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WHAT TO DO WITH THE "WELL" HALF... AN EXPANDED ROLE OF THE POPULATION MANAGER

May 30, 2013

In the doom & gloom discussions on healthcare finance and the constant media attention on chronic disease it is easy to lose site of one key population-- the “healthy.”  Most American’s are not sick and incur little healthcare cost.  In 2010, the lowest utilizing 50% of Americans accounted for only 2.8% of healthcare spending.  By comparison, the top 1% of the population accounted for 21.4% of total cost.(1)  Even when looking just at Medicare, in 2008 the least costly half of the population represented 5% of spending, and the least costly 75% accounted for only 19% of total costs.(2)  There is certainly a cheaper side of the health continuum.


Traditional Population Management, to the extent such a concept exists, does not ignore the healthy segments.  The clinical agenda for this group commonly entails:
 

1. Ensuring compliance with screenings, vaccinations, and preventative care,
2. Regularly re-assessing patient risk to detect onset of chronic diseases,
3. Reducing key unhealthy behaviors, notably smoking, poor nutrition, and to a lesser extent addressing stress and other behavioral health problems,
4. Improving access and convenience to reduce reliance on ERs for acute illnesses, and,
5. In the case of the health plans and employers, helping consumers appreciate the value of the health benefit. 
 

One cannot argue with the above list.  However, is it enough, and, is there more value to be captured?  In the wake of healthcare reform, provider-risk sharing, and growth of healthcare consumerism, perhaps this agenda should be expanded to include:
 

1. Creating a health culture vs. simply health engagement. 

​Most Population Managers have a myriad of statistics to demonstrate how the masses are “engaged.” Metrics often include the percent of patients who have taken a Health Risk Assessment (HRA), participated in a wellness program, or logged into a clinical portal.  These activities are all good things, but realistically are superficial indicators of “culture” at best.  (Not to mention consumers often receive financial incentives for performing these tasks.)  For example, 65% of employers in 2012 report they have workplace health improvement and wellness programs in place.(3)  Would you characterize the majority of American workplaces to truly be fostering a wellness culture?  Me neither.  However, it can be.  Employers like Gentle Giant, William Gallagher & Associates, and others have created self-sustaining environments where being healthy is part of the job.(4) This can and must be more pervasive. 


2. Building trust in the healthcare system and establishing a primary care relationship. 

Even healthy people see the doctor and use the pharmacy at some point over the year.  Per AHRQ, 72% of Americans annually incur an office-based medical provider expense, and 61% have some prescription medication expense.(5)  According to the Commonwealth Fund: “People who have access to a regular primary care physician are more likely than those who do not to receive recommended preventive services and timely care for medical conditions before they become more serious and more costly to treat. Having a regular doctor is also associated with fewer preventable emergency department visits and fewer hospital admissions, as well as with greater trust in and adherence to physicians’ treatment recommendations.”(6) Thus, fostering effective doctor-patient relationships, including long-term health goal setting, can not only reduce costs today, but put the infrastructure in place to begin managing chronic illness early in its onset going forward.
 

3. Making wellness contagious, and mobilizing the majority. 

​Healthy people in a community are an asset.  There is an emerging body of literature, including the work of Nicholas Christakis and James Fowler, that suggests that certain health behaviors, notably smoking and obesity, may be “contagious.”(7) Contagious in this context means behaviors seen in one person are often adopted by others with whom the interact, i.e., they are "transmitted" from one person to another.  Companies and their wellness vendors are attempting to foster this transmission of positive behaviors via team wellness competitions and other gamification programs.(8)  They are also establishing or encouraging the use of online health social networks, where peers can help and encourage one another.(9)  In fact, so called peer-to-peer healthcare is not a niche phenomenon.  According to PEW, “One in four internet users living with high blood pressure, diabetes, heart conditions, lung conditions, cancer, or some other chronic ailment say they have gone online to find others with similar health concerns.”(10)  Rather than simply engaging the well, Population Managers need to mobilize them to make the sicker healthier, and keep the healthy healthy longer.

4. Laying the ground work for innovative clinical programs when they are needed. 

Getting millions of people to do anything is tough, just ask any consumer marketer.  Getting people to change health behaviors when they are sick can be particularly challenging.  In fact, most chronic illness is the result of years if not decades of bad habits, many of which are pleasurable.  Yet, at the so called “teachable moment” of disease diagnoses, Population Managers ask consumers to change eating habits, actively self-monitor bio-metrics, and regularly research and remain current on their disease, along with many other things.  Wouldn’t getting consumers accustomed to these activities, e.g., health tracking, online health research from reputable sources, smart food shopping, be easier if it didn’t need to happen all at once and during a particularly stressful time?  Would getting consumers to wear FitBits® today prepare them for remote home monitoring tomorrow, if it doesn’t forestall the hypertension and diabetes all together? Does getting consumers used to interacting with physicians online for sinus infections today position them as future tele-health users for more serious conditions in the future?  While research is still needed on this topic, my gut is yes.
 

5. Listening and learning about the consumer. 

​By definition, tomorrows “Chronics” start as today’s “Well.”  While certain things about a person change over time, others do not.  The actionable consumer segmentations created today will be the framework on which future cost-containing Population Management programs will be built. Fortunately, in the age on the online consumer and Big Data, getting this level of consumer insight is easier than ever.   For example, innovative vendors are culling through User Generated Content on the Internet to distill the voice of millions of people in actionable insights for pharmacos.  Going forward, knowing what makes the consumer tick and how to change that wiring may be a key element in reducing chronic disease costs, as much as the chemist’s drug or the surgeon’s knife today.  Building this knowledge base will take time, so the time to start is now. 
 

6. Monetizing the relationship as appropriate. 

Providers and Health Plans have a transactional relationship with healthy consumers, have multiple touch points (online, in-clinic, phone, mail), and have brand loyalty.  This can used to generate revenue from consumers in numerous ways—all of which could be accretive to the brand.  Some ideas include self-pay services (e.g., cosmetic procedures); higher tiers of service such as concierge-lite models (e.g., Privia Health); direct product sales such at OTCs, health & beauty, wellness tools; and most obviously for payers, ancillary insurance & financial products.  There are many more.


As with anything in life that is worth doing, the above list is not easy.  However, we are not talking about a sliver of the population, but the majority.   The advantage of doing so is multifaceted:
 

1. Reduce the long term risk of the population, as some of today's low cost members are tomorrow’s high-cost ones,
2. Create infrastructure leveraging the scale of the well to serve all patients, including those where cost compression opportunities exist today,
3. Maintain an actuarially viable risk pool, and,
4. Generate some new revenues, while at the same time building the consumer brand.
 

Much talk is given to changing US medicine from a “sick care” to a “well care” model.  In doing so, let’s make sure serve the “well” in the process.

1. Cohen SB.  “The Concentration & Persistence in the Level of Health Expenditures Over Time.”  AHRQ MEPS, Nov 2012.
2. MedPAC.  A Data Book, Health Care Spending & the Medicare Program.  Figure 1-10.
3. Health Plan Week, September 24, 2012, p. 5, citing survey of Sept 17, 2012 by Aon Hewitt. 
4. Regan K.  “Healthiest Employers: Wellness ‘part of our culture now.’” Boston Business Journal, Mar 29, 2013.
5. Carper K et. al.  “National Health Care Expenses in the U.S. Civilian Non-institutionalized Population, 2010,” AHRQ MEPS, Jan 2103. Fig 2.
6. Abrams M et. al.  “Realizing Health Reform’s Potential.”  The Commonwealth Fund, Jan 2011.  
7. Christakis NA and Fowler JH. Two articles: “The Collective Dynamics of Smoking in a Large Social Network,” N Engl J Med 2008: 358:2249-2258, and “The Spread of Obesity in a Large Social Network over 32 Years,” N Engl J Med 2007; 357:370-379.
8. Sammer J. “Launching a ‘Winning’ Wellness Contest.  Society for Human Resource Management, Dec 3, 2012.
9. Deloitte.  “Issue Brief: Social Networks in Health Care: Communication, collaboration, and insights.”  2010.
10.  Fox S. “Peer-to-Peer Healthcare.”  Pew Internet & American Life Project. Feb 28, 2011.

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