Summary: Medica Health Plans, a Minnesota-based insurer, launched a health coaching program in June 2008 to support its members in strengthening their self-management skills and achieving their health goals. The program has reduced health care expenditures, inpatient utilization, and emergency department usage, while increasing enrollees' self-reported quality-of-life scores and satisfaction ratings. Expanding the program to other health care organizations will require investment by employers, government, and private insurers, as well as cooperation from providers who play a key role in encouraging patients to participate in such programs.
By Sarah Klein
Issue
Preliminary research suggests coaching patients on how to become more engaged in managing their health can both improve health outcomes and reduce inappropriate health care utilization.[1] Many health care organizations and health plans are now investing in coaching programs as a means of accomplishing both. These programs often differ from traditional disease management programs, which tend to focus on patients with a specific condition or a high disease burden and encourage them to follow treatment guidelines. In contrast, health coaching programs are designed to motivate patients to engage in self-care. Many of these programs operate on the premise that increasing patients' confidence— to manage their health by setting and achieving their own goals—will have a more lasting and dramatic effect on outcomes and utilization than other approaches.
Organization
Medica Health Plans (Medica) is a Minnetonka, Minn.–based insurer serving more than 1.6 million members in Minnesota and neighboring counties in Wisconsin, North Dakota, and South Dakota through programs offered to individuals, employers, and government programs. Its network includes 27,000 providers in more than 4,000 offices, clinics, and hospitals.
Objective
In June 2008, Medica launched a health coaching program designed to improve the health and lower the cost of care delivered to its commercial members who are fully insured and its Medicaid-covered members, a total population of 392,000 people.[2] The voluntary program, which begins with an assessment of members' willingness and preparedness to engage in self-management, assigns a health coach to those identified through claims and health risk assessment data as likely to be high-cost consumers of health care services in the coming year.
The health coach helps such individuals identify long- and short-term goals for health improvement and supports them in achieving those goals. Unlike traditional disease management programs, the health coaching model encourages members to set their own goals and the direction of the program. The coach does not provide medical advice, but is instead trained to use motivational techniques to identify member goals and provide support in achieving them. "We allow the member to drive the agenda," says Leslie Frank, Medica's senior director of health improvement.
Population Served
To identify members who may benefit from such a service, Medica uses the Johns Hopkins ACG System, a predictive model designed to help case management and disease management programs identify patients or health plan members who suffer from a high disease burden before they become high-cost utilizers of health care services. Medica uses the algorithm to review claims data monthly on its fully insured members. It also uses health risk assessment data to identify candidates and invites members to refer themselves to the program. Through these methods, Medica has identified 11 percent of its members who may benefit from its health coaching service. Although the program does not limit enrollment by condition, many participants suffer from diseases such as depression, diabetes, hypertension, multiple sclerosis, and fibromyalgia. Of those offered the opportunity to participate in the program, which is free of charge, roughly 20 percent choose to enroll. At any given time, there are approximately 4,000 members using this service. For many of these members, "the biggest challenge is time. People don't feel they have the time to invest in themselves," Frank says.
Staffing Model
Medica employs 28 health coaches, some on a part-time basis. All have at least a bachelor's degree and a health background. Many are trained as psychologists, nurses, exercise physiologists, or nutritionists—professions that emphasize effective communication and empathy. The health coaches are paid between $50,000 and $60,000 per year.
Each coach undergoes 300 hours of training through a program created in partnership with the University of Minnesota's Center for Spirituality and Healing on how to talk with individuals about taking a more active role in their health and how to support health behavior changes. The training is provided by internal staff and external consultants who have a background in health behavior change and motivational interviewing, as well as in specific heath conditions. The training covers clinical research and guidelines for coaching, recruitment and enrollment strategies, theories of behavior change, effective communication strategies, and guidance on finding community resources. The health coaches, who have a caseload of approximately 150 to 175 members, also participate in health coaching case rounds.
Process
Once Medica has identified a member who might benefit from the program, he or she receives a personalized letter from a health coach inviting him or her to participate. The letter, which emphasizes the value of the program by noting that if the individual attempted to purchase the same service in the marketplace it might cost as much as $100 per session, encourages the member to contact the health coach by telephone or e-mail. The letter promotes the benefits of improving health through better self-management and lifestyle changes but does not mention any specific medical conditions. If the member does not respond to the invitation within two weeks, the health coach makes two or three calls to see if they are interested in participating.
"Through the whole process we are able to reach our goal of 20 percent participation, which was significantly improved from where we were," Frank says. Previously, Medica had a traditional disease management program that attracted only about 5 percent of the target population.
Of the 80 percent who decline the offer, many say they are interested in the program, but don't have the time to take advantage of it. They often ask the coach to keep them on the list and contact them again in a few months. Pushback from members is extremely rare. "We had one guy who was suspicious of why a health plan would do this. But that was one guy," Frank says.
Once a member has enrolled, the health coach contacts him or her to introduce the program and conduct a 20-minute interview designed to help the coach assess the health challenges the member faces and his or her level of motivation. This and all subsequent contacts are made through telephone calls. To assess members' motivation, the coach administers the 13-question patient activation measure developed by researchers from the University of Oregon to determine a patient's level of confidence in managing his or her care (see In Focus for more detail). "That then gives us a score on somebody so we can really see are they highly activated and very engaged in their health or are they not activated and not very engaged in their health," Frank says. Members who are less activated often say things like "I just don't know what I can do. There is nothing I can do to manage this condition."
The conversation helps the patient to focus on his or her unique challenges. "That really launches a discussion about setting goals and what the member really wants to accomplish," Frank says. To help enrollees focus on achieving their goals, all receive a Medica-produced workbook that describes how to make health behavior changes, encourages them to become more self-aware of their behaviors, and suggests ways to increase their ability to manage stress.
At this stage, participants set long- and short-term goals. If, for example, someone would like to become more active through exercise or would like to lose weight, the health coach encourages him or her to think about interim steps to achieving those goals. The focus is on helping members achieve success early and often so they develop confidence to take on problems that are more challenging.
Participants determine the frequency of contact with the coach. "If the member really feels their confidence and their motivation level is low and they need a lot of support, they may want weekly calls at first," Frank says. Other members, who are more self-directed, check in monthly. "We allow a lot of flexibility, but we do see a heavier concentration of calls in the beginning. As they gain confidence, it wanes out," she says.
To encourage success, the coaches pay close attention to how a person's behavior, emotions, and mood are affecting their health choices. The coach also attempts to link health behaviors to intrinsic values. "If you can hit on a sort of personal chord—there are a lot of early-on discussions about what is meaningful to members—it is almost like, they say, 'O.K., I've got to make time for this,'" Frank says.
To gain the trust necessary to make such changes, Frank says, coaches must remain non-judgmental in their communication, a point Medica emphasizes in its training. She says this often surprises members. They say things like, "Oh, I can tell you I ate a Big Mac and you are not going to yell at me." A coach is more likely to ask what precipitated the decision to eat Big Mac. "We're not here to lecture," Frank says.
Coaches may also help members improve communication with providers. They help them formulate questions, such as whether there is an alternative to a medication or treatment plan they oppose. If the member requests it, the health coach will send a report to the participant so that he or she may present it to the doctor. Only on rare occasions will the health coach communicate directly with the medical practice. "We want to teach them self-coping and self-management skills," Frank says.
Participants have said they value the non-judgmental approach of the health coaches. In video testimonials, they describe how they have improved their eating habits and increased their daily exercise. Others have reported improvement in the management of diabetes.
On average the relationship lasts six months. Highly motivated members are often finished with the program in three months, but those who have multiple health issues and/or start with a low activation score may remain in the program for as long as 18 months. The goal is to improve the member's sense of self-efficacy as quickly as possible. "The concept is to teach the member to fish and encourage them to go out and fish on their own. We don't want to be here forever," Frank says. Many members terminate the relationship themselves when they feel confident they can manage their goals on their own, Frank says. Those who complete the program receive a $75 gift card, which can be used in one of more than 200 retail stores.
Results
To assess the program's impact on patient outcomes and cost, Medica measures: how long people stay in the program, how many calls people receive, the number of members who engage in the program, and their progress toward attaining their goals, as well as the program's effect on inpatient and outpatient utilization. The insurer also collects data from members on quality-of-life, self-perceived health status, and satisfaction ratings, and it monitors changes in health behavior, as reflected by fruit and vegetable intake and daily exercise.
"A lot of what we are trying to do right now is really figure out what are the key measures that tell us how effective the program is. Now we have enough data to start to really measure that," Frank says.
An early evaluation of the program, which compared its impact on inpatient utilization, emergency department visits, cholesterol values, body mass index, and self-reported improvement in patient activation scores, found that in the first six months of the program members who engaged with a health coach reduced their inpatient utilization by 18 percent compared with similar members who did not engage with a coach. Emergency department visits fell by 12 percent in the intervention group. Quality-of-life scores improved for 81 percent of participants. Forty-five percent showed improvement in cholesterol values and 42 percent demonstrated a reduction in body mass index. Two-thirds of the participants, or 66 percent, reported an improvement in their patient activation score.
The members' health care expenditures dropped by $139 per member per month after six months. Even with the cost of training materials and staff, Medica broke even on the program, Frank says.
While these measures represent preliminary results, Medica expects to complete a more extensive evaluation of the program by the first quarter of 2011.
Next Steps
Medica is looking into ways to expand the program to cover children and teens. It is also considering ways to increase the number of patients who receive the service by introducing group coaching.
To find ways to increase participation in the program, the insurer is also experimenting with the location of health coaches. It has placed one health coach in a suburban medical practice and another in an inner-city clinic. Early results suggest placing a health coach in a medical practice helps to improve referrals to the program by making it more visible to providers. The insurer has also placed a health coach at an employer's on-site wellness clinic.
Medica also plans to conduct more research using the data it has already collected on goal attainment. Such research may help the insurer determine whether the goals members select are having a significant impact on health outcomes and whether the patient activation score can be tied directly to outcomes. The insurer would also like to know whether members who have only partially met their goals still achieve health benefits and more appropriate health care utilization. "Maybe somebody who partially meets the goal has just as good outcomes as if they meet the goal," Frank says.
Implications
Health coaching represents a significant departure from disease management programs, which tend to focus on patients with specific chronic diseases and those with the highest disease burden. In contrast, a health coaching program is directed by patients with minimal guidance from the coach. "Even if we knew a member had diabetes and hypertension and depression, we weren't feeding them those goals," Frank says. As such it requires a shift in philosophy and approach. "It is such a different philosophy. In health care, we are helpers; we want to help fix things. To give that control up to the patient and allow them to drive it is scary," she says.
Medica's leadership believes such a shift is justified because its results suggest patient confidence rather than disease burden is a more significant predictor of cost savings. In the health plan's experience, coaching a member who has a serious condition but is highly motivated to manage his or her care (and is following the doctor's advice and treatment recommendations perfectly) is not likely to make a large difference in outcomes or cost. It sees greater opportunity for improvement among members who are not motivated to engage in self-care, even if their health conditions are less dire. Health plans that focus their attention on members with the highest disease burden alone may miss this opportunity. "It's a little counterintuitive," Frank says.
Medica's research has also found little to no correlation between the severity of illness and a patient's level of motivation or confidence. "We have seen very, very sick, complicated people who are level four, meaning they are very activated. They really understand how their behavior affects their health and their outcomes whereas you can see a very healthy person be a level one—a low level of activation. They don't understand that their eating a Big Mac is contributing to their health."
Despite the potential benefits, there are still significant challenges to expanding the coaching program. Placing health coaches in medical practices provides visibility for the program and improves the referral rate, but it is a logistical and financial challenge because many medical practices treat patients from different insurers. Extending the model may require health care providers to hire coaches for their full panel of patients. This requires concerted cooperation among insurers to financially support this practice. Another possibility is for self-insured employers to finance the service through a per-member per-month fee, a practice Medica already encourages.
Providers have been generally appreciative of the program when they see it in action, Frank says. "They recognize that they are not delivering this type of service and that their patients really need it," Frank says.
Gaining such widespread support may require more research. "Even though our preliminary results and studies have shown that is a very effective intervention, it is kind of a leap of faith," Frank says.
Contact: Leslie Frank, senior director of health improvement at Medica, [email protected].
Notes
[1] R. Q. Wolever, M. Dreusicke, J. Fikkan et al., Integrative Health Coaching for Patients with Type 2 Diabetes: A Randomized Clinical Trial, The Diabetes Educator,
July/August 2010 36(4):629–39; D. E. Wennberg, A. Marr, L. Lang et al., A Randomized Trial of a Telephone Care-Management Strategy, New England Journal of Medicine, September 2010 363(13): 1245–55; S. Butterworth, A. Linden, W. McClay et al., Effect of Motivational Interviewing–Based Health Coaching on Employees' Physical and Mental Health Status, Journal of Occupational Health Psychology, October 2006 11(4):358–65; and C. N. Melko and P. E. Terry, Diabetes Health Coaching Improves Medication
Adherence: A Pilot Study, American Journal of Lifestyle Medicine, March/April 2010 4(2):187–194.
[2] In fully insured plans, the health plan provides coverage for a fixed annual premium. In so doing, the health plan bears the risk if claims for health services exceed premiums. In self-insured plans, employers pay companies such as Medica to administer the claims, but the employer assumes responsibility for paying those claims. Medica offers the program to its 350,000 self-insured members on a per-member, per-month basis. Approximately half of its self-insured customers purchase the program. The service is also offered to approximately 2,000 dually eligible for Medicare and Medicaid or in special needs plans.
This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution.
The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.
