Health Risk Incentives

Increasingly, payors offer incentives to complete health risk assessments (HRAs) and/or interventions. Not to mention myriad quizzes in magazines, on Web sites ranging from Hoodia hawkers to the American Heart Association , but we'll focus on the MCO-sponsored HRAs today.

When a plan asks "clinical questions," expectations of benefit and/or negative consequences often arise. More transparency around how, when and why HRAs drive payor behavior would be welcome, as well as the role patients' clinicians should play.

Let's assume that inducements for completing a HRA are intended to accomplish some combination of the following:

1. Increase awareness of modifiable risks

2. Increase awareness of less modifiable risks, e.g. family history

3. Increase likelihood that modifiable risks will be addressed

4. Increase awareness of preventive health overall

5. Seek medical advice as HRA suggests appropriate

6. Increase payor awareness of high-risk members, and targeting of appropriate interventions

Studies assessing progress toward #3, 5 and 6 could be claims, survey and/or chart-based. We can track health outcomes, events like hospitalization and drug/medical trend. But there's more than ROI involved. What about unintended negative effects on members? Some possibilities:

--False reassurance, since HRAs cover only a few risk factors

--Catalyst for denial, since "bad news" may not have been delivered in that format previously

--Oppositional behavior, since lack of questions regarding members' known conditions may be seen as unresponsive to their needs

--Resistance to disease management stemming from HRA completion may arise, since the relationship between the two could be perceived as intrusive (careful message crafting can avoid this)

--As an automated tool rather than a one-to-one conversation, HRAs may induce or enhance a feeling of disassociation from the plan / health system

HRAs remain a good idea, but as yet they are a blunt instrument. Hopefully, we are heading toward baseline HRAs and tracking customized by member claims; integration into longitudinal patient data that includes survey and claims data; periodic chart audits to complement these data. Perhaps most importantly, such data can enable plans to act more proactively in partnership with clinicians and third party associations toward eliciting and helping to address health issues that are troubling the member.

For example, payors are generally not helping members with complex and concomitant chronic conditions find knowledgeable and coordinated care, which often would require no more than disciplined claims sifting. Patients often experience a trial and error process that costs both them and the plan extra money, with adverse health outcomes as well. Center of excellence programs are only the tip of the iceberg for optimizing inputs.

It’s strange that HRA data collection forms are less sophisticated than many "marketing research" surveys. For the most part, HRAs do not permit open-ended data collection, branching or piping, so everyone basically sees the same questions. Moreover, HRAs seem fairly far behind the literature. For instance, we are finding that not all LDL is created equal; multiple inflammatory /autoimmune conditions may be related, etc. The "goodwill investment" in HRA completion is fairly substantial and merits the most actionable questions possible.

Yes, the typical subject areas of BMI, depression, smoking, diabetes, cholesterol, HTN and MVAs all relate to health status and cost, but it is not always clear how in what patients, nor how HRAs can optimize care in the year(s) following this snapshot. An HRA may be one of the few plan touch points related to her health that a patient ever sees (EOBs and flu shot reminders notwithstanding). Many plan e-mails, which should be dynamic and personal, are somehow presumptuous, condescending and irrelevant all at the same time -- we can do better.

Industry/MCO collaborations are often based on the flimsiest of targeting algorithms, when the claims, charts, and the humans involved (clinicians, patients, payors) hold so much information that could improve those algorithms. As EHRs and PHRs are developed, how well are they integrating these data?

Incidentally, the methods paper for the first study of patient medication adherence to integrate claims, charts and surveys at the physician and patient levels is now in print (disclaimer: I am a co-author). This kind of project demonstrates that claims can be used for more than cost comparisons, surveys can drive more than product-specific marketing and chart audits can do more than fulfill HEDIS requirements.

Thoughts?

Health Literacy and the Misplaced Mantra, part 2 of 2

Health Literacy and the Misplaced Mantra, part 2 of 2

The Dilemma

Web-based decision support and concierge health services are on the rise, yet most people still believe (with considerable justification) that the most complete and objective advice remains reserved for the rich or well-connected. Meanwhile, system integrators believe that the best consumer is informed and would rather, for example, link her BMI to cash than evaluate plan designs. So, while incentives to “do the right thing” are coming into play, when/how to do it is still a very real issue for the consumer receiving constant, often contradictory, stimuli.

At the point of care, the patient, who still lacks access to much of her medical record, is told at one visit, "I can't decide for you," and acted for paternalistically the next, in both cases with the best of intentions, under a system that rewards speed, test orders and upcoding more than outcomes.

The Reality

The ability to limit health information stimuli to self-initiated searches no longer exists. What if you were as besieged with information about lawn mowers (which you may not even need) as you are with health information? How soon would you turn off and drop out? Now, what makes health information so compelling? At its root, it’s a catalog of ways to die. There are ways to dress it up, but charging ahead under the assumption that living’s easy is not the way. High utilizers are often the most likely to have at least one uncontrollable risk factor. How well are you illuminating what’s controllable and what’s not? And when you put together your health/disease education modules, shouldn’t you overlay all the content with incentive to actually use it?

We need to address the barriers to optimal decision-making head-on, rational or not. These include lack of self-efficacy, emotion/information overload and a perception that inputs relate poorly to outputs (everyone hears about the runner who dies of an early MI). P4P and CDHC designs in and of themselves cannot drive outcomes and may even make things worse. So we need to address the most pressing patient questions head-on:

• How important is making this decision? What are the risks and benefits of doing nothing vs. acting?
• How controllable is the risk of acting? Can the risks be spread out by making a series of decisions over time?
• What are the best and worst cases?
• How achievable is a positive outcome?
• How predictable are the positive and negative consequences?

In short, we can help deciders prioritize their decisions to optimize the achievable delta. Rather than agonize over which multivitamin to buy this month, what if I can spend that energy on overcoming my addiction to sweetened fruit drinks? The reason that so many people read Prevention, a monthly digest of often contradictory information, is that when its authors make a declarative statement, they are usually fairly good about telling readers how to implement it in their own lives. How well do your Web site, direct mail, brochures and e-mails do that? And no, “it’s easy to eat 5-7 vegetable servings per day” doesn’t count, because it’s not easy!

Imagine…

Today, tests for the extent of health literacy (e.g. the ability to read a product label) don’t measure the propensity to follow the label’s instructions, take it seriously, extrapolate it to other health decisions, etc. These are where motivation to spend time on the key decisions and wade through all the extraneous and repetitive information comes in.

Now imagine it’s 2017, and there are robust question batteries that reliably predict the capacity for and propensity to use health literacy. When rating or treating a group or individual, wouldn’t you want to combine this assay with medical underwriting and the patient’s past ratio of achieved to achievable health improvement, since the three together have a more direct effect on costs and outcomes?

So what is your organization putting into place today, to prepare you to develop, implement and/or integrate this algorithm in 2017? And underlying this entire fantasy has to be real-time access to claims and/or chart data, with the clinical and communication savvy to use these data intelligently. How close are you there?

Next…what self-administered risk assessments do and don’t do…and what might work better.

Health literacy: do we have the mantra right? (Part 1 of 2)

Health literacy: do we have the mantra right? (Part 1 of 2)

The Mantra

“Health literacy is increasing; consumers are becoming more sophisticated.”

This statement supports the textbook definition of health literacy: the ability to obtain and use health information and services. Unfortunately, patients’ motivation to (1) cultivate and (2) utilize that capacity is often missing from both the definition and reality.

In what other consumer behavior would we overlook the fact that action requires both motivation and capacity? Walk into any car dealership and you’ll see how quickly the salesperson assesses your motivation, as distinguished from your capacity to act!

The Gap

Unlike literacy in general, which has clear utility in daily life, there are significant disincentives for health literacy, e.g. the potential consequences of a bad choice, the effort of making it, etc. It is also relatively easy to choose not to exercise health literacy, whereas it would be difficult to choose not to read more generally. Moreover, a plethora of choices is a natural rationale for denial and shutting down.

We’ve all experienced some version of health care hell, in which decisions:

o Had to be made while in physical and/or emotional pain

o Were only supported by information that was either over-simplified, or in a foreign language

o Were clearly a “choice between evils” and/or offered less than even odds of the most favorable outcome

Thus, choice is often less about empowerment (the movement to redefine CDHC as “patient-empowered care” notwithstanding) than necessity and hope. Everyone who seeks to influence health behavior should consider daily that information-seeking, care-seeking and self-treatment each carries significant emotional, physical and economic (including opportunity) costs. Though making one’s own decisions with appropriate support may be better than the alternatives, it is not the pain-free, no-muss event too often portrayed.

So the circular incentive presented for exercising health literacy (“take charge of your health”) may be less than persuasive when it comes to action. For many, including the uninsured, that directive entails time and/or money they don’t think they have, and/or appears to be a code word for increasing OOP costs.

With great power comes great responsibility. Health literacy can increase both, yet, often, neither is desired.

Next, some thoughts on alleviating the huge burden of health decision-making. Please leave a comment (with a URL if appropriate) to let everyone know what your organization is thinking and doing, as well.

Laurie Gelb's Welcome

Welcome to the MCOL Blog. As a survey/outcomes researcher/strategist who's been on the hospital, payor, manufacturer and consultant sides of the table, I'm looking forward to some lively conversation on decision support, my particular passion. Anyone who delivers, funds, receives or regulates care these days faces an unprecedented burden of choice. How do we minimize this burden while optimizing health? Please bring your experience and insight to our discussion.