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d

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

B1031. B.E. Meyerowitz, J. Richardson, S. Hudson, and B. Leedham (1998) Ethnicity and cancer outcomes: Behavioral and psychosocial considerations. Psychological Bulletins 123(1):47-70.

• Summary. Cancer is the second leading cause of death for all Americans, but there are ethnic differences in terms of the likelihood of timely screening, attitudes toward the disease, and survival and quality of life after diagnosis. After examining the research, the authors found few of these differences truly are based on ethnicity. Socioeconomic status proved critical for variation in survivability; understanding of the disease varies with education (e.g., many women with lower educational achievement thought breast cancer results from injury). Higher-than-average rates of fatalism, anxiety, and depression as well as lower quality of life after diagnosis are associated with Mexican- Americans (not Hispanics generally). Low acculturation scores, rather than education or income, were associated with fatalism.

Comment. Because behavioral and psychosocial issues, rather than the immutable characteritic of ethnicity, are key to understanding and coping with cancer, community-based groups that can credibly provide information on cancer and on life after diagnosis have potential roles to play in reaching the population at risk. Providers who have proven their worth on prenatal outreach can make a difference in cancer care.

B1032. D.S. Davenport and K. Wooley (1997) Innovative brief pithy psychotherapy: A contribution from corporate managed mental health care. Professional Psychology: Research and Practice 28(2):197-200.

• Summary. Parody of guidelines issued to encourage use of brief interventions in managed mental health care. The authors ridicule watered-down professional qualifications ("all therapists must have a high school diploma, except those grandfathered in"), phony theoretical justifications (the procedure is similar to Cognitive Therapy except that it assumes no relationship with the patient), and how-to workshops (training in the procedure should take approximately 40 hours, including breaks). Above all, they skewer the search for short-and-simple solutions to complex mental health problems ("reducing an entire therapy session to three-word, two-word, and finally one-word interventions").

Comment. The scary truth is that it took a few minutes to realize that this is not the real thing but rather a witty introduction to concerns about managed care among psychotherapists. Members of the behavioral health team who are not psychologists or psychiatrists may be annoyed by passages in the parody that appear to impugn their training, especially since they can provide crucial interaction with clients as prevention and early intervention specialists.

B1033. H.H. Schauffler, M. Hennessey, and B. Neiger. (1997) Health Promotion and Managed Care: An Assessment of Collaboration by State Directors of Health Promotion. Association of State and Territorial Directors of Health Promotion and Public Health Education. 48 pages.

• Summary. Report of a 1996 state-by-state survey of the relationships achieved between the offices of State and Territorial Directors of Health Promotion and Public Health Education and the managed care organizations in their states. At first, 30 of the 49 responding states reported at least one activity; when probed to consider specific activities, 45 of the 49 could identify an activity in which MCOs collaborated on health promotion. The most frequently-cited activities were serving on coalitions and task forces with MCO representatives (33 states), implementing community health promotion interventions with MCOs (26 states), developing health promotion guidelines for MCOs (21 states), and training managed care providers in how to do health education (17 states). Report provides details on specific examples of cooperation, including their benefits, and barriers to implementation.

Comment. A must-read for anyone who (a) believes that MCOs as a group do not care about health promotion, (b) assumes that public-private partnership must be fostered by the federal government, or (c) would like some models on how managed care can work with prevention specialists. Only six states reported that they supported local integration of public/MCO health promotion (five small states lack local public health agencies). Most states did not report that mental health promotion or substance abuse prevention were included in their work with managed care—6 had collaborative efforts on tobacco dependence and 2 had activities addressing domestic violence—but mental health, alcohol, and drug abuse are seldom handled by the same state agency that provides generic health promotion.

B1034. D. L. Olds, J. Eckenrode, C.R. Henderson, H. Kitzman, J. Powers, R. Cole, K. Sidora, P. Morris, L. M. Pettitt, and D. Luckey (1997) Long-term effects of home visitation on maternal life course and child abuse and neglect. Journal of the American Medical Association 278:637-648 (August 27).

• Summary. 15-year follow-up report on a randomized clinical trial of effects of prenatal and early childhood home visits on child abuse and neglect, subsequent pregnancies among unmarried mothers, and substance abuse. Intervention consisted of an average of 9 home visits during pregnancy and an average of 23 home visits from birth through the second birthday. For all mothers over the 15 years, the intervention significantly reduced the number of women identified as perpetrators of child abuse and neglect (p<.001). Among unmarried, low- income women, the intervention had statistically significant effects on incidence of subsequent pregnancy (p<.02), mean time prior to next birth (more than five years for intervention group compared to 3 years for controls), and decreased likelihood of impairment due to abuse of alcohol or drugs (p<.03).

Comment. One of the growing number of controlled clinical trials of prevention that document long-term effects. All of the positive outcomes are associated with reduction of significant healthcare costs, as well as important implications for the behavioral health of the children. In this trial, the home visits were performed by nurses, but similar results might be possible with the use of trained outreach staff, particularly among Medicaid clientele.

B1035. The price of pleasure. Business and Health 16(4):71- 72.

• Summary. Brief discussion of the incidence and costs of specific sexually-transmitted diseases in the US healthcare system, and the benefits of screening, education, and partner notification for timely detection and prevention. Cites Group Health of Puget Sound's achievement of a 56 per cent reduction in chlamydia caseload through screening policies.

Comment. According to the article, enrollees are reluctant to use MCO services for STDs due to concerns about confidentiality and anonymity. Community-based providers contracted by managed care, including the public health department, can overcome this reluctance. When a community-based contractor performs the preventive services, a "firewall" of confidentiality is established between the patient and the health plan.

B1036. R.E. Patricelli and F.C. Lee (1996) Employer- based innovations in behavioral health benefits. Professional Psychology: Research and Practice 27(4):325-334.

• Summary. Provides a brief history of employer- based benefit for mental health and substance abuse, focusing on Employee Assitance Programs (EAPs) that intervene with troubled employees, on training supervisory personnel on how to act without becoming involved in employees' personal problems, and on critical incident debriefing for employees involved in such incidents as vehicle crashes, worksite accidents, and violence. Cites Southland Corporation's experience with replacing traditional telephone-based case review for mental health with a network
   of facilities combined with EAP services. Resulting savings and employee satisfaction encouraged Southland to extend mental health benefit to all employees rather than limiting it to employees with one year of service. Cites additional examples from Conoco and Orange County School Board.

Comment. Offers specific statistics to justify the prevention components of EAPs. Focus on prevention is particularly interesting because authors are CEO and former senior executive of Value Health, a large behavioral managed care firm.

B1037. Frederick/Schneiders, Inc. (1995) Analysis of Focus Groups Concerning Managed Care and Medicare. Menlo Park, CA: The Henry J. Kaiser Family Foundation. 101 pages.

• Summary. Report of 14 focus groups conducted in eight locations among consumers aged 60 to 65 regarding attitudes towards doctors, hospitals, Medicare, and HMOs, including both HMO members and nonmembers. "Managed care" as a concept and a phrase evoked strongly negative reactions, largely because focus group participants do not like to feel managed and want to be in charge of their own health care choices, especially the choice of physician. Few participants had any knowledge of how managed care operates and nonbeneficiaries particularly were unaware of the prevention philosophy as a central facet of HMOs.

Comments. Prevention and behavioral health promotion that provides real interaction with older enrollees emerges from the focus groups as a very powerful way to counter negative stereotypes of HMOs...but it must be prevention that reflects an investment of time and personnel on the part of the managed care organization. Otherwise, the health promotion reinforces the view that "they [HMOs] don't take enough time for prevention."

B1038. J.P. Hoffman, C. Larison, and A. Sanderson. (1997) An Analysis of Worker Drug Use and Workplace Policies and Programs. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. 68 pages.

• Summary. Reports data collected during the 1994 National Household Survey on Drug Abuse with questions regarding workplace issues developed by the U.S. Department of Labor and Small Business Administration. Among workers 18-to-49 years old, roughly 8 percent reported using an illicit drug (usually marijuana) during the previous 30 days. No real difference in use rates between full- and part- time workers; however, very low income (<$9,000) and high income ($75,000+) employees were significantly more likely to use drugs than other workers. Roughly 8 percent of workers reported heavy alcohol use (5+ drinks on at least 5 occasions during the past 30 days); less than one-fourth of heavy alcohol users also used an illegal drug. Workers in sites with both EAPs and workplace information on alcohol and drug use were less likely than workers in similarly-sized establishments to be current drug users; the lowest level of exposure to EAPs among full-time workers by category was found among food preparers, waitstaff, and bartenders...occupations with relatively high rates of substance abuse.

Comments. There's a lot in this report, including data suggesting that EAPs have a real impact on use rates, but the authors are too cautious in explaining the implictions of the findings. For example, the finding that few employed heavy alcohol users also use drugs is barely mentioned, although it means that nearly 15% of workers were involved in one or both of these behaviors. Similarly, the discovery that better-paid employees are more likely than middle-income workers to use illicit drugs may be familiar to soap opera fans but is not reflected in most health promotion programs and is not mentioned in the report conclusions.

B1039. A.N. Thorndike, N.A. Rigotti, R.S. Stafford, and D.E. Singer (1998) National patterns in the treatment of smokers by physicians. Journal of the American Medical Association 279:604-608.

• Summary. Analyzes data from the annual National Ambulatory Medical Care Survey on the proportion of visits in which a physician identified patient's smoking status, counseled smokers to quit, and used nicotine replacement therapy. Physicians identify smoking status in two-thirds of all visits; this proportion did not changed in 1991-95. In 1993, counseling to quit peaked at 29% of all smokers' visits; fell to 21% in 1995. Nicotine replacement therapy also peaked at 2.2% of all smokers' visits in 1993; fell to 1.3% by 1995; much more common to be administered to smokers already diagnosed with tobacco-related problems.

Comments. Survey is significant because it suggests that managed care penetration was first associated with increase in tobacco use prevention among physicians but is now associated with declining prevention activity. Also suggests that treatment-orientation of physicians continues to drive most toward prescribing "prevention" only after a health problem requires care...use of prevention to drive down future treatment costs may need to depend on other healthcare staff.

B1040. M. Rosnick (1998) Building public health goals into the purchasing process:Managed care perspective. American Journal of Preventive Medicine 14(3S):78-83.

• Summary. Part of a special edition of the journal devoted to proceedings of a CDC-sponsored conference in January 1997. The author distinguishes between managed care and public health orientations: "MCOs treat the diseases and injuries that result from alcohol, refer for or provide chemical dependency services to groups or individuals with alcohol problems, and publish educational materials aimed at prevention. Public health...extends its efforts to the factors that lead people into alcohol problems...." He then states, "With patient behavior being identified as a major cause of pathology, managed care has started paying greater attention to patients' habits in nutrition, alcohol, tobacco, and exercise...Whereas, at one time, MCOs were accused of promoting their preventive services as a marketing ploy, MCOs are now being accused of only paying attention to preventive services and not addressing disease care." The end of the article provides examples of public health and MCO collaboration in Milwaukee, with emphasis on agreements by the health department and the school health system to provide specific preventive interventions for enrollees and MCO funding for part-time outreach at Boys and Girls Clubs, community health fairs, Head Start, and a weekly youth-directed TV show.

Comment. Few of the articles based on the proceedings of this CDC conference addressed behavioral health promotion or presented outcomes. This article authored by a physician-executive with the Humana chain of HMOs is interesting because of its many contradictions. For example, he points out that "community-based providers want to be reimbursed for case management and health education because it is cost-effective" but cites examples of ineffective MCO prevention investments, such as publishing "educational materials aimed at prevention" of alcohol-related problems and funding a weekly TV show. Perhaps community-based providers should be reinbursed because they know what they're doing?