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Engaging members for better health and lower costs


Public and private insurers are seizing the opportunity to devise programs that promote preventive care and positive behaviors.

As research continues to indicate that patients who actively participate in managing their health fare better than those who don’t, public and private insurers are seizing the opportunity to devise programs that promote preventive care and positive behaviors. For managed care organizations, healthier outcomes result in reduced costs, so patient engagement has become a key focus of plan designs.

But not all patients react the same to these efforts. “Some are very passive with regard to their health, and some of them are very proactive,” says Judith H. Hibbard, DrPH, professor emerita at the University of Oregon in Eugene. Hibbard and her colleagues developed an assessment tool, the Patient Activation Measure (PAM), to evaluate an individual’s capacity to take charge of his or her own health and treatments. By gleaning insight into a person’s knowledge, skill and confidence for self-management, health plans are more effectively tailoring strategies for that member.

“A lot more organizations are using the patient activation measure to know how well they are engaging their patients,” Hibbard says. “It is quite predictive of health behavior.” The diagnostic tool allows health plans to meet patients at their level from the outset and to gauge their progress--for instance, in following an exercise regimen, making better food choices or taking medications as directed.

With passive members, it’s best to begin with smaller steps while fostering encouragement and a can-do attitude. “All the steps are really about building people’s confidence that they can actually be successful in managing their health,” Hibbard says. “That’s what it’s all about it.”

Read how a pilot program launched by Independence Blue Cross and Accolade is producing real-world results for members

Case management is particularly important for members with expected high utilization of services. The reasons range from chronic diseases, acute impairments or transitions between levels of care, says Mary Jo Muscolino, RN, MPA, CCM, CASAC, manager of case management services at the Monroe Plan for Medical Care in Pittsford, New York.

The Medicaid-managed care company’s nurses and social workers perform assessments via phone and face to face with high-risk members who meet specific monitoring criteria, such as high blood pressure, diabetes, HIV/AIDs, a prior stroke or coronary bypass. “In most cases, when possible, we will go out and see the person for the initial visit,” Muscolino says, adding that nonverbal communication and a sense of the patient’s surroundings often tell a lot about the situation.

NEXT: Preparation allows for a more accurate application


Before the visit, the case manager reviews claims history and attempts to identify “a utilization pattern that begins to give a story of who the person is and what kind of issues they’ve been dealing with,” she says. Preparation allows for more accurate application of the PAM self-assessment tool during the visit and strategies for partnering together toward better health. “This really gives us an opportunity to assess what the person is able and willing to do about their health at that point.”

Outreach workers assist case managers in locating transient members. The workers canvass communities “to do people finding.” They may ask someone answering the door at a member’s listed address where that person might be living. For diabetics, they typically check if the refrigerator is functioning and keeping their insulin cool, Muscolino says.

Related:Should patients be accountable for poor health choices?

A case is usually open six months for follow-up, and about 60% of members demonstrate an increase in their PAM scores at the end of that period. At least 90% report satisfaction with the program and more capability in understanding and managing their conditions, she says.

Awareness of members’ psychosocial needs is an essential ingredient in successful engagement efforts. As part of an integrated care management model aimed at high-risk members with chronic diseases, addressing the psychosocial factor can help insurers reap a return on their investment. Significant savings come from reductions in utilization of emergency rooms and hospital services and lower readmission rates, says Sam Toney, MD, chief medical officer and vice chairman of the board at Health Integrated, a Tampa-based nationwide care management company.

In its most intense program, Synergy, the company employs licensed psychotherapists with master’s degrees to delve into the underlying psychosocial barriers that may prevent a person from adhering to a treatment plan for a physical ailment. “Engagement is just at the front end of what we do,” says Toney, who trained as a psychiatrist. Specialized interventions facilitate behavioral changes while encouraging patients to view the world around them differently and to reframe perceptions of their own illnesses.

For scalability purposes intended to serve a lot of plan members, the Synergy program functions entirely by phone and spans about nine months. It typically piques members’ interest via mail or e-mail. Telephonic outreach follows, with the system transferring the call immediately to an engagement specialist, Toney says.

A dedicated clinician interacts with a member every two to three weeks at a scheduled time during the initial phase, then every four to six weeks. Calls average 35 to 45 minutes. “These are [almost] therapy-like sessions,” he says, while adding that the company has done multiple studies that demonstrate long-lasting behavioral changes after the program’s completion.

NEXT: Different communication methods for different audiences


Tech-savvy consumers tend to prefer online communication, and insurers often favor this lower-cost option for patient engagement. The result is a win-win situation, says Frank Hone, vice president of marketing and engagement at Indianapolis-based Healthx.com, which contracts with payers for care management. The trend is particularly pronounced among members in their 20s. “Phone calls just aren’t in their vocabulary,” Hone says. “They want to interact with their health plan digitally.”

While health plans cater more to modern consumers, patient engagement sometimes resorts to an old-fashioned approach. “For those people who want to-- or need to--talk on the telephone, that medium is still available,” he adds. “You’re never going to find a single medium that fits everybody all the time.”

The National Committee for Quality Assurance found that “patient engagement enabled by health IT is a major, untapped opportunity (particularly among marginalized communities) with the potential to improve inefficient communication methods and change the dynamic of the relationship between the patient and the healthcare system,” according to a report released in February 2014. However, “health IT design must be user-centric, starting with the needs and preferences of patients and their families. In addition to existing efforts to guide design priorities, an evidence framework to evaluate the quality and effectiveness of health IT tools specific to patient engagement will be instrumental in advancing interventions that are meaningful to patients.”

What consumers want

To find out what people want from an insurance company, Oregon’s Health CO-OP held focus groups around the state, involving potential members from all demographic categories, says Ralph M. Prows, MD, president and chief executive officer. The process initiated more than a year before the new Portland-based company launched and enrolled members beginning in January 2014. About 2,000 Oregonians contributed suggestions, leading to the creation of meaningful programs that encourage people to stay healthy.

Members can access up to $300 in rewards for participating in three programs--each with a $100 incentive--to become more knowledgeable about their own health and to make improvements, Prows says. In the first program, members are rewarded for selecting and establishing a relationship with a primary care physician who steers them toward building a health plan collaboratively to receive immunizations, cancer screenings and other preventive services. 

A second program offers $100 for taking an online health-risk assessment and a patient activation measure. Members learn whether they are at risk for hypertension, diabetes or other medical conditions. The third program is an online educational tool that rewards members for reading eight articles and undertaking eight specific activities to address a particular health concern, such as weight management or factors that contribute to overeating.

The programs can be done in any order once per calendar year. Although it’s too soon to calculate their impact, about 40% of Oregon’s Health CO-OP membership has so far opted to participate. “They want to take a very active role in their own health,” says Prows, an internist who volunteers at a clinic on a monthly basis.

Also in line with every focus groups’ recommendations for patient engagement is the nonprofit health plan that brought naturopathic physicians into its panel as primary care physicians. In Oregon, naturopathic physicians are licensed to perform primary care, allowing them to write prescriptions, order tests and interpret results.

The company continues to seek new opportunities to make its offerings more relevant to potential members while hosting meetings anywhere from churches to night clubs.

“Each community has its own very unique health issues,” Prows says. “We have to take a larger view of health. We’re not just an insurance company.” In a world where clean air along with good schools and jobs can make a difference, “we’re trying to be a socially conscious company in all of these ways.”

Susan Kreimer is a New York-based freelance medical writer.

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