Soon after Sharon Beaty’s husband was diagnosed with a serious chronic condition, he got a letter in the mail from his insurance company and a call from a health coach employed by the company. The letter included a medical form for his doctor to complete so the coach could help him monitor and manage the disease. For returning the medical form, he would receive a gift card.
So why is an insurance company offering gift cards to encourage patients to fill out a medical form? It’s a small price to pay compared to the bigger bucks insurance companies have to shell out if chronic health problems are left unchecked. Chronic disease is the leading cause of death and disability in the United States, according to the Centers for Disease Control, and accounts for 75 percent of the nation’s health care spending. Any efforts to manage chronic diseases (heart disease, stroke, cancer, diabetes, obesity and arthritis top the list) have huge paybacks given that 1 percent of the population accounts for 21 percent of all health care costs—and those people are mostly elderly and/or have chronic diseases, according to the Agency for Healthcare Research and Quality.
Sharon Beaty understands better than most the cost of health care, and this was not the first time she’d come across this type of letter. As CEO of Mid-State Health Center in Plymouth, she has seen many patients bring in such letters. Insurers have been using telephone health coaches (often trained nurses) for years, but primary care offices have also been exploring their use in recent years, using nurses as well as staff without medical training as health coaches. And while there is no data on the prevalence of health coaches in primary care settings, wellness coaching ranked 13th on the 2015 American College of Sports Medicine’s annual survey of fitness trends, rising from 17th in 2014 (the biggest jump of any trend). The survey listed the top 20 fitness trends based on responses from 3,403 health and fitness professionals.
There are no set standards for health coaches, or requirements that they be a trained medical professional, but there are numerous training programs available, including a wellness coaching certification approved by the Centers for Disease Control for treating diabetes that includes hundreds of YMCAs, hospitals, public health departments and independent health and wellness centers.
Changing Behaviors
Dartmouth-Hitchcock in Lebanon just wrapped a three-year study of the effect of health coaching on 250 patients with diabetes. Depending on their situation and preferences, they received coaching either over the phone, in a group setting, or during one-on-one office visits. The coaches had a medical background and the program included a specialist in shared decision making and someone trained as a therapist. Coaches met with patients, often weekly, to discuss lifestyle changes, diet, family changes, personal issues and medication management.
While final data is not in yet, lead researcher M. Brooke Herndon says preliminary results are promising and include weight loss and lower blood sugar. The study also uncovered unexpected findings. “Groups activities led to spontaneous coaching. There is increasing awareness that there are some really important benefits of putting groups of patients with similar situations together so they can teach each other things we can’t teach,” says Herndon.
At Mid-State Health Center, health coaching is provided by a team of two health coaches who are registered nurses, two social workers and three psychologists. It is not reimbursed by insurance companies, but Mid-State uses money from monthly payments it receives from insurers for meeting quality benchmarks to fund the work, which has been in place for the last three years. Beaty says there are not set standards for health coaches that she knows of, given there are many different models.
“Health coaching supports the work of our primary care doctors. It’s not helpful if the doctor says you are fat and need to quit smoking. But if he says we have a health coach who helps people deal with lifestyle issues, and we think it would be helpful to speak with her, most people will take you up on that,” Beaty says.
Mid-State uses a motivational interviewing technique, which involves working with patients to identify what they are willing to do and working on those things, Beaty says. “The change has to be their idea or it never works,” she says, adding that other issues are often involved in the root cause, including the ability to afford and/or access healthy food, or dealing with family issues and mental health issues. “If the issue is smoking and you can’t quit right now, what are you willing to do? Are you willing to cut back? Are you willing to not smoke in your house so your children don’t inhale it?” she says of the kind of discussions coaches have.
Managing Finances
The Partnership to Fight Chronic Disease reports that if the cost to treat chronic illness in the United States is divided among all citizens, it comes to about $5,300 per person annually. Put another way, 96 cents per dollar of Medicare spending and 83 cents per dollar of Medicaid spending is used to treat chronic illness.
Doctors and insurers are hoping the health coach model will significantly reduce those costs given that it addresses the exact population that generates big bills. But first, providers and insurers need to agree on who should provide the service and how it should be reimbursed.
Health coaching is primarily provided through insurance companies and primary care offices. The insurance model is often via telemedicine. For instance, Anthem Blue Cross Blue Shield in NH has been running its Condition Care program for more than 15 years. Anthem monitors patient claims data and flags people who submit a claim for a chronic condition. The insurer then sends a letter, asking the patient to call an Anthem health coach and fill out a medical history form, often with help from a physician. The health coach speaks with patients and their caregivers about how to avoid health risks, the details of their condition, and how they can make lifestyle changes and manage the medications they take. These discussions happen about once a month for anywhere from four to eight months depending on the patient meeting certain goals.
The program engages patients in part by working with employers to create incentives to participate. These include gift cards and contributions to health savings accounts. Anthem has no hard data on success rates and participation, but Dr. Richard Lafleur, medical director, says participation is increasing and the health of those patients is improving. “Obviously our goal is to get them from their current state and get them into a healthier state,” Lafleur says, adding providers are made aware of patients who are participating. “Providers see this as an extension of their medical practice. Some providers use it more or recommend it more.”
Other providers prefer to keep health coaches based in the primary care setting. “I think to some extent all primary care doctors are health coaches. It’s intrinsic to our work,” says Dr. Cathy Morrow of Dartmouth-Hitchcock, a primary care provider who oversees three health coaches funded by the three-year national study of which Dartmouth-Hitchcock is a participant. While some of her patients have successfully worked with health coaches via telephone, provided through an insurance company, not all patients find it helpful and she says it does not work as well as a health coach that is associated with the doctor’s office.
“I certainly have patients who have health coaches who contact them through insurance, and my experiences is some of them are very good, but generally speaking, they are in touch maybe once a month, some every three months. My concern is frankly the focus is often on the costs of medication,” Morrow says. She says her coaches often focus on mental health, given that chronic disease and depression have strong links.
Anthem stresses it does work with providers and is, in fact, moving from fee-for-service to outcome-based payments through its Enhanced Personal Health Care program. It pays providers up-front per patient per month for care activities that take place outside of a scheduled office visit, such as follow-up calls from a nurse or health coach. Providers participating in this program are also incented to improve quality and reduce cost. They are paid a percentage of their cost savings based on their performance on quality measures. As of July 1, 82 percent of NH primary care physicians in Anthem’s network will be participating in the program.
Morrow and Dartmouth-Hitchcock are now under pressure to fund the health coach program when the grant that funded the three-year study on health coaching for diabetes ends this month. The project was funded by the High Value Healthcare Collaborative (HVHC), a consortium of 17 healthcare delivery systems and The Dartmouth Institute for Health Policy and Clinical Practice. Still, Morrow is looking even further into the future.
“Someday, I hope before I die, all offices will have embedded health coaches. The communication is in real time; there is nothing that can replace that personal engagement,” she says.
Current Issue - May 2024