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

B1051. R McCarthy (1998) Corporate health gets creative. BUSINESS & HEALTH 16(7):39-44.

• Summary: Briefly describes six innovations in healthcare benefits in which employers moved the care system toward prevention. GE seeks to establish regional alliances with its preferred health plans, based in part on the plans' willingness to support on-site preventive care clinics. Burlington Industries encouraged CIGNA to offer a Well-Baby Program combining worksite activities for pregnant workers with financial incentives for prenatal care. Baxter International requires its managed care "partners" to report on activities to improve the health of the community.

Comment: Although interesting the innovations have a scattershot feel. For example, why does Sara Lee bakeries offer osteoporosis-screening only in one plant, if it is important to the employees? The justification that a healthcare company subsidizes the screening in that plant suggests that employers should provide any useful prevention that somebody else will pay for.

B1052. J Ziegler (1996) America's healthiest companies. BUSINESS & HEALTH 16(12):29-31.

• Summary. Provides brief descriptions and, in some cases, evaluation data from the seven winners of the 1998 C. Everett Koop National Health Award: Chevron, Sentara, Citibank, Eli Lilly, Pitney Bowes, Applied Materials, and Texas Instruments. The Chevron program of worksite health promotion is closely tied to managed health because so many of the employees work on ships and oil rigs where company-provided care is the only option; fitness promotion is the big corporate push. Sentara, a managed care provider, pays its employees to participate in self-care and risk reduction. Employees participating in Sentara's Healthy Edge program report modest but consistent reductions in body mass and changes in diet, as well as significant increases in psychological well-being. Both the Sentara and Citibank programs reportedly saved over $6.00 for every $1.00 spent.

Comment: The Chevron and Sentara descriptions offer useful models for other companies to adopt, but they focus on high blood pressure, obesity, and tobacco use as the prevention targets. Behavioral health specialists might like to know more about the "psychological counseling" provided by the five on-site clinics in Eli Lilly pharmaceutical workplaces.

B1053. G Sorensen, A Stoddard, MK Hunt, JR Hebert, JK Ockene, JS Avrunin, J Himmelstein, and SK Hammond (1998) The effects of a health promotion-health protection intervention on behavior change: The WellWorks Study. AMERICAN JOURNAL OF PUBLIC HEALTH 88(11):1685-1690 (November).

• Summary: The WellWorks study was the largest of four work-site interventions operated by the Working Well cooperative agreement with the National Cancer Institute and Liberty Mutual. Its worksite program included joint worker-manager participation in program planning, changes in the worksite environment, and health education programs targeted to individual change in diet and tobacco use. WellWorks' developers recognize that blue-collar workers often identify their top health priorities as reducing involuntary company-created risks, including exposure to carinogens and safety hazards; "reduction of job risks may be required in order to gain credibility ...and to increase their receptivity to health education messages regarding their own individual health behaviors." From 1989 to 1994, worksites reported 17.9% sustained tobacco abstinence among blue-collar WellWorks participants compared to 9% among blue-collar workers in control sites). Blue-collar workers in WellWorks also showed greater improvement in fiber consumption and consumption of fruits and vegetables.

Comment: Liberty Mutual succeeded in getting worksite management to reduce environmental risks to health as part of the overall health promotion/disease prevention package. The result includes solid gains in risk reduction that do not assume that individual workers are solely responsible for their own "failures" in preventing cancer.

B1054. F Jossi (1999) Defusing workplace violence. BUSINESS & HEALTH 17(2):36-39.

Summary: Companies often develop response plans after a particularly serious incident and focus on security issues. Nevertheless:

One of six violent crimes is committed in the workplace

The health care industry accounts for nearly two-thirds of non-fatal worksite assaults, with about half committed by patients and half by co-workers.

Over 90% of workplace homicide is related to robbery attempts.

Polaroid, Liz Claiborne, and the Newton-Wellesley Hospital in Newton, MA are cited as leaders in domestic violence prevention. An important component of the prevention programs are changing human resource and EAP policies to help female workers leave battering relationships and to educate clinicians on identifying problems.

Comment: Results of these programs are difficult to track; the Newton-Wellesley program, for example, considered itself successful when the number of domestic violence complaints increased! Nevertheless, Blue Cross Blue Shield of Massachusetts and several hospital-based programs have adopted the Polaroid Domestic Violence Prevention program.

B1055. K Hill (1999) Too few cooks. FAITH & HEALTH Summer, p. 13.

• Summary: "A major problem in South Carolina is obesity among African-Americans: 69 percent of African-American women in this state are overweight, as are 59 percent of the men…Their lifestyle, including being sedentary, has really promoted chronic disease." Jeanette Jordan, an education coordinator for Hollings Cancer Center, used a small state grant to fund a response to this problem through health risk surveys and the recruitment of a culinary arts school in Charleston to teach healthier versions of traditional recipes to 41 of the 360 A.M.E. congregations in the State.

Comment: This health promotion program represents an unusual collaboration between health care providers and a part of the faith community reaching a traditionally-resistant culture. Surveys helped to focus the program on culturally-relevant health issues: tobacco cessation, for example, is not a priority because members of A.M.E. congregations in the South usually don't smoke. A more appropriate behavioral target is reduction of the fat content of traditional diets (without changing the menu or the taste).

B1056. G Oster, D Thompson, J Edelsburg, AP Bird, and GA Colditz (1999) Lifetime health and economic benefits of weight loss among obese persons. AMERICAN JOURNAL OF PUBLIC HEALTH 89(10):1536-1542 (October).

• Summary. Using a dynamic model of the relationship between Body Mass Index and the risks and costs of five diseases (hypertension, type II diabetes, stroke, etc.), the researchers found that a sustained 10% weight loss would make significant reductions in the incidence of chronic obesity-related illness. For a man or woman aged 45-to-64 years, the lifetime savings of treatment costs for such a reduction ranged from $2500 to $5300, depending on how severe the initial obesity was.

Comment. Just in case you wanted to know how much the Too Few Cooks program described in B1055 is worth in terms of per patient savings. All that needs to happen to save an average of $2000 per middle-aged patient is for those people who weigh in at 250 pounds to cut their weight down to 225.

B1057. JK Bobo (1997) Efforts to quit smoking among persons with a history of alcohol problems. CDC MORBIDITY AND MORTALITY WEELY REPORT 46(48):1144-1148 (December 5).

• Summary: At least eighty percent of adults receiving treatment for alcohol problems are also daily smokers and therefore likely to be at risk for oral cancer and other chronic, costly disease conditions. Could the use of individually-tailored counseling sessions toward the end of treatment for alcohol problems make a difference (and address two cost-saving health promotion tasks at the same time)? This study of 575 daily smokers admitted to residential alcohol treatment centers found that only 8 percent successfully quit after exposure to four ten-minute antismoking discussions. Men were slightly more likely than women to give up smoking, and Native Americans were more likely than non-Hispanic white patients to quit tobacco.

Comment. One interesting finding: patients encouraged to quit smoking were significantly LESS LIKELY to relapse into alcohol problems (even if they continued to smoke) than other patients who did not receive antismoking advice. In effect, exposure to behavioral health promotion didn't have much effect on the target health behavior, but it reinforced the effects of the treatment!

B1058. UM Kujala, J Kaprio, S Sarna, and M Koskenvuo (1998) Relationship of leisure-time physical activity and mortality: the Finnish Twin Cohort. JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 279:440-444.

• Summary: "Premature mortality" usually is preceded by major medical costs, as chronic conditions overwhelm the individual's ability to cope. How much of this problem is due to genetic factors and how much is due to the behavioral health strategies chosen by the individual? The research team studied nearly adult 16000 twins over a 17-year period. People who exercised at least six times per month, with an effort equivalent to a brisk half-hour walk, were much less likely to die during the study period than their more sedentary.

Comments: Of course heredity affects lifespan and illness rates, but the things we can control or encourage through health promotion programs also play a role. Even as simple a goal as encouraging people to walk for 30 minutes twice each week has a strong protective effect on patients…and their health care costs.

B1059. G Goettling (1999) Counting on accountability. FAITH & HEALTH Summer, pp 4-10.

• Summary: Provides a simple discussion and recommendations of various "tools" for outcome evaluation of health promotion programs involving congregations of the faith community. A very brief discussion of the Coordinated Care Network of Pittsburgh describes how a faith-based network mobilized to provide community-based prevention and treatment has been able to document multimillion dollar savings to the supporting HMOs, including $9 million annual reduction in er costs and additional savings in neonatal costs for drug-exposed infants. An organizer of the network points out, "We've gone to HMOs and said, 'This is the network, this is the work we plan to do, and…the difference it will mean in cost savings for you."

Comments: The article focuses a lot of attention on Results Mapping, a somewhat controversial evaluation approach developed by Barry Kibel, PhD, but also includes a lot of practical information on sources to obtain other layperson-focused outcome evaluation help.

B1060.TJ Dishion, F Poulin, and J McCord. When interventions harm: peer groups and problem behavior. AMERICAN PSYCHOLOGIST 54(8):755-764.

• Summary. Many preventive interventions for mental health and substance abuse problems, whether funded by managed care or other sources, like to put their "bad apples" together for group sessions over long periods of time. Tom Dishion and Joan McCord, two very respected researchers in evaluation of prevention, offer the results of the long-term effects of the Cambridge-Somerville Youth Study Evaluation and the Adolescent Transition Program. They conclude that "interventions to reduce adolescent problem behavior backfires when peers with similar behavior problems are grouped together in the intervention." In the short-term, teenagers with moderate problems who received intensive interventions often become worse. In the long run, "those who received the most attention over the longest period of time were the most likely to have (a) died before reaching 35, (b) been concicted of a serious crime or (c) been diagnostic with alcoholism or severe mental health impairment."

Comments: This research strongly reinforces the advantages of short, intensive, individual programs for mental health promotion and prevention of behavioral problems…the kind most acceptable for managed care. Just as jail time can transform occasional offenders into hardened criminals, long-term group interventions may reinforce delinquent behavior and attitudes among youth leaning toward problems.