American Institute for Preventive Medicine
 

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Demand Side Management
Characteristics of a Successful Self-Care Program
Don R. Powell, Ph.D.


Despite efforts by the government, corporations, health care providers and insurance companies, health care costs continue to spiral in the United States. In 1995, over one trillion dollars or 14.1 percent of the gross domestic product was spent on health care. 1 This represented a 7.1 percent increase over expenditures in 1994. 1 This increase was the second smallest for any year since 1960. However, health care costs are currently $3,626 for every U.S. citizen. Physician services alone accounted for about $700 per capita. 1

Most of the efforts to control health care costs have involved supply-side management. This involves the use of a gatekeeper, i.e., case manager or utilization reviewer, whose role is to restrict consumer access to health care services and/or steer them to lower cost services. Over the last five years, more consideration has been given to reducing consumer demand for health care services and this has led to a concept called demand-side management. In demand-side management, consumers are taught to become better health care consumers. The result will reduce their actual and perceived need for health care services.

Demand-side management encompasses a number of areas including:
  • Wellness programs
  • Chronic disease management
  • Benefit designed financial incentives
  • Employee assistance programs
  • Disability management
  • Self care and wise consumerism
This article will focus on the last area - self care and wise consumerism - which I prefer to call self-health management. Consumers who are knowledgeable about health care systems can make more informed medical decisions and tend to use fewer services. The goal of self-health management is to eliminate inappropriate use of the system, not appropriate use. And inappropriate use is rampant.

In demand-side management, consumers are taught to become better health care consumers.

According to the National Center for Health Statistics, in 1992 there were over 762 million visits to primary care physicians in non-federally employed physician offices. 2 It has been estimated that 25 percent or 190.5 million of these visits were unnecessary. 3 The American Hospital Association has stated that 55.4 percent of the 97.4 million visits to emergency rooms in 1994 were for non-urgent conditions. 2, 4

Besides producing lower health care costs, self-health management empowers patients, increases their satisfaction and improves the overall quality of care.

Besides producing lower health care costs, self-health management empowers patients, increases their satisfaction and improves the overall quality of care. Both consumers and providers stand to gain when this occurs.

Self-Health Management Program Components
There are four major elements that can comprise a self-health management program: self-care guides, workshops, promotional materials and health information telephone hotlines. Each of these elements can be offered individually or combined to produce a more comprehensive intervention.

Self-Care Guide
The most important ingredient in a self-care program is the guide. This can be either a book or booklet, depending on how comprehensive you want the publication to be and your budget. The material will address the most common health problems, such as colds, earaches and cuts. Table I lists 27 of the most common health conditions as identified by the National Center for Health Statistics. 4 It is interesting to note that 27 health problems account for the majority of acute care office visits.

TABLE 1
HealthyLife Self-Care Guide Topics
1. Acne 14. Flu
2. Asthma 15. Hay Fever
3. Backaches 16. Headaches
4. Bronchitis 17. Heartburn
5. Chest Pain 18. Ingrown Toenails
6. Common Cold 19. Laryngitis
7. Coughs 20. Premenstrual Syndrome (PMS)
8. Cuts, Scrapes, and Punctures 21. Sinus Problems
9. Diarrhea 22. Sore Throat
10. Earache 23. Sprains and Strains
11. Eczema 24. Urinary Tract Infections
12. Fatigue 25. Vomiting and Nausea
13. Fever
Source: HealthyLife Self-Care Guide
American Institute for Preventive Medicine

Self-care guides help consumers recognize, treat and manage their own health problems. They help consumers decide whether medical care is needed when a symptom or injury occurs. The guides also let them know how to determine the urgency of the signs or symptoms so that they can choose the right type of care. When a doctor is not required, the guides suggest home treatments and over-the-counter medications. Many of these guides use easy-to-follow flow charts (see Figure 1) with clearly defined icons. The advice generally consists of the following:
  • Get emergency care
  • See provider
  • Call provider
  • Use self care
FIGURE 1
Questions to Ask
Do you have any of the following?
  • A tightness in your chest that radiates to the neck, jaw or arm?
  • Sweating or shortness of breath?
  • Nausea?
  • Discomfort that gets worse with exertion?
Yes Seek Emergency Care
Are you vomiting black or red-colored material? Yes Seek Emergency Care
Are your stools tar-like and black in color? Yes Seek Emergency Care
Do you also have pain that goes through to your back or a gripping pain in the upper abdomen? Yes See Doctor
Are you having a hard time swallowing? Yes See Doctor
Has the heartburn occurred often over 3 days? Yes See Doctor
Source: HealthyLife Self-Care Guide
American Institute for Preventive Medicine

Self-Care Workshops
When self-care guides are given out at a workshop, use of the self-care guides and subsequently the cost savings can increase. 5 Workshops are not practical, however, when there is a large number of managed care subscribers you want to reach, or if you do not have instructors. Because of this fact, approximately 80 percent of all managed care organizations (MCOs) that use the American Institute for Preventive Medicine's self-care guides, distribute them to subscribers through the mail. This is another reason for offering a simple-to-understand guide to your subscribers rather than one that is complicated and may need instruction.

If a workshop can be offered, there are several options including instructor-led workshops, video and audiotape workshops.

Instructor-led workshops can be conducted with training manuals and with overheads supplied by self-care vendors. Instructors can either train your trainers to present the workshop or have their own staff conduct it.

Videotape workshops can be shown to groups of subscribers at clinic settings or even sent to the subscriber's home on a loaner basis.

Audiotape workshops are another low-cost option. Subscribers can receive an audiotape with their self-care guide that explains how to use it and reinforces the benefits of its use.

Regardless of the format, the workshop should teach subscribers a number of things, including:

  • The importance and the benefits of self care
  • How and when to use the self-care guides
  • How to make better medical decisions
  • How to communicate more effectively with providers
  • Questions to ask when given a prescription
  • How to evaluate the care received
Self-Care Promotional Materials
Another key to a successful program is to maximize subscriber awareness and use of the self-care guide. The more people using the guide, the greater the reduction in health care costs. Unfortunately, too many MCOs that provide a self-care program view it is as a one-time event, rather than an ongoing process. It is not likely that subscribers will continue to use a self-care guide two to three years after having received it. Some subscribers will have misplaced their guides, while others will have forgotten about them. The more MCOs can do to constantly reinforce use of the self-care guide, the better the outcomes.

Ideally, an MCO should send a quarterly self-care newsletter and quarterly self-care postcards to subscribers. These materials would be designed to motivate the subscriber to use the guide when they are ill. Other self-care reinforcement materials can include posters, billing inserts, refrigerator magnets and stickers for the telephone and the medicine cabinet. MCOs should also consider giving out a new self-care guide at the start of each year. An annual guide will contain updated information that keeps the concept of self care fresh in the subscriber's mind and benefits those who have lost their original guide.

MCOs that want to offer a very comprehensive self-health management program should consider a telephone counseling service.

Health Information Hotline
Managed care organizations that want to offer a very comprehensive self-health management program should consider a telephone counseling service. These phone lines are staffed by registered nurses with a number of years of clinical experience. Subscribers can access the lines 24 hours a day, 365 days a year. The nurses will not give a diagnosis, but they can offer general ideas on what a caller should consider doing in response to their symptoms. The nurses can also provide information about specific diseases, exams and tests, medications, surgical procedures and wellness. In addition to the ability to speak with a nurse, some of the services provide an audiotape library of popular topics and fax-on-demand literature.

Selecting a Self-Care Guide
There are a number of factors managed care professionals should consider when selecting or developing a self-care publication:

Reading Level
The guide should be written at a level appropriate for recipients. A glossary of terms will also enhance the readability of a self-care guide.

Graphic Design
The information should be presented in a manner that motivates subscribers to use the publication. Use of graphic elements, white space and color all play a role.

Type Size
The typeface should be simple and easy to read. The typesize should be no smaller than 10 point.

Clinical Review Team
The author and/or acknowledgment page should be reviewed to ascertain the expertise of those involved with the development of the guide. In general, specialists as well as primary care physicians should be involved.

Updates
Ask how the guide is kept current. Note the date of the last printing. Ask who is responsible for updates.

Research Studies
Make sure the publication does what it's supposed to do -- reduce health care costs. Ask to see studies that have been conducted on the effectiveness of the guide. Note how the studies were designed and if they have been published in a peer-reviewed journal.

Target Subscriber Groups
Most guides are general in content, but there are some that can address the needs of specific populations such as children, women, men, seniors, pregnant women, people who over-use the emergency room and Medicaid recipients. Also, find out if the guides are available in other languages.

The cost for self-care guides can range from as little as $1.00 per copy for a booklet that addresses the 10 most common health problems in 32 pages and could be as high as $8.95 a copy for a book that addresses over 130 health problems and is over 400 pages in length.

Length
Most self-care books are 350 pages or more. Although they present a lot of useful information, they could be intimidating and overwhelming to subscribers. The result will be that they'll get put on the bookshelf to collect dust. A shorter self-care guide may get used more often. A shorter, user-friendly guide could produce a greater reduction in health care costs than a lengthier publication.

Cost
The budget for a self-care program will be a primary factor in what materials are selected. The cost for self-care guides can range from as little as $1.00 per copy for a booklet that addresses the 10 most common health problems in 32 pages and could be as high as $8.95 a copy for a book that addresses over 130 health problems and is over 400 pages in length. Even if a budget allows purchase of the most expensive self-care publication, it may not be the best one for your target population.

Customization
Many health organizations want to put their own personalized influence on a self-care guide. The options here can be limitless. They include customized imprints on the front cover, all new custom covers, adding a center insert and adding or subtracting self-care topics.

Blue Cross Blue Shield of Massachusetts custom designed a totally new self-care guide that addressed their 25 most commonly used ICD-9 codes. Guides designed to promote physician referral programs can insert a list of staff physicians. Manufacturers of health care products can add center insert discount coupons.

The medical protocols in some publications can also be altered. For example, one HMO wanted all their primary care doctors to be accessible by phone rather than through an office visit. Thus, all of the icons that said "See Health Care Provider" were changed to "Call Health Care Provider."

Plan Identification
Plans want to differentiate themselves from their competitors. In this regard, private labeling of a self-care guide or offering a guide that has not saturated a particular market may be desirable. By providing a guide that the competition isn't using can help distinguish an MCO in the marketplace. This is where customization also plays an important role.

Selecting a Nurse-Advice Telephone Service
Some of the criteria to consider when evaluating a telephone service are listed below:

Service Issues

  1. Determine exactly how many nurse counselors are employed, the hours and days they work and where they are physically located.
  2. Inquire about their call load characteristics and trends.
  3. Find out how your callers access the service.
  4. Determine if special information about your company's benefit structure is made available to the nurses who, in turn, can inform your callers.
  5. Inquire about the average call waiting time during prime hours before human contact is made.
  6. Determine the percent of time callers receive a busy signal.
  7. Ask if there are follow-up contacts and/or mailings with written educational materials.
Quality Control and Evaluation Issues
  1. Find out about the evaluation process.
  2. Determine the system for assessing customer satisfaction, both for the callers and the employer.
  3. Find out the minimum requirements for staff credentialing and experience.
  4. Inquire about what and how much in-service education is conducted for the phone staff each year.
  5. Ask what percentage of eligible callers will use the service and how that percentage can be increased.
  6. Ask to see sample reports and if they can be customized to meet your needs.
  7. Determine how quality control is maintained by the nurses answering the calls.
Marketing Issues
  1. Find out who is responsible for the marketing.
  2. Inquire about what should be done at the outset to launch the telephonic service.
  3. Ask how new members are made aware of the service.
  4. Determine what printed material is available.
  5. Determine what specialty advertising items, i.e., refrigerator magnet, medicine chest sticker, etc., are available and what they cost.
  6. Determine if the marketing materials can be customized with your logo or name.
Research on Self-Care Guides
There has been a good deal of research to support the cost savings associated with implementing a self-care program. Below are the highlights from nine studies conducted on the HealthyLife Self-Care Guide publication by the American Institute for Preventive Medicine in Farmington Hills, Michigan.

Capital Blue Cross in Harrisburg, PA, implemented a self-care program for Berk-Tek, a manufacturing company.6 The claims data for 371 employees was analyzed over one year time periods for both pre- and post-distribution of the self-care guide. There were no other changes in the company's benefit design during the study period.

The data showed that employees who received the guide had decreases in both the frequency and total costs for all types of physician office visits, lab tests and emergency room visits. The 12-month savings was $39.06 per employee, which amounted to a 24.3 percent decrease in costs. The frequency of physician office visits was reduced by 18.4 percent while emergency room visits decreased 19.8 percent.

The study also demonstrated the benefits of the self-care program generalized to the dependents of employees as they, too, reduced their utilization. An analysis of all members showed a 12-month savings of $21.67 per member. This represented a 17.8 percent reduction in costs. The frequency of physician and emergency room visits for members decreased 11 percent. Significant decreases in the frequency and costs for inpatient hospital visits were also found in both the employee and member groups after the self-care program was implemented.

A self-care program offered by Florida Hospital Medical Center in Orlando showed significant savings for 365 employees. 7 An evaluation of this program revealed that employees had made 126 fewer physician office visits and 52 fewer emergency room visits during the period studied. Using the hospital's insurance records, it was calculated that the average cost for a physician office visit is $55 and an emergency room visit is $462. This amounted to a savings of $30,954 or $84.81 per employee in five months.

Florida Hospital conducted a second study that involved 436 employees.7 The results were similar to those in the first study. During a 5-month period of time, there was a reduction of 139 physician office visits and 47 emergency room visits. This produced a total savings of $29,359 or $67.34 per employee.

Florida Hospital also conducted a study on a children's self-care guide. This study involved 183 parents. They found a reduction of 39 pediatrician visits and 31 emergency room visits. The total savings was $16,467 or $89.98 per family in five months. Bell South in Atlanta, Georgia did an evaluation of 229 employees who received the self-care guide. They found a reduction of 85 physician and 15 emergency room visits. The savings were $9,200 or $40.17 per employee in only three months.

Electronic Data Systems in Herndon, Virginia evaluated 65 employees who received the guide. During a six-month period, there was a reduction of 18 physician office and 5 emergency room visits. This produced a total savings of $3,290 or $49.85 per employee.

Indian Industries did a study on 197 employees. They found a reduction in 35 physician office visits and 34 emergency room visits. This produced a total savings of $14,840 or $75.33 per employee in a six month time period.

Western Southern Life Insurance Co. conducted a study on 197 employees six months after they received the guide. They found a decrease of 67 physician office visits and 20 emergency room visits. This produced a total savings of $11,350 or $57.61 per employee.

These studies show a fairly strong correlation between distribution of self-care guides and a reduction in health care utilization. The results are summarized in Table 2.


Table 2. Savings and Return on Investment Using Types of Self-Care Guides.
Healthy Self-Care Evaluation Studies
Organization
Year
N
Period (mos.)
Doctor Visit Savings/Person
ER Visit Savings/Person
Total
Savings/Person
ROI
Western Southern Life
1996
197
6
$17.00
$40.61
$57.61
26:1
Capital Blue Cross
1995
371
12
$26.01
$13.05
$39.06
5:1
Capital Blue Cross
1995
938
12
$16.45
$5.22
$21.67
7:1
Indian Industries
1995
197
6
$8.88
$66.45
$75.33
30:1
Florida Hospital
1994
365
5
$18.99
$65.82
$84.81
42:1
Florida Hospital
1994
436
5
$17.53
$4.80
$67.33
34:1
Bell South
1994
229
3
$18.56
$21.62
$40.18
16:1
EDS
1994
65
6
$15.24
$35.38
$50.62
20:1
Healthy Children's Self-Care Evaluation Studies
Florida Hospital 1995 183 5
$11.72
$78.26
$89.98
45:1

Physician Attitudes
Physician attitudes toward self care have improved remarkably over the past 10 years. Initially, physicians were skeptical of self care, and there was active resistance from them.

Fortunately, today, most physicians understand the value of well-educated patients. Improved communication with patients can lead to fewer frustrations. There is also a reduced administrative burden on physicians, since ,many calls that may have been directed to them can be satisfied with the information provided in the self-care guide. In a sense, the self-care guide acts as a gatekeeper and prevents unnecessary calls to the doctor's office. The reduced workload at physicians' offices allows them to better use and focus their resources.

Patients will also view a physician who empowers and respects them more positively. Also, patients who take an active role in their treatment might be less likely to file a malpractice claim if something should go wrong.

Self care is in ideal program for MCOs. The goal of self care is the appropriate use of the health care system, not to eliminate use. In this regard, patients who might normally have gone to the emergency room for treatment, may determine that after using a self-care guide, their problem can be treated in a physician's office. By the same token, patients who determine a very minor problem can be treated at home can free up their physician's time to treat more serious problems. The cost savings to MCOs for these kinds of decisions can be quite significant.

Conclusion Managed care organizations can benefit from teaching their subscribers to manage their demand for health services. This strategy of self-health management should work in concert with the more traditional supply-side management strategies. By empowering their patients to make better health care decisions, MCOs can begin to make an impact on the high cost of health care.

References

  1. Burner S, Waldo D. National health expenditure projections, 1994-2005. Health Care Financing Review. l995,16:221-238.
  2. 1992 National Hospital Ambulatory Medical Care Survey: Emergency Department Summary. Advance date, National Center for Health Statistics of the Centers for Disease Control and Prevention. Washington, DC: NCHS; March 2, 1994, p. 7.
  3. Dunnell K, Cartwright C. Medicine Takers, Prescribers and Hoarders. Boston, MA: Routledge & Kegan Paul Ltd.; 1972, p. 121.
  4. Schappert, SM. National Ambulatory Medical Care Survey: 1992 Summary. Advanced data from Vital and Health Statistics, No. 253. Hyattsville, MD: National Center for Health Statistics; 1994.
  5. Kemper DW, Lorig K, Mettler M. The effectiveness of medical self-care interventions. Patient Education and Counseling. 1993;21:29-39.
  6. Lewis S. Employees who use self-care cut costs by 25%. Employee Health and Fitness. 1995;17:133- 136.
  7. Powell DR, Breedlove-Williams C. The evaluation of an employee self-care program. Health Values. 1995;19:17-22.
Health Care Innovations
May/June 1996

   

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