Is your healthcare management program designed to be effective where it counts most? Does it target the critical element for better outcomes and sustainable change?

Employers are challenged to ensure their health benefit programs are delivering on their promise of healthier, more productive employees at the lowest cost. Healthcare management programs are intended to help with the challenge, whether in the coordination of clinical services, care for participants with chronic or complex medical conditions, or, as one healthcare system describes it, the “personalized service to deliver the care you need in the way you need it.”

What we intend by “healthcare management” is the set of resources devoted to services and activities organized through principally three functions: identifying populations with modifiable risks, ensuring alignment of available services to the needs of the population, and arranging for the right clinical personnel to deliver the needed services. (See US Agency for Healthcare Research and Quality.)

Despite this attempt at a standard definition, the practice of healthcare management varies from one program to another. Further, some programs are more effective than others in producing long-term better health and less dependence on medical interventions.

The most important element in effective healthcare management, what we’ve found to be the critical factor in achieving the best healthcare outcomes for individuals and the total plan population, is the willing participant.

THE CRITICAL ELEMENT: THE WILLING PARTICIPANT

To be most effective in improving health—reducing the need for medical interventions and eliminating much of the cost of care provided in the plan—health plan participants must be more than passive recipients of services. Instead, plan participants must be actively engaged in improving their health and the effectiveness of the healthcare services they receive.

Evidence of the unwilling or noncompliant participant is all around. In its study of patient noncompliance, the Journal of the American Osteopathic Association cited findings from World Health Organization analyses on the extent of the problem:

• Approximately 125,000 people with treatable ailments die each year in the United States because they do not take their medication properly.
• 10% to 25% of hospital and nursing home admissions result from patient noncompliance.
• 50% of prescriptions filled for chronic diseases in developed countries are not taken correctly, and as many as 40% of patients do not adhere to their treatment regimens.

Additional research reported in the Journal of the American Medical Association highlighted the problem of patient noncompliance with prescribed preventive care regimens, finding that only 55% of high-risk individuals received lung cancer screening. The rate is even lower among other groups.

To address the problem of patient noncompliance, providers must increase their focus on engaging the person consistent with treatment recommendations.

Experts from the Department of Family Medicine and Population Health at Virginia Commonwealth University focused on the patient as willing participant in their study of patient engagement. The authors affirmed that patient engagement is important to healthcare decision making, health behavior change and chronic disease management, and they highlighted several studies. Some conclusions:

• When it comes to medical decisions, only by engaging the plan participant (patient), taking into account their values and preferences, can a good medical decision be made, where benefits outweigh the harms. “Chronic disease management and health behavior change must be done by the patient. Without complete buy-in and understanding of care and needed changes, a patient will not be able to effectively manage their health. Ultimately, the patient must suffer or enjoy the outcomes associated with any medical decision, test, treatment or health behavior change.”
• In an international study of patients with complex health needs, countries with higher levels of patient engagement had better quality of care, lower medical error rates and greater satisfaction in the experience of care.
• Better patient engagement increases patient perception of control, increases trust and decreases uncertainty.
• Specifically engaging patients in healthcare decision making results in multiple benefits, including higher patient satisfaction with their care; greater patient knowledge about their conditions, tests and treatment; more realistic expectations about benefits and harms; and increased likelihood that patients adhere to screening, diagnostic or treatment plans.

Among all aspects of participant engagement, behavior change is particularly important to improving health. Studies have shown that unhealthy behaviors account for 35% to 50% of premature death and substantial morbidity in the US.

Increasing plan participants’ adherence to healthcare recommendations is particularly important as individual behavior change is key to improving individual health, and therefore the health of the population, which lowers the healthcare costs of the population.

In other words, participant engagement toward improved adherence to health recommendations and behavior change is key to fully achieving the goals of the health benefit plan’s healthcare management program.

THE CHALLENGE: ENGAGING THE PARTICIPANT IN DECISION MAKING, BEHAVIOR CHANGE

If behavior change is important to both individual participant and population health, and participant engagement in decision making leads to greater participant adherence to treatment plans and behavior change, then shouldn’t clinicians do more to engage plan participants in decision making?

In reality, both clinicians and participants would like to see greater participant engagement in decision making. Studies say two-thirds of patients would like to share medical decisions with their providers, but it happens less than half the time—there are constraints on the clinician-patient relationship that make it less likely. Poor communication between clinicians and participants is one problem, as is the lack of adequate time for the clinician to be effective in engaging the patient.

There are several strategies that can be used to achieve greater participant engagement toward medical compliance and behavior change. An example is communication and coaching that leverages the participant’s personal values and goals to build intrinsic motivation for sustained better health. Such development can serve the patient for life.

Setting aside the reasons clinicians are generally ineffective in engaging participants in decision making and behavior change, Curally recognized that participant engagement generally doesn’t happen.

To fill the void, Curally established a team of medical professionals and strategies to complement existing care plans with additional services, including personalized, often intensive communication and coaching.

For many health plan participants, compliance with provider-recommended treatment plans is difficult, especially recommendations requiring behavior change. Plan participants with more complex or chronic conditions, with higher health risks and modifiable behaviors will therefore receive individual, often intensive attention, recognizing the participant’s personal situation and values and addressing the needs accordingly.

The process is really one of relationship building. Participants and Curally’s clinicians develop trust in each other, creating a professional bond that increases the participant’s engagement in decision making. It also fosters an intrinsic desire in the participant to do what is necessary to improve their health.

It is hard work, but, as Curally has found, the payoff can be enormous. The value, in terms of personal gain in health, productivity and quality of life, is priceless. The value to the plan is also large but perhaps more quantifiable, both in terms of employee satisfaction and reduced cost—upwards of 5-to-1 return on investment.