American Institute for Preventive Medicine
 

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Implementing a Self Care Program
Effect on Employee Health Care Utilization
by Don R. Powell, Ph.D., President, American Institute for Preventive Medicine
Stephanie L. Sharp, B.S., Senior Consultant, Health Education Department, Capital Blue Cross
Shelley D. Farnell, B.A., Consultant, Health Education Department, Capital Blue Cross
P. Timothy Smith, M.P.A., Health Care Project Analyst, Pennsylvania Blue Shield

Abstract
This study presents the results of a self-care program that was conducted by a large insurer for a manufacturing company. The claims data for 371 employees was analyzed over one year time periods both pre- and post-distribution of a self-care guide. The results show that the frequency of physician office visits was reduced by 18.4 percent while emergency room visits decreased 19.8 percent. The 12 month outpatient savings was $39.65 per employee which amounted to a 24.4 percent decrease in costs. An analysis of all 938 subscribers (employees along with their dependents) showed a 12 month outpatient savings of $26.72 per subscriber or a 21.5 percent reduction in costs. The frequency of physician visits for the entire subscriber group was reduced 12.2 percent while emergency room visits declined 9.5 percent.

Introduction

The High Cost of Health Care
In 1995, the cost of health care in the United States totaled $1,008 billion, which represented 14.1% of the Gross Domestic Product (GDP) 1. In addition, companies paid an average of $3,821 per employee for health care costs compared to $3,741 in 1994 2. Although this represented only a 2.1% increase in costs, the need to lower health care expenses is paramount to the financial health of corporations in the United States.

Managing the Demand for Services
One way to reduce employer health care costs is by reducing the demand for services. This can be accomplished by teaching employees to make more informed decisions about when they should seek medical assistance, what type of assistance they should seek and when they can treat themselves at home using self-care.

In 1993, Americans went to hospital emergency rooms 97.4 million times 3. It has been estimated that 55.4% of all these emergency room visits were for non-urgent conditions such as headaches, sore throats and stubbed toes 4. Since the cost for the same procedure is about 3-4 times higher in an emergency room than in a physician's office, money is being spent needlessly.

In addition, many people seek professional health care for problems that could be treated at home using self-care. According to the National Ambulatory Medical Care Survey in 1992, there were approximately 762 million visits (about 3 visits per person) to non-federally employed, office-based physicians 5. It is estimated that 25% of these visits or 190.5 million are unnecessary 6.

Other Benefits of Self-Care There are other benefits of teaching consumers to make better health care decisions in addition to reducing unnecessary utilization. Consumers will feel more empowered when they are involved with medical decision making. It can also lead to increased patient satisfaction while improving the overall quality of care. Finally, self-care can save time. Almost all consumers at some point have been frustrated with having to wait in a doctor's office or emergency room reception area.

Literature Review Although there has been a good deal of attention given to self-care publications over the past 5 years, the concept is hardly new. In 1747, one of the first self-care books, Primitive Remedies, was written by Reverend John Wesley, founder of the Methodist Church 7. A second self-care book, Domestic Medicine, by William Buchanan, appeared in 1769 8. The 1970s saw the publication of 3 major self-care books, Course for the Activated Patient and How to be Your Own Doctor Sometimes by Keith Sehnert and Our Bodies, Our Selves by the Boston Women's Health Collective. These latter books served as a basis for many of the self-care books used today 9,10,11.

Although self-care has been used for centuries, the impact of self-care interventions was not thoroughly investigated until the 1980s. Three studies conducted in HMO environments demonstrated a reduction in health care services after the implementation of a self-care program. Moore et al demonstrated a 21-24% decrease in physician office visits 12. A study by Kemper et al showed a 11% decrease in clinic visits and a 35% decrease in referrals to physician specialists, but no reduction in total costs 13. Vickery et al demonstrated a 17% decrease in first doctor visits for minor problems and a 21% decrease in visits due to upper respiratory infections for an intervention consisting of a self-care book, telephonic nurse advice line and monthly wellness newsletter 14.

Self-care has also proven to be cost effective in groups comprised of mature adults. Vickery et al demonstrated a savings of $30.29 per person with a Medicare population group 15. Leigh et al found that claims decreased by $74 per person in the experimental group while they increased $266 per person for the control group 16.

Employees of corporations and hospitals can also benefit from self-care. Powell et al demonstrated a $75.30 per employee savings in 5 months in a hospital setting due to a reduction in physician office and emergency room visits. The hospital's Return on Investment (ROI) was 55:1 17,18. In another study, Powell found that a self-care program in a manufacturing company reduced the number of limited duty assignments due to medical reasons. This decrease in the number of such assignments saved the company $331,878 in one year 19.

Methodology

Study Population
The study site was Berk-Tek, Inc., a manufacturer of copper and fiber optic data communication wire and cable based in New Holland, Pennsylvania. The total employee population was 371 and consisted of 134 females (36%) and 237 males (64%). The average employee age was 36 years. Berk-Tek is an experience-rated employer group, i.e., the company's health care costs reflect utilization specific to their own employees and their dependents. The only other occupational health and safety programs conducted at Berk-Tek include those required by the Occupational Safety and Health Administration (OSHA). There has been no involvement by an occupational health nurse in providing these programs.

The study was conducted by Capital Blue Cross and Pennsylvania Blue Shield (CBC/PBS) of the Harrisburg, Pennsylvania, area. CBC/PBS is a health insurer that serves approximately 1.5 million members in 21 counties in Central Pennsylvania and the Lehigh Valley. The company currently markets traditional indemnity coverage, HMO coverage through Keystone Health Plan Central and Point of Service programs. As an adjunct to health coverage packages, CBC/PBS offers customers health promotion and disease prevention educational resources to assist them in maintaining or achieving good health.

Selecting the Self-Care Publication
To complement existing educational resources, CBC/PBS wanted to identify a medical self-care guide to make available to customers. The criteria for booklet selection were finding a guide effective in assisting readers to correctly assess the level of medical care needed when ill or injured and controlling health care costs associated with acute care medical visits and emergency room use. The American Institute for Preventive Medicine's HealthyLife Self-Care Guide was chosen as the medical self-care resource to be used in the study 20. This booklet contained 64 pages and presented 25 of the most common health problems including colds, flus, backaches, coughs, headaches, fever, sore throats, nausea and chest pain. It also contained information on how to communicate effectively with health care providers.

Study Site Requirements
To become eligible to serve as a study site, Berk-Tek, Inc., was asked to provide the following program support:

  • Offer time for employees to attend an educational program that would introduce the concepts of medical self-care and allow for distribution of the HealthyLife Self-Care Guide publication
  • Assist CBC/PBS in promoting the program and generating interest among employees
  • Review program promotion materials and distribute communication materials to employees
  • Organize/assign employees into groups of 25-30 and inform them of their program meeting time
  • Help CBC/PBS evaluate the program by distributing final evaluations to employees six months following the program
  • Provide incentives, i.e., items with the company logo, to employees to take their book home and keep it readily accessible so it is available for reference
  • Sign a partnership agreement to demonstrate commitment to the program

Researcher Requirements
Capital Blue Cross and Pennsylvania Blue Shield agreed to provide the following program support:

  • Prepare program promotion and communication materials and provide materials to Berk-
  • Tek for review and distribution
  • Present program to employees in class sizes of 25-30 participants
  • Emphasize the key to program success is using the book as a resource at home
  • Provide a copy of the guide for all participants

Self-Care Program Workshop
Employees were scheduled to attend a 55 minute on-site medical self-care workshop and were provided a copy of the guide. The workshop informed employees about concepts in medical decision-making and prepared employees to utilize the guide. Classes were scheduled in a company conference room for all three shifts: 7:00 am - 3:00 pm, 3:00 pm - 11:00 pm and 11:00 pm - 7:00 am. Designed as an interactive experience, the workshop consisted of lecture, discussion, group activities, and a question and answer period.

Workshop sessions were conducted by health education consultants from Capital Blue Cross whose backgrounds include health education, communication and public health both on the undergraduate and graduate level. None of the instructors have nursing backgrounds.

Throughout the workshop, care was taken to inform participants that the HealthyLife Self-Care Guide program was designed to assist participants in seeking appropriate medical care. Examples of appropriate medical care included both the avoidance of emergency room treatment for common illnesses such as a sore throat, and the need for emergency treatment for life-threatening situations that may appear harmless. The danger of mistaking a heart attack for indigestion was one example given to show how knowing when to seek appropriate medical care could save a life.

Additionally, participants were instructed to consult their doctor if, after a reasonable amount of time, they did not find relief from one or more of the self-care procedures outlined in the guide. This point was stressed several times throughout the workshop.

Capital Blue Cross/Pennsylvania Blue Shield provided promotional materials personalized for the worksite that were shared with various levels of management. These included supervisor and employee memos, newsletter articles, posters, table tents and incentives. Of the 371 employees, 328 attended the workshops. Employees who didn't attend the workshop did not receive the guide.

Results

Audit of Claims Data
Data was gathered both objectively and subjectively. The objective measures involved an audit of medical claims data. An evaluation mechanism was designed to measure the program's effect on utilization related to acute care medical visits and emergency room use. CBC/ PBS created two separate reports to identify and track medical procedure codes. These reports analyzed employee and subscriber visits to primary care physicians and emergency rooms both pre- and post-distribution of the self-care guides. The reports reflect claims paid during the following comparable one year time periods.

Pre-Distribution of Self-Care Guide: 6/1/93 - 5/31/94
Post-Distribution of Self-Care Guide: 6/1/94 - 5/31/95

During the study period, there were no other changes in the benefit structure at Berk-Tek that could account for the results.

Employee Results
After implementation of the self-care program, the company hired 23 additional employees, making it necessary to normalize the data. Each of the total payments and number of services in each category have been divided by the number of employees at that time and multiplied by 1000 allowing the data from the two periods to be compared. Once the data is normalized to account for the new employees, the results showed that the frequency of physician office visits decreased by 932 visits or 18.4%. All categories of physician office visits showed declines (freestanding lab, accidents, consultations, regular, all other). The 12 month savings was $29,279 or $29.28 per employee. This represented a 23.3% decrease in costs. (See Table 1.)

The frequency of emergency room visits decreased by 100 visits or 19.8%. This produced a 12 month savings of $10,369 or $10.37 per employee. (See Table 1.)

Table 1
Self-Care Analysis Reports for Employees
Non-Inpatient Categories Total Payments # of Services Services Per 1000 Total Payments Per 1000
Before After Before After Before After Before After
Physician Visits & Lab
Lab, Freestanding
$3,798
$2,921
271
274
795
749
$11,270
$7,873
Office visits, all other
$25,650
$25,135
798
718
2,332
1,960
$76,113
$67,749
Office visits, consultations
$1,109
$823
23
17
68
46
$3,291
$2,219
Office visits, regular
$11,789
$6,877
642
506
1,877
1,385
$34,982
$18,536
Sub-total
$42,346
$35,756
1,734
1,515
5,072
4,140
$125,656
$96,376
Emergency Room:
Emergency Accident
$11,885
$6,979
166
125
487
344
$35,267
$18,811
Emergency Medical
$613
$2,933
6
33
17
60
$1,819
$7,906
Sub-total
$12,498
$9,912
172
158
504
404
$37,086
$26,717
Total
$54,844
$45,668
1,906
1,673
5,576
4,544
$162,742
$123,094
# Employees During "Before" Period: 337
# Employees During "After" Period: 371
Time Period - 12 Months Before and 12 Months After Self-Care Program

The frequency of all outpatient visits declined by 1,032 or 18.5%. This averaged a little over 1 fewer visit per employee. The total savings due to the reduction in physician and emergency room visits was $39,648 or $39.65 per employee. This represented a 24.4% reduction in health care costs. (See Table 2.)

Table 2
Employee Self-Care Savings Summary - 12 Months
(Normalized per 1,000 Employees)
Self-Care Group (After) Prior to Self-Care Group (Before) Total Savings Per Employee Savings Percent Saving
Total payments
$123,094
$162,742
$39,648
$3965
244%
Number of Services
4,544
5,576
1,032
103
185%

Subscriber Results
Even though employee dependents did not attend the self-care workshops or receive the guides, data were collected on them as well. An analysis of the claims data for all 938 subscribers (371 employees and 567 dependents) covered by Berk-Tek showed that the frequency of physician office visits decreased by 522 visits or 12.2%. All categories of physician visits showed declines. This produced a savings of $20,514 or $21.87 per subscriber. (See Table 3.)

Emergency room utilization increased by 27 visits or 8.4%, but the total cost was reduced by $6,205 or $6.62 per subscriber. (See Table 3.)

Table 3
Self-Care Analysis Reports for All Subscribers
Non-Inpatient Categories Total Payments # of Services Services Per 1000 Total Payments Per 1000
Before After Before After Before After Before After
Physician Visits & Lab
Lab, Freestanding
$6,749
$4,124
489
422
583
459
$8,210
$4,397
Office visits-all other
$48,484
$49,528
1,790
1,791
2,098
1,947
$58,984
$52,802
Office visits-consultations
$1,757
$1,410
41
37
49
40
$2,137
$1,503
Office visits-regular
$24,608
$18,809
1,300
1,197
1,542
1,304
$29,937
$20,052
Sub-total
$81,598
$73,871
3,620
3,447
4,272
3,750
$99,267
$78,754
Emergency:
Emergency Accident
$19,285
$12,549
271
250
273
273
$23,461
$13,378
Emergency Medical
$1,163
$4,964
18
44
21
48
$1,415
$5,292
Sub-total
$20,448
$17,513
289
294
294
321
$24,876
$18,670
Total
$102,046
$91,384
3,909
3,741
4,566
4,071
$124,144
$97,424
# Subscribers During "Before" Period: 822
# Subscribers During "After" Period: 938
Time Period - 12 Months Before and 12 Months After Self-Care Program

The frequency of subscriber total outpatient visits declined by 495 visits or 10.8%. The total 12 month savings was $26,720 or $26.72 per subscriber. This represents a 21.5% decrease in costs. (See Table 4.)

Table 4
Subscriber Self-Care Savings Summary - 12 Months
(Normalized Per 1,000 Subscribers)
Self-Care Group (After) Prior to Self-Care Group (Before) Total Savings Per Subscriber Savings Percent Savings
Total Payments
$97,424
$124,144
$26,719
$2672
215%
Number of Services
4,071
4,566
495
50
108%

Return-On-Investment (ROI)
The expense to implement the self-care program involved the cost of the guides, staff time to conduct the workshops, employee time to attend the workshops, and the cost of promotional material and incentive gifts. The Guides cost $1.70 per copy or a total of $558.00, staff time to conduct the workshops totaled $1,935, employee time to attend the workshop totaled $2,867 and the materials and gifts cost $275. This amounted to a total expense of $5,635 or $15.19 per employee. When compared to the outpatient savings of $39.65 per employee, the employee Return-On-Investment was 2.6:1. In other words, $2.60 were saved for every dollar spent on the program.

Return-on-Investment for subscribers was even greater. This was because dependents were not given self-care guides and there were no other costs incurred for them. The program cost only $6.01 per subscriber. Since they still demonstrated a savings of $26.72 per subscriber, the Return-On-Investment for all subscribers was 4.4:1 or a savings of $4.40 for every dollar spent.

Employee Evaluations of Self-Care Workshop
In addition to the audit of claims data, participating employees were surveyed immediately following the self-care workshop to determine their satisfaction with the program. The survey consisted of eight quantitative and three qualitative questions and was returned by 99 percent of participants. The results show a high level of satisfaction with the guide and the workshop.

  • 97% of the employees found the workshop to be helpful.
  • 96% of the employees found the workshop to be enjoyable.
  • 89% of the employees reported having a better understanding of when to see the doctor
  • 92% of the employees feel they are wiser health care consumers
  • 73% of the employees think they will need to visit their doctor less frequently
  • 66% of the employees think they will be absent from work less often
Employee Self-Reported Evaluations at Six Months
Employees were also asked to complete a final evaluation conducted six months following the intervention to determine self-reported efficacy using the guide.

  • A three-tiered incentive program was designed to ensure the return of final evaluations.
  • Employees were offered a small promotional item for returning the final evaluation to supervisors. These evaluations did not contain the employee's name, but rather had a code number to ensure confidentiality.
  • Supervisors who received evaluations from all of their employees and returned them to the company benefit manager received a more expensive promotional item. As stated above, these evaluations had a code number and were placed in a box in order to maintain confidentiality.
  • Interested participants registered to win prizes via a telephone-based incentive program. Employees whose names were randomly selected received a call at home and were asked to locate their guides. After successfully answering a simple question reflecting their ability to use the guide, employees were awarded a prize sponsored by their employer. Prizes included: movie tickets, salad bar gift certificates and other health related items. Two hundred and eighteen participants (66%) returned the 22 item evaluation.
Of these participants:
  • 59% reported using the guide before contacting their physician.
  • 61% felt the guide better prepared them for physician visits.
  • 63% stated the guide positively affected their families.
  • 47% felt the guide helped them decide when to see a doctor.
  • 97% felt the guide is a source of good health advice.
  • 86% felt the guide was an invaluable employee benefit.
  • 97% stated the guide was easy to understand.
  • 39% stated the guide helped them save money on medical care during the last 6 months.
  • 59% felt the guide will help them save money on health care in the coming 6 months.

Discussion
The results from the study are noteworthy for a number of reasons. First, the data was based upon an audit of actual claims data. This provides more reliable results than the many self-care studies that use self-reported data to demonstrate a reduction in utilization. Self-reported studies ask participants to recall whether using a self-care guide had helped them to avoid one or more visits to a physician's office or an emergency room. One's subjective responses about utilization are not as valid as the objective data.

Second, the fact that the study analyzed the claims data over two 1 year time intervals is an asset (June 1, 1993 - May 31, 1994 versus June 1, 1994 - May 31, 1995). This enabled the researchers to rule out seasonal factors that may affect health care utilization. For instance, utilization tends to be greater during the winter months due to colds and flus. The one year time period is also of sufficient length from which to make assumptions.

Another important aspect to the research is that the intervention consisted solely of a 64 page self-care booklet and a workshop. A number of other self-care studies appearing in the literature evaluated self-care books in conjunction with telephonic nurse lines, wellness newsletters and workshops. These studies are unable to isolate the impact of the self-care publication and workshop alone. Also, when comparing the cost of a $1.70 booklet and a $13.49 workshop (this figure includes the cost of both staff and employee time) to a book that costs approximately $5.00 per copy, a newsletter that costs approximately $6.00 per subscription and a telephonic nurse advice line that costs about $9.00 per employee per year, the intervention used in this study is less costly to an organization.

Occupational health nurses will find this study of particular interest as many employers are struggling to find ways to reduce health care costs. This study describes a simple, low cost intervention that occupational health nurses and wellness professionals can easily implement. The program can decrease unnecessary health care utilization, thereby reducing health care costs.

The fact that there were no other changes in the benefit structure at Berk-Tek enhances the findings. There were no other incentives or programs available to employees that might account for the findings. Finally, using a pre- and post-research design allowed the study to compare the same people over time.

Plans are currently underway to provide the HealthyLife Self-Care Guide program to new employees and those who missed the original workshop. Ideally, the workshop should be extended to employees' spouses and dependents. This would likely increase the cost savings to the employer.

We have no explanation as to why there was a slight increase in the frequency of subscriber emergency room visits. The fact that the total cost for emergency room visits was lower is more important.

There are several methodological limitations to the study. The first is the sample size. A sample size greater than 371 employees would have made the results even more reliable. The sample size of 938, however, for the number of subscribers is a reliable number for evaluation. A second weakness of the study is that it lacked a control group. This makes it difficult to rule out factors other than the self-care program as the reason for the decrease in utilization. Preparations are being made by CBC/PBS to conduct another study that will include a control group with a larger employer group. A third weakness is that the researchers were unable to track the original 348 employees as a group by themselves both pre- and post-implementation of the self-care program. The 23 employees who joined the company during the self-care program did not receive the self-care guide. We cannot determine how their utilization rates affected the outcomes.

Conclusion
The present study has some strengths as well as methodological weaknesses. Weighing the two, it still appears that a self-care booklet distributed during a self-care workshop is a cost effective tool for reducing the frequency and total cost of health care services within a worksite setting. It is also interesting to note that the results of this study are similar to several self-reported studies on the same publication21,22. Studies are presently underway to replicate the research with a larger employee population as well as for 18 and 24 month time periods with the same employee population. Based upon this study as well as others that have appeared in the literature, we can cautiously say that self-care programs can make an immediate and significant impact on health care utilization and costs. They can play an important role in efforts to moderate the tremendous medical expenditures that employees experience each year.

References

  1. Burner S, Waldo D: National Health Expenditure Projections, 1994-2005. Health Care Financing Review, Summer 1995.
  2. Ibid
  3. AHA Hospital Statistics 1994-95. American Hospital Association, Chicago, IL. 1995.
  4. 1992 National Hospital Ambulatory Medical Care Survey; Emergency Department Summary, Advance Data, National Center for Health Statistics of the Centers for Disease Control and Prevention, NCHS, March 2, 1994, p.7.
  5. Schappert, SM. National Ambulatory Medical Care Survey: 1992 summary. Advanced data from Vital and Health Statistics; No 253, Hyattsville, Maryland. National Center for Health Statistics. 1994.
  6. Dunnell K, Cartwright C. Medicine Takers, Prescribers and Hoarders. Boston, Routledge & Kegan Paul Ltd. 1972, p 121.
  7. Wesley J. Valuable primitive remedies. Chicago: William H. Wilson, 1747.
  8. Buchanan W. Domestic medicine. Edinburgh 1769.
  9. Sehnert K, Nocerino JT. The Activated Patient: A Consumer-Oriented Program on Preventive Medicine and Self-Help Medicine. Washington, D.C.: The Center for Continuing Health Education, Georgetown University 1977.
  10. Sehnert KW. How to be your own doctor sometimes. New York: Grosset & Dunlap 1975.
  11. Boston Woman's Health Book Collective. Our bodies ourselves. New York: Simon and Schuster 1971.
  12. Moore S, Loberfo J, Invi T. Journal of the American Medical Assoc. 1980;243:2317-2320.
  13. Kemper D. Self Education: Impact on HMO Costs. Medical Care 1982; 20:710-718.
  14. Vickery DM, Kalmer H, Lowry, D, Constantine M, Wright E, Loren W. Effect of a self-care education program on medical visits. JAMA 1983;250:2952-6.
  15. Vickery, DM, Golaszewski TJ, Wright EC, Kalmer H. The effect of self-care interventions on the use of medical service within a Medicare population. Med Care 1988; 26:580-8.
  16. Leigh, JP, Richardson N, Beck R, Kerr C, Harrington H, Parcel CL, Fries JF. Randomized controlled study of a retiree health promotion program. The Bank of America Study, February 1990.
  17. Powell DR, Breedlove-Williams C. The Evaluation of an Employee Self-Care Program. Health Values 1995:19:17-22.
  18. Powell DR. Demand-Side Management: Characteristics of a Successful Self-Care Program. Health Care Innovations 1996: 6:22-28.
  19. Powell DR. Controlling Health Care Costs by Controlling Demand. Human Resource Professional 1995; 8:19-22.
  20. Powell DR et al: HealthyLife Self-Care Guide. Farmington Hills, Michigan. American Institute for Preventive Medicine Press 1994.
  21. Powell DR, Breedlove-Williams C. The Evaluation of an Employee Self-Care Program. Health Values 1995:19:17-22.
  22. Four unpublished studies on the HealthyLife Self-Care Guide, American Institute for Preventive Medicine, Farmington Hills, Michigan.

AAOHN Journal
Volume 45, Number 5
May 1997

   

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