on the relationship between literacy and health among Prudential's Medicare enrollees. Although conference participants did not go into detail on solutions, the comments of Dr. Karen Hein, executive officer of the Institute of Medicine, on doctors as health illiterates are insightful. Drawing upon her experience in adolescent medicine, she pointed out that part of the problem is that health professionals are not trained to communicate with or treat the population that needs services.

Comments. Dr. Hein concludes that "turning health illiterates into health literates" requires change in how the health care field interacts with patients rather than just educating patients. That's a familiar theme in the prevention game.

B1020. H. Lippman. (1997) Are employers missing the signs? Our 1997 Executive Opinion Poll. BUSINESS & HEALTH 15(12):36 to 41.

• Summary. The results of Business & Health's annual survey of a representative national sample of small (2 to 19 employees), midsized (20 to 499 employees), and large firms document regional variation. In the West, for example, indemnity coverage is nearly extinct and most employers offer an HMO option, but in the South, PPOs dominate and fewer than a third of employers offer HMOs. The survey reports price is a decreasing issue in selection of health plans, evidenced by the fact that most large firms offering employees choices of plans subsidize more expensive plans rather than passing the cost onto enrollees. Such subsidies eliminate the competitive advantage of lower premiums. The survey also reports that about 10 percent of employers plan to add new behavioral health benefits in 1998. Inhouse preventive services, however, have not kept pace with expanding benefits. Few firms offered either smoking cessation or stress reduction benefits, and prenatal care is offered by fewer than 8 in 10 employers. Employee Assistance Programs (EAPs) are in place at most large firms, but are available to only about one in four employees nationwide.

Comments. The survey results are not as grim for prevention as they might seem, because many EAPs and HMOs offer behavioral health interventions without specifically being contracted to do so. However, the survey results should remind preventionists that employers need to be educated about the benefits of behavioral health interventions, especially now that nearly 75% are offering a mental health and substance abuse treatment benefit.