Putting Personalized Healthcare on the Line

Putting Personal Health Management on the Line

Reprinted with permission, Managed Healthcare, July 1997.

In November 1879, the British journal Lancet recognized the first application of medical advice rendered over the telephone; just three years after Alexander Graham Bell invented the device.

While the true power of this provider-patient communication was not recognized at the time, it opened the door for an increasingly powerful application of a common household appliance. Today, the power of the telephone in rendering medical advice is evident among the many medical call centers across the United States.

This movement has given rise to a new care management strategy now known as "personal health management." Call centers represent the principle delivery point for personal health management and an important form of leverage for hospitals and health plans that accept risk and responsibility in caring for patients.

Creating value in healthcare

According to Stuart Goldberg, an analyst with Merrill Lynch &Co., medical call center programs are growing at a rate of more than 25%per year and could swell from the 35 million members currently served to more than 100 million in the next four years

National conferences on building and managing call centers are sustaining the momentum for new programs, while requests for proposals from potential purchasers are requiring the capability in place as a condition of a contract

This industry momentum illustrates the benefits of call centers by:

  • Increasing member satisfaction by affording access to healthcare inflation 24 hours a day;
  • Supporting the organization's goals toward quality improvement and accredited status and
  • Controlling costs by ensuring the member's proper use of resources.

Looking at these benefits has caused personal health management to be heralded as a model for the future of health-care delivery: one that allows plans to move away from the perspective of a "gatekeeper" to that of a "gateway" to the medical system, ensuring access to care for those who need it.

Personal health management programs allow an organization to offer this form of one-stop shopping" while demonstrating the provider's fiscal responsibility for managing care.

The philosophy of personal health management is to take proven population and public health initiatives and to apply them selectively at the individual level, using the call center as the conduit to access the healthcare delivery system.

In fact an effective PHM program can be as important in getting a contract as it is in servicing it. Whether the provider is capitated for care or not, organized payees are motivated to work with one provider across the continuum.

By demonstrating the ability to manage an integrated network of facilities and services, yet still be able to respond to the unique, individual needs of each patient/member, network sponsors are strategically well-positioned for future challenges in the landscape of managed care.

Fiscal responsibility through personal health management

The economics of personal health management are compelling. In a recent study of calls to the Phoenix-based National Health medical Call Center, for example, 62% of those requesting emergency care, or indicating they might need it, were redirected to appropriate lower cost alternatives.

Similarly, 56% of those seeking immediate contact with their physician were advised they could safely wait 24 hours before seeking care.

To validate the true savings associated with personal health management programs, it is critical to move beyond reports on redirection and to focus on bottom-line measures. Many studies have supported the claim that personal health management works:

  • A provider-based health plan in the Midwest demonstrated a 3-to-1 return on investment from personal health management due to redirected ER visits.
  • A health plan in the Pacific Northwest tracked a reduction in emergency room visits from a Medicaid population to 16 visits per 1,000 members per month, down from 60 visits per 1,000 members per month two years earlier.
  • A national health plan validated $450,000 saved per month from a member base of 425,000; they are now expanding the program nationally to all regional health plans.
  • Personal health management actually can lower the cost of providing care for populations in ways that previous efforts at cost cutting cannot.

Phone calls are less expensive than office visits, and often are more appropriate as well.

Many other efforts at managing cost were introduced under the auspices of "managing care," but what they introduced was a onetime shift in medical costs.

A quality, humanistic alternative

Recognizing the myriad of problems with access to care, the federal government and several states are considering the Access to Emergency Services Act, in which any patient can be assured coverage for an emergency room visit if they present symptoms that a "prudent layperson" reasonably could expect to result in serious impairment to their health.

The legislation would further prohibit all health plans from requiring prior authorization for care before allowing members to receive it. But the bill would do little to solve the problems of overcrowding or unnecessary visits

A comprehensive effort at personal health management applied on a population basis can introduce the discipline required for true management, of care toward improved heath status at lower overall cost.

Future applications

The future of personal health management projects will be limited only to the creativity of program sponsors. Some specific applications include:

  • Support of disease management initiatives

    Recognizing that 80% to 90% of medical costs are focused an the needs of 10%to 20% of a denied population, personal health management programs are focusing on the development of critical pathways for managing chronic conditions through call center monitoring.

  • Expanded use of Internet.

    The economies and convenience of conveying information over the Internet have led to an explosion in healthcare programming. Programs already have been developed for asthma, diabetes, congestive heart failure and other common medical conditions for which best-practice guidelines already have been developed.

  • Reduction in workers comp costs.

    As much as 80% of an employer's expense associated With workers' Compensation deals not with medical costs, but the incremental claims associated with the claim, such lost productivity and temporary replacement workers.

  • Integration of medical triage and emergency transportation

    Preventing necessary 911 calls and ambulance trips represents a new frontier for many health care providers. The combination of a triage and transport program not only guarantees the right care in the right setting but also ensures the right level of transport to get there.

  • Protection of medical savings account investments.

    MSA's are a tax-deferred financial instrument to help plan for and fund major medical expenses. By attaching a personal health management program to an MSA, investors can protect their savings by becoming more actively engaged in managing their health.

  • Improved use of PPO network providers.

    By assuring that members use their designated network of providers. PPOs are able to generate greater savings for their members and their employer-clients. They also are able to compete more effectively with HMOs because persona1 health management programs increase the visibility and value from the PPO relationship.

  • Support of new health plan products

    Recognizing the ad for affordable health plan products for part-time employees, students and other low-wage-earning employees, new products are emerging that are more affordable for small employers or for direct purchase by those who typically could not purchase an individual policy.

Although the current healthcare delivery system has suffered from criticism and controversy, it is encouraging to find a subtle-but effective care management strategy so accommodating to the needs of our current culture and a strategy leverages all stakeholders into the system.

by Ian R. Lazarus Reprinted with permission of the author. Mr. Lazarus may be contacted at irl@creato.com

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