Wellness gains steam
Industry taking broader view of programs
Eight of 10 major health plans and employers who responded to a DMAA: The Care Continuum Alliance survey offer wellness programs, and that number is expected to jump to 91% within the next year.
In what is being called the first state of disease management (DM)/wellness market survey, DMAA’s Disease Management and Wellness: Results of a Market Research Survey sought to gain a complete picture of the DM/population health industry, given DMAA’s expanded focus to population health. DMAA received 114 responses to the survey from companies that are responsible for between 166 and 197 million lives.
This emphasis on wellness makes sense, says Elaine Mischler, MD, cochair of the DMAA Market Analysis Workgroup and independent consultant at Mischler Consultants, LLC, in Madison, WI. Service organizations, health plans, and employers that catch a person before he or she spirals into chronic illness will save money in the long run.
Unlike earlier DM programs, service organizations are offering programs that go beyond a specific ailment, such as heart disease, and focus on the whole person.
“It comes down to you have to change one person at a time. You can talk about the population, but in the end, it’s engaging each individual in their own health journey,” says Mischler.
The results did not surprise those in DM and wellness. “I personally don’t think the report is aimed at the industry. The industry already knows all this. I think the report is aimed at making everyone else, all the other stakeholders, the employers, for example, aware of the impact of wellness,” says Jaan Sidorov, MD, MHSA, FACP, an independent consultant who owns and operates Sidorov Health Solutions in Harrisburg, PA.
Dexter W. Shurney, MD, MBA, MPH, senior vice president and chief medical officer at Healthways in Franklin, TN, says wellness has changed from being thought of as “feel-good programs” to something that improves outcomes and lowers long-term health costs. DM programs aren’t going away, because chronic disease will continue to occur. But wellness programs can help decrease the number of those who sink into chronic illness, according to Shurney.
“It’s only through the wellness programs that we have any hope to stem the [chronic illness] tide,” Shurney says. “I’m a true believer on how this stuff works and needs to work, and if we’re missing the wellness opportunities, then we are really missing the boat.”
Christobel Selecky, president and CEO of LifeMasters Supported SelfCare, Inc., in Irvine, CA, says preventive wellness and chronic care DM programs are needed. “No matter what you do, you can age healthfully, but the reality is we are all aging,” Selecky says. “A lot of people who are now entering the older years have not had the opportunity to take advantage of wellness programs. It’s going to be a long, long time, if ever, before we don’t have people who have chronic disease.”
But there are still some experts who question the cost-effectiveness of wellness programs. Readers can count Ian Duncan, FSA,MAAA, president of Farmington, CT–based Solucia, Inc., a provider of analytical and consulting services to the healthcare financing industry, as one of those skeptics. “DM makes perfect economic sense because the prevalence of chronic disease in the typical employer population is between 5% and 6%; 1%–1.5% have severe enough illness to warrant enrollment in a program staffed by clinical resources.But wellness programs are focused on the remaining 90% or so of the population, and to provide each person with their own health coach is probably uneconomic, unless it can be delivered in an extremely cost-effective fashion,” Duncan says.
Although the DMAA survey reported that 84% of health plans and employers offer wellness programs, service organizations surveyed have not been as quick to implement wellness with DM. Fifty percent of service organizations offer wellness programs and 11% provide wellness support technology, such as health risk assessments and self-directed online interventions.
But service organizations plan to significantly increase wellness investment in the future. Seventy-one percent of service organizations surveyed plan to offer wellness programs within the next 12 months. On the other hand, 14% of those companies have no plans to offer wellness programs in the next two years, according to the survey. (See Figure 1 on PDF.)
As wellness programs gain momentum, DM offerings remain a constant for health plans and employers. Ninety-two percent of health plans and employers offer at least one DM program, and that number is expected to swell to 95% within the next 12 months, according to the survey.
The foundation of DM programs remains diabetes, coronary artery disease, chronic heart failure, chronic obstructive pulmonary disease, and asthma, but companies are increasingly offering depression and low back pain programs.
Mischler says depression often goes hand in hand with chronic illness, and programs tackling mental health have historically been integrated into DM programs. Now, many DM providers have separate depression programs.
“I think, in the future, you’ll see depression start to be brought more and more inside of other programs, and you are already starting to see some of that today,” Shurney says. “Disease management programs are going to have to deal with those issues with members before they can effectively deal with the chronic conditions.”
Employers know that low back pain problems can negatively affect productivity. However, it is difficult to find employees with those issues early and enroll them in low back pain DM programs because of claims lag, says Mischler.
In addition to these findings, the DMAA survey reported that:
Health plans and employers view participant satisfaction with wellness programs as an important measure of success, and 87% of service organizations reported that satisfaction measures are the most common elements in requests for proposals (RFP). DM/population health companies reported that RFPs include a strong expectation of data integration, and more than 60% of service organizations have integrated data systems.
Diabetes, coronary artery disease, and asthma are the top three conditions for DM program enrollment. Health risk assessments (HRA) are the most popular wellness initiatives among employers and service organizations, whereas health plans prefer cholesterol screening and counseling.
Approximately one in five respondents considered physician engagement important to a wellness program’s success, and about 40% of respondents pointed to physician engagement, which ranked third in the survey, as a critical component of DM program success. Getting physicians involved in DM and wellness is a major tenet of the medical home concept that several organizations, including DMAA, have promoted as a way to improve healthcare.
“These findings reinforce the long-held understanding that the key contributor to a program’s success is, in fact, the attitude and behavior of the patients themselves and the encouragement and engagement of their physicians,” the authors wrote.
Physician involvement is not deemed as important in wellness programs as in DM programs. However, the study’s authors wrote that physicians can benefit from promoting wellness programs. “From the patient’s perspective, wellness programs can teach them to make more effective use of their time with their physicians and to better follow their directions. They can learn to be more accountable for their own health outcomes. For the physicians, wellness programs can increase and improve the information they have to understand and manage the patient and result in improved outcomes over time,” the authors wrote.
Most service organizations (69%) acknowledge that physicians view DM programs as interfering with their care. Forty-one percent of service organization respondents said that physicians are not inclined to encourage patients to engage in DM programs.
This disconnect has been an ongoing problem, as the two groups have worked in parallel universes. Mischler says DMAA is trying to bridge that gap and is communicating with physician organizations.
By forging better communication, DM can show physicians that DM programs are “office extenders” that can empower patients and help physicians with efficiency, Mischler says, adding that it will take time for everyone to work as a team and learn to reach the goal of optimal health for the patient.
In the DMAA study, the three respondent groups disagreed about what aspects of a DM program bring the most notably positive results. Health plans and employers pointed to better identification of at-risk members, whereas service organizations said incentives that improve participation are important. “It is interesting to observe that the view of health plans and employers reflect a bias toward the belief that the inherent abilities of the service organizations’ products are key to improved performance, while service organizations attribute the greatest capacity for improving performance to factors controlled by health plans and employers,” wrote the authors.
Mischler says the groups have different opinions because they approach the issue of DM from different vantage points. “It’s from the perspective from which you’re working,” she says. “The important thing is all three are talking to each other and working with each other to accomplish the end goal, which is maximizing engagement and maximizing behavior change that is long-lasting.”
Duncan says he finds it interesting that the three respondent groups disagree. “This is one of the biggest current gaps in DM and needs to be filled.The fact that the three respondent groups essentially point fingers at each other doesn’t suggest we are close to answering this question,” he says.
Employers and service organizations agreed that HRAs get the most eligible members enrolled in wellness programs, but health plans pointed to cholesterol screening and counseling as the way to get the most eligible members enrolled.
Sidorov says HRAs are a baseline offering for any wellness program. “Health risk assessments are a no-brainer. You can’t have a program like that without rolling in health risk assessments. I’m not even sure why that’s necessarily an insight,” he says.
Shurney says HRAs can benefit other programs, such as health coaching. “The whole idea there is to reduce risks for populations. A nice way that can be integrated in a disease management program is that the same health risk assessments act as a feed to your disease management software and program so that the nurses have that information as well, and you can also use that when you do your predictive modeling.”
Some of the more common trends in RFPs for DM/wellness services are patient satisfaction measures, performance guarantees, DM/wellness requirements, and data integration, according to the survey.
Mischler says there is a trend to move away from calculation of individual program element return on investment (ROI) to measuring a reduction in overall trend, adding that this is consistent with the industry moving away from the DM/individual illness model to population health.
Sidorov says there is a change of thinking in the DM industry about the cost savings associated with the programs. “Five years ago, I would have been willing to bet the ranch it saves money,” he says. The previous belief that DM saves money has been replaced by the understanding that, although DM improves health, some DM programs may not provide positive ROI. “Even if [DM] doesn’t save money, for the money you spend, you get great value,” Sidorov says.
“There’s not as much attention to ROI because I think people understand that a lot of ROI might be in the future and not within the first year or second year,” says Shurney, adding that there is a greater emphasis on ROI in programs that integrate wellness and DM.
Selecky says ROI is still used but is now just one of many gauges of a program’s success. Other ways to measure success include engagement level, clinical results, and program outreach.
Integrated data platforms
Service organizations who responded to the survey said integrated data platforms are extremely important. Sixty-one percent of respondents reported that they have an integrated data platform, whereas another 21% plan on implementing platforms in the near future.
Respondents said integrated data platforms are important because they provide a “more comprehensive profile of members. This complete profile is essential for delivering accurate, customized interventions. Individual-specific interventions result in better outcomes and enhance reporting abilities,” according to the study.
These platforms provide real-time information on a patient’s health, meaning DM and health plans can intervene with at-risk patients quickly, instead of having to wait weeks or months for claims data. “The ability to transition members quickly and smoothly impacts the outcomes and value for these programs. Platforms that are not integrated may have a longer waiting period to get needed data, or the data might not arrive until the member’s health has deteriorated,” the authors wrote.
Duncan says he is seeing little integration of wellness and DM and even less coordination via integrated systems. He agrees the goal is to transition members quickly and smoothly, but says he simply isn’t seeing it. Plus, he questions whether companies are analyzing and integrating data collected from HRAs. He says he would like to see results on the efficiency of HRA models versus biometric screening models, as well as results from different coaching methods, such as Internet, e-mail, and telephone.
A lack of PDAs
Mischler says one surprise from the survey is the lack of PDAs in DM programs.
No health plans or employers said they use PDAs in DM programs. Small percentages of service organizations used PDAs, with the highest percentage a mere 9% for diabetes. Mischler says this lack of usage could be due to cost, lack of functionality, and inability to integrate the data. Telephone and mailings topped the list for DM interventions, with the Internet coming in a distant third.
Mischler says DMAA will conduct the survey annually for the next two years, which will allow the organization to track changes in the field and acquire new data to further define the DM and health and wellness industry.
Duncan says he hopes DMAA adds a question about participation rates for wellness programs in a future edition of the survey. “Where there is an employer incentive, it is often so large that the only way it can be justified is as a faith-based program, rather than on economic grounds. One of the challenges for the industry is to find ways to improve participation and persistency without sizeable employer incentives, and there are some interesting experiments going on in this area,” he says.