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Promoting Wellness—What Works in Managed Care (aka Prevention)

B1021. C.T. Davoli (1997) Use of capitated reimbursement to provide comprehensive management of childhood lead poisoning. AMERICAN JOURNAL OF PUBLIC HEALTH 87(12):2056-2057.

• Summary: Since establishment in June 1994, the Lead Poisoning Prevention Program of the Kennedy Krieger Institute at Johns Hopkins University has provided treatment and prevention services through capitated payments from several HMOs and other third payers. Third party payers previously reimbursed only direct medical treatment, resulting in re- exposed subjects and retreatment. Program replaces hospital-based care with treatment in less expensive, more home-like setting, and includes community outreach and funding for elimination of lead sources in the patient's home. During the first two years, 392 children received services at an average cost that is 60% lower than traditional treatment, and more than half of the children were released to newly lead-free homes.

Comments: A win-win situation for all parties, funded by managed care without federal prodding, that produces better and cheaper treatment outcomes, greater patient satisfaction, and effective intervention to prevent the problem. This is what managed care is supposed to be about.

B1022. T.J. Chapel and P.V. Stange (1997) Is altruism killing prevention? When health systems take on the role of public health provider. HEALTHCARE FORUM JOURNAL 40(5):46-50.

• Summary: Based on a CDC-funded study of eight health plans regarded as industry leaders in prevention and public health models. Plans conducted a variety of outreach projects such as participation in Healthier Community coalitions, community summits on domestic violence and youth violence, links with churches for screening and health promotion, etc. Less than one-fourth of prevention activity was fueled by business motivations. Such altruism provides no solid justification for continuation of prevention... "as healthcare organizations are squeezed financially, all activities are held to a stricter standard: contribution to the business strategy." The good news is that "some sites in our study took the longer view and used prevention activities to position themselves for the environment of the future. The most business-minded health organizations were creating or expanding these activities to develop experience working with ethnically diverse and low-income communities." In other words, market forces favor continuation and expansion of prevention when prevention is clearly defined with current and future business growth.

Comments: All of the reviewers agreed that this could be one of the year's most important articles for prevention and managed care. Using hard data from health plans throughout the Midwest and East (surprisingly, no West Coast plans included in the study), the authors start by presenting a grim future for preventive interventions under managed care because it is community- rather than bottom line- oriented. They then provide five "rules" to protect the survival of effective prevention by making it part of the business plan rather than an altruistic "community benefit."

B1023. K. Cohen, E. Vogt, D. Naughton, and S. Sullivan (1997) Equating health and productivity. BUSINESS & HEALTH. 15(9):23-26.

• Summary: Determining whether preventive interventions and wellness programs produce a net cost-benefit in productivity gains is difficult because "...experts disagree as to the actual costs an employee's absence incurs" and because "Researchers are also starting to look at workers who are on the job but clearly functioning in a diminished capacity." Article refers to a McDonnell Douglas study that shows the EAP cut lost work days by 25% for employees with mental disorders, producing a 4:1 return on investment in EAP, and 1990 findings that a $585,000 annual investment in Coors Brewing employee wellness programs produced $1.9 million in "increased productivity, reduced sick leave, and lower medical costs." Medical director of First Chicago NBD quoted extensively on benefits of worksite breast cancer screening and of EAP. Many case studies cited address impacts of depression on productivity and savings achieved through early intervention/prevention.

Comments: Tantalizing case studies, particularly for depression. However, the authors continually remind readers that cost-benefit for prevention resists calculation because of lack of a dollar value for health-related productivity changes.

B1024. S.D. Pinkerton and D.R. Holtgrave (1998) The cost- effectiveness of HIV prevention from a managed care perspective. J PUBLIC HEALTH MANAGEMENT & PRACTICE 4(1):59-66.

• Summary: Provides framework for evaluating cost-effectiveness of HIV preventive interventions, applied to five types of intervention. Authors note:

  • Few benefits to any individual MCO for reducing rate of new infections;
  • MCO may incur costs of prevention while competitors reaps the benefits due to high rates of disenrollment;
  • Screening not justified from a cost-savings perspective...in addition to the screening costs, medications and care to extend patient life are expensive. Since market forces alone do not justify preventive interventions, the authors suggest
  • Including HIV prevention in externally-imposed performance measures and/or;
  • Using low-cost group cognitive-behavioral interventions to change behaviors; and/or
  • Partnerships with other providers of HIV prevention services, such as public health and community groups, to spread both costs and benefits fairly.

Comment: Identifies economic issues confronting justification for prevention of (relatively) low-frequency conditions. However, authors may be too conservative in assessing the benefits of behavioral change only in terms of HIV. If group-level cognitive-behavioral interventions change condom-use or drug-use behavior, they also reduce incidence of other STDs and/or dependence on injected drugs. Those good things should be added to the benefit side of the equation.

B1025. S. Reese. (1997) Disenrollment: What it costs, how to stop it. BUSINESS & HEALTH 15(10):41-44.

• Summary: Voluntary and involuntary enrollee turnover costs health plans millions of dollars. Estimates of the scope of enrollee switching varies from 40% of all enrollees per year to single digits. Quoting Roberta Clarke of Boston University, the article notes that the value of preventive interventions is compromised by disenrollment: "If you're turning over your membership all of the time, you're not keeping people long enough to have an incentive to invest in them." Employers who expect to achieve a healthy, productive workforce from managed care also lose the benefits of preventive services when disenrollment is widespread. The article presents two case studies of attempts to bring employers and MCOs together to reduce disenrollment.

Comment: Interesting perspective on the dynamic interaction between preventive interventions and disenrollment.Offering attractive "lifestyle" interventions, such as smoking cessation and parent classes, increases consumer satisfaction and reduces voluntary disenrollment, while disenrollment reduces the effectiveness of preventive interventions.

B1026. Isham, G. (1997) Population health and HMO's: The Partners for Better Health experience. HEALTHCARE FORUM JOURNAL 40(6).

• Summary: Describes HMO's program of health promotion for enrolled members, organizing around eight measurable goals (screening rates for breast cancer, childhood immunizations, reduction in childhood injuries and domestic violence, prevention of acute stages of heart disease and diabetes, etc.) to be achieved during four years. Program relies on Partners for Better Health Registry, an inventory that tracks enrollees' behavioral risk factors for the targeted conditions, and a survey that identifies how ready enrollees are to change their behaviors, using the Prochaska et al. readiness-to-change scale. Most enrollees willing to volunteer the necessary information; about 73% wish to be contacted by a physician about potential interventions. Cohort study found early achievement of process goals: increased pediatric immunization, increased breast cancer screening, and increased healthcare providers queries related to domestic violence. Also achieved is a 30 percent decrease in microvascular complications of diabetes in clinic. Community-wide efforts are Tobacco Use Cessation and Prevention Program, and an annual month-long campaign that encourages restaurants to offer low-fat entrees: both are highly visible collaborations with American Cancer Society and American Heart Association.

Comments: The author is Medical Director of the HealthPartners HMO and co-chair of the NCQA committee responsible for the development of HEDIS. This example of the Strategic Investment model (see Stoil and Hill article) illustrates that long-term benefits sought by MCOs can include marketing (the high visibility community campaigns) as well as reduction in demand for clinical services. The focus on enrollees indicating readiness-to-change behavior concentrates preventive resources on the individuals most likely to respond.

B1027. Lasker, R.D. (1997) Medicine and Public Health: The Power of Collaboration. NY: New York Academy of Medicine. 178 pages.

• Summary: Monograph based primarily on analysis of 414 cases of medical/public health collaboration collected by the NY Academy of Medicine. Provides background on why preventive care (i.e., public health) and medical care diverged in this century, and develops six models of collaborations. Several case studies illustrating the models, including Albany "Healthy Partnerships," the Kennedy Krieger Institute Lead Program (see #1021 above), and the community campaign examples, involve managed care participants or leadership. Final section presents general observations on collaboration derived from the case studies.

Comments: Good starting point for discussion of ways to involve medical providers, including managed care organizations, in population-based health issues. A focus on the type of activities that result from collaboration rather than a problem-oriented approach requires some readers to dig extensively through the collection to find useful suggestions.

B1028. Schaufler, H.H., Brown, E.R., and Rice, T. (1997) The State of Health Insurance in California, 1996. Los Angeles: UCLA Center for Health Policy Research. 90 pages.

• Summary: The first comprehensive examination of health insurance in California, based on data from statewide surveys of representative samples of the population and employers, all HMOs, PPOs, major health insurers, and purchasing cooperatives operating in California. A section on Health Plans and Health Promotion documents that:

  1. Over three-fourths of HMOs have specific preventive interventions addressing at least five health risks. Relatively few, however, offer prevention addressing substance abuse (other than smoking) or mental health.
  2. Preventive interventions among PPOs and indemnity insurers generally are limited to childhood immunization and smoking cessation.
  3. HMOs use multiple health education techniques with varying success; PPOs and indemnity programs limit health education (if any) to newsletters.
  4. A majority of HMOs rely on member satisfaction surveys and preventive service utilization rates to "assess" health promotion programs; most PPOs and indemnity programs offering health promotion do not conduct any assessments.
  5. Participation of population in any health promotion activities ranged from 1% (among the uninsured) to 3% (among HMO enrollees).

Comments: Although a small part of the monograph, the information on health promotion presents a clear image of the state-of-the-art in California, where MCOs have high market penetration. As expected, HMOs appeared more willing than either PPOs or traditional insurers to invest in health promotion but generally do not make the effort to target programs with maximum cost effectiveness or to evaluate outcomes. Conwal's survey research among HMOs and PPOs in Ohio, Florida, and New Mexico confirms applicability of the study findings in other states.

B1029. Edmunds, M., Frank, R., Hogan, M., McCarty, D., Robinson-Beale, R., and Weisner, C. (1997) MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH. Washington, D.C.: National Academy Press. 370 pages.

• Summary: Self-described evidence-based assessment of the National Institute of Medicine of the use of managed care for behavioral health. Provides detailed summary of the structure of managed behavioral health, focusing on the "carve-out" programs, and identifies trends in accreditation, professional responsibilities, etc. The "findings" related to prevention/behavioral health promotion consist of the following:

  1. Society and individual workers need safe and supportive work environments.
  2. The federal government has responded through the passage of legislation...concerning safety and other standards.
  3. The workplace environment provides an excellent arena in which to address behavioral health problems.
  4. The needs of many high-risk youth are unmet because of lack of focus on this population.
  5. Prevention and treatment programs for mental health and substance abuse problems are not adequately linked.
  6. Many individual (10 to 20 percent of the population) consult primary care physicians for behavioral health problems.

Comments: This long-awaited report is a disappointment from the health promotion perspective because it presents little evidence for many of its findings and barely touches upon preventive interventions. The report's statement that behavioral health promotion is not addressed in "readily available" quality standards for health plans is already out-of-date.

B1030. P. Fishman, M. Von Korff, P. Lozano, and J. Hecht (1997) Chronic care costs in managed care. HEALTH AFFAIRS 16(3):239-247.

• Summary: Presents results of a cost-of-care analysis for chronic conditions at Group Health Cooperative of Puget Sound. Pregnancy and cancer caused major change in patient costs, followed by multiple sclerosis, HIV infection, and chronic headaches. Of mental health issues tracked, dementia and depression were responsible for highest change in patient costs (175% and 122.3%, respectively).

Comments: Cited in response to many contacts interested in an accurate baseline of managed care costs for chronic conditions whose incidence or treatment costs could be reduced by preventive interventions and patient self-management. Despite limitations and caveats, this study provides a serious effort to calculate those costs.