MCOs must shift focus to primary prevention
MCOs must shift focus to primary prevention
Employers ask MCOs for wellness programs
It's time for managed care organizations (MCOs) to break out of their reactive medical model. It's no longer enough to say, "If we develop a disease management program, they will come." Instead, MCOs must develop global, well-integrated health promotion efforts aimed at preventing disease rather than managing it, experts say.
The first step is the periodic capture of key information on your plan members, says Larry S. Chapman, MPH, Chairman and senior consultant for Summex, an integrated health management services company in Seattle. "Many MCOs don't have data systems that can make connections between the elements necessary to manage long-term health risk reduction programs population-wide in a proactive fashion," he says.
Information Chapman says MCOs must track regularly includes the following:
· health risk prevalence;
· health behavioral patterns;
· readiness to change;
· newly diagnosed conditions;
· medical activity/utilization;
· anticipated health care use (such as a scheduled surgical procedure);
· adequacy of support network;
· mental health events (stressful life events);
· personal perception of health.
"The information you need to plan effective health promotion programs can be gathered with the help of a few well-worded questions on a health risk appraisal [HRA]. If you have a handle on this information you can target the risks you want to focus on," Chapman says. "For example, medical activity and utilization can be handled with a few questions about the number of times members have seen their primary care provider or visited the emergency room in the past year. Support network can be assessed with questions about friends, community involvement, relatives living locally, etc. Your goal should be to gather information that allows you to move slowly but steadily upstream from disease management to disease prevention programs."
However, administering HRAs should not be used for program development alone, he notes. "It's important that you follow-up on any identified risks," he says. "For example, if a member's HRA indicates that he or she has three or four identified risk factors for heart disease, find an intervention that fits the risk and take action.
"Do you have a newsletter on heart disease risk reduction you can send the member? Do you have a health educator or case manager who can call the member and discuss risk reduction? Does the member's employer have a workplace health promotion program designed to reduce risk of heart disease you can refer the member to? Does the local hospital offer a stress management program?"
The big threeHealth promotion efforts fall into three categories, Chapman says. Those are:
· Tertiary prevention efforts. "In tertiary prevention, a diagnosis has been confirmed and efforts are made to manage or control utilization and acuity," he says. This is the approach most familiar to case managers.
· Primary prevention efforts. "Primary prevention programs attempt to reduce precursors to morbidity," Chapman explains. "These programs include weight reduction and smoking cessation programs."
· Secondary prevention efforts. "Secondary prevention efforts include early screening and health assessment efforts aimed at identifying risk early enough to intervene and change clinical outcomes." An example of this type of activity includes offering a pregnancy risk screening tool to all pregnant members to identify women at risk for premature labor.
The key to a successful MCO-based health promotion effort is to focus on programs that yield high return in the first year, Chapman says. "Many MCOs complain that there is too much member mobility between plans to make investing in health promotion activities practical. The argument goes like this: Members leave the plan long before MCOs can measure the effects of their weight management or smoking cessation programs and reap the economic benefits of risk reduction," he says. (For more on factors deterring MCOs from entering the health promotion arena, see story, p. 87.) "It's true that a small percentage of MCO members turn over frequently. But most MCOs have 60% of their members with them for an average of 15 years. The key is to start your health promotion efforts by developing programs that bring high yield in terms of cost savings even for those plan members who may leave you in the first two years."
The global perspectiveSome examples of health promotion programs Chapman says produce almost immediate reductions in health care costs include:
· Medical self-care training. "It's not enough to hand out a good medical self-care text. We've found that the most effective way to encourage self-care is to have plan members attend a course where the book is used to work through some case examples."
· Seat belt use programs. "Seat belt campaigns are easy and yield immediate obvious results," he says.
· Somatic complaint interventions. "Nearly one-third of all primary care and emergency room visits are for somatic complaints such as migraine headaches or chronic indigestion. Helping plan members identify those patterns and take better care of themselves greatly reduces your total number of office and ER visits."
"There has been a basic innate flaw in the way MCOs have structured prevention efforts to date," Chapman says. "They have not thought from a global perspective. They've allowed garden variety programs to sprout here and there without any one person in charge of the full view." (For details on common pitfalls of health promotion programs, see stories at right and on p. 86.)
He blames HEDIS (The Health Plan Employer Data Information Set developed by the National Committee for Quality Assurance in Washing ton, DC) for the narrow focus most MCOs take to health promotion and disease prevention activities.
"HEDIS focuses on countable events," he notes. "It asks health plans to count the diabetic rather than to count the person who has risk factors for diabetes. This turns the focus of prevention to tertiary prevention efforts rather than primary prevention efforts," he explains.
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