Pro-Change Behavior Systems: CCA Members Employee Wellness Showcase

NEWM_2013_Supporter_Logo_fPro-Change LifeStyle Management Suite

The Pro-Change LifeStyle Management Suite is an evidence-based behavior change solution designed to improve employee well-being, reduce health care costs, and improve productivity in an easy and cost effective way. Built from over 35 years of scientific research and $10 million in grant funding from NIH, the programs meet the needs of entire populations, not just the 20% ready to take action.

Based on the Transtheoretical Model, the LifeStyle Management Suite’s entry point is the Pro-Change HRI, a Health Risk Assessment + Intervention. Unlike other HRAs, it uses validated questions to assess readiness to change leading health risks and provides immediate evidence-based, stage-matched feedback about the most important strategy individuals can use to make progress on each specific behavior. Every time the HRI is taken, feedback is updated to reflect change since the last one.

Pro-Change Image

Results from the HRI are used to dynamically populate a home page and recommend relevant fully tailored LifeStyle Management programs. These programs address the major issues currently driving preventable health care costs: smoking, stress, depression, obesity, sedentary lifestyle, unhealthy eating, and non-adherence to prescribed anti-hypertensive and/or cholesterol lowering medication. Each time users return to the program, they receive tailored feedback on how they are doing, what change strategies they are using well, which they are underutilizing, and what steps they can take to continue progressing.

Each LifeStyle program is complemented by an engaging interactive Personal Activity Center (PAC) easily accessed from the users homepage. The PACs are filled with activities that promote the use of recommended behavior change strategies.

The suite includes a Clinical Dashboard that provides health coaches or health care providers with an overview of each participant’s progress, along with targeted behavior change messages to motivate and guide participants toward healthier lifestyles. Specific LifeStyle programs can be prescribed directly from the dashboard, which is automatically updated as participants engage with the program(s).  Robust reporting features enable tracking of each populations’ program usage, progress and outcomes.

The LifeStyle Management Suite is supported by rigorous research including randomized clinical trials and case studies which have been published in over a dozen peer reviewed journals. Results include: over 65% of participants starting to effectively manage stress, 30% of participants losing 5% or more of body weight, 73% of participants experiencing a reduction in depression symptoms, and 45% of individuals meeting national guidelines for regular exercise. A full description of program outcomes can be found at http://www.prochange.com/pro-change-lifestyle-suite-behavior-change-program-outcomes

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CCA Featured Member: April 2013

Enrollment in HealthSciences Institute’s CCP Health Coach Learning and Certification Program continues to expand nationally and the organization is making inroads in Asia and the Middle East as well. HealthSciences is the largest chronic care and evidence-based health coaching training and performance improvement organization. Our fifth edition of the CCP program was released in February.

Our faculty includes NIH-funded specialists in health behavior change and engagement who have quadrupled engagement rates for employer purchasers in joint projects with Mercer, and assisted others in delivering measurable gains in patient-level outcomes by improving the proficiency of health care professionals to deliver evidence-based health behavior change solutions.

HealthSciences values the CCA partnership and continues to promote CCA membership as an avenue for a 25% reduction on the CCP Health Coach Learning and Certification Program tuition.

National Population Health Improvement Learning Collaborative

Since 2010 with the not-for-profit Partners In Improvement Alliance we have built a community of over 15,000 health care professionals from health plans, providers, federal and state units of health, among others. Each month our free learning collaborative webinar sessions are attended by 800 to 1,000 individuals. Learn more.

Health Coaching Performance Assessment (HCPA): Assessing the Proficiency of Health Coaches and the Quality of Population Health Services 

The first externally validated, standardized tool for measuring the quality of health coaching services delivered in wellness, disease management and care management programs. The HCPA is being used widely by BCBS affiliates, and other population health programs at Mayo Clinic, Marshfield Clinic, Stanford University Health System and the VA to benchmark and improve individual and program adherence to the evidence-based health coaching interventions demonstrated in hundreds of peer-reviewed publications to improve patient-level change. Learn more.

In an independently evaluated study by Ariel Linden, HealthSciences was the first to demonstrate a link between evidence-based health coaching proficiency (based on motivational interviewing health coaching) and member enrollment.

Registered Health Coach Program 

As you know, with lay people developing health coach training and certification programs, or wellness organizations WELLCOA offering theirs, we are proud to offer the only learning and certification programs in health coaching backed by outcomes and developed by specialists in behavioral medicine, motivational interviewing, medical psychology and health psychology. The Registered Health Coach credentials build on CCP, by offering proficiency-based training in MI health coaching. CCPs and RHCs are eligible for membership in the National Health Coach Registry http://registeredhealthcoach.org/.

CALL FOR ACTION: Showcase The Value of Workplace Wellness Incentives

CCA has reviewed the March 2013 Health Affairs article discussing the use of incentives in wellness programs. The authors’ conclusions are not reflective of the evidence and experience of CCA members in implementing health contingent wellness programs. In addition, the title of the article seems to be unduly inflammatory, and not fully supported by the analysis.

We are concerned that the timing of this publication could adversely affect the nature of the forthcoming regulations on non-discriminatory wellness programs.  Therefore, the Care Continuum Alliance is:

  1. Alerting our members and the industry to the potential impact of this negative-toned article in the current regulatory and policy environment;
  2. Conducting a comprehensive literature review including CCA’s recent research on Participant Engagement and the Use of Incentives;
  3. Issuing a Call for Case Studies from the CCA membership to address the points made in the Health Affairs article;
  4. Calling our members to a concerted action in response to the assertions made in this article:
    1. Respond to CCA’s Call for Case Studies.
    2. Read Care Continuum Alliance Evidence Statements: The Use of Incentives in Employer-Sponsored Wellness Programs.
    3. Attend CCA Capitol Caucus, on April 11, where discussions on incentives and other regulatory issues will be center stage. Learn more and register today.
    4. Highlight your organization’s research and outcomes on incentives for wellness programs through media and public outreach.

Article’s Key Points

The article Wellness Incentives In The Workplace: Cost Savings Through Cost Shifting To Unhealthy, published in the peer-reviewed journal Health Affairs, offers a conceptual framework for assessing whether health-contingent wellness programs are effective in achieving cost-savings through health improvement. The authors determine that the relationship between high-risk health conditions/ behaviors and increased healthcare costs is not definitive; conclude that the current evidence on the effectiveness of incentives in behavior change science is ambiguous; and posit that demonstrated cost-savings from wellness programs may result from cost-shifting and placing an undue burden on those of lower socioeconomic status.

Our Response

CCA is developing a more detailed, comprehensive, and evidence-based response, which will incorporate our members’ research.

Please submit your case studies, experience and evidence illustrating the following points:

  • CCA members engage in rigorous program evaluations and scientific assessments with ample data to ensure wellness programs are appropriately designed and tailored to improved health outcomes.
  • Significant evidence suggests a clear relationship between high-risk health conditions/ behaviors and increased healthcare costs.
  • Years of epidemiological data clearly show that a healthy lifestyle reduces the likelihood of disease.
  • CCA acknowledges that current evidence yields mixed outcomes on the effectiveness of incentives in behavior change science. Though, as program innovation continues, a growing body of research positively indicates that incentives can, in some cases, facilitate behavior change to increase patient engagement in wellness programs.
  • Appropriate incentive and wellness program design can produce cost savings for employers without any cost shifting to less healthy employees.
  • The value of wellness programs extends beyond direct healthcare cost-savings. As one component of an organizational culture of health, wellness programs can produce additional positive outcomes such as workforce productivity, aside from short-term Return On Investment.

The final rules on Incentives for Nondiscriminatory Wellness Programs in Group Health Plans from the Department of Health and Human Services (HHS), the Department of the Treasury, and the Department of Labor are under development and expected in the coming months. In addition, there is concern about the possibility of lawsuits. Read CCA Letter to HHS Secretary Sebelius on Incentives for Wellness Programs.

CCA’s Actions

Your Actions

Prevention is Not Expendable

A core component of the Affordable Care Act is the most comprehensive recognition to date of the value of prevention and health promotion. Numerous provisions in the ACA support wellness and prevention efforts in the workplace and in Medicare and Medicaid. CCA has repeatedly applauded these provisions and actively and aggressively supports their rapid implementation.

Yet, we continually face efforts by Congress and even the administration to target the ACA’s landmark Prevention and Public Health Fund as an extraneous cost – particularly now, in discussions on the fiscal 2013 federal budget. But the Prevention Fund is anything but extraneous or expendable. Rather, it provides a critical catalyst for the surge nationally in health care system innovation and care delivery improvements.

CCA strongly supports allocating monies dedicated to the Prevention Fund to fulfill its intended purpose and to power health care transformation. The Department of Health and Human Services must seize the opportunities made possible by the Prevention Fund through community collaborations and partnerships with health care industry leaders. Congress, rather than looking to the fund for easy cuts, should instead encourage its constructive use legislatively, such as through Sen. Ron Wyden’s “Medicare Better Health Rewards Program,” which would apply Prevention Fund monies toward initiatives that build on programs already established through reform.

States have a stake in the Prevention Fund’s viability, as well. The Fund materially impacts and advances individual state health care initiatives, such as behavioral health screenings, data infrastructures and wellness services. It has contributed more than $121 million toward state projects in Ohio, California, Nevada and Kentucky alone. HealthCare.gov provides a full public accounting of individual state contributions and program descriptions.

The Prevention Fund already has sustained a 10-year, 33 percent cut through February’s Middle Class Tax Relief and Jobs Creation Act. Additional cuts would derail federal and state progress toward prevention and health promotion, stifle health care transformation and undermine significant industry investments in innovation.

Stakeholders are working continuously and at an unprecedented pace to drive the health system toward better care, better health and lower costs. The Prevention Fund must remain available to achieve this important goal.

Incentive-Based Wellness Initiatives for All: Good practices = Good Outcomes

CCA has long supported the use of incentive-based workplace wellness programs. We’ve issued recommendations on core components and the role of incentives, and certainly agree that programs should not “inappropriately punish workers in poor health, [be] overly coercive, or create perverse financial incentives that result in poorer health outcomes.” We further believe that existing federal and state safeguards should be applied to programs that violate existing HIPAA requirements for reasonable design, annual requalification, alternative standards and other benchmarks. In short, there’s a growing body of research that clearly demonstrates the value of wellness programs, including those employing incentives for participation and outcomes, for improving health and reducing preventable health care costs (see here, here, here and here).

Congress, too, recognizes the value of wellness programs for all populations. The Affordable Care Act provided landmark recognition of workplace and community-based wellness and prevention programs. Particularly important, the statute in 2014 will increase from 20 percent to 30 percent of total premiums the allowable value of incentives employers may offer employees to participate in workplace wellness programs. We applaud Sen. Tom Harkin, D-Iowa, for his continued support for workplace wellness initiatives.

Now, another leading Senate Democrat is poised this week to unveil legislation that would offer incentive-based wellness programs to Medicare beneficiaries. This legislation recognizes the importance of wellness initiatives, including smoking cessation and weight management, and the success of incentive-driven wellness initiatives for our nation’s seniors.

I’m delighted to report on these developments and the sustained march toward greater awareness of the value of wellness programs for all populations. These developments stand in direct contrast to the thinly veiled conjecture and anecdotes propagated by policy organizations and advocacy groups that repeatedly ignore the preponderance of evidence on the benefits of workplace wellness programs.

Clearly, there is significant evidence of the positive impact of incentive-based wellness. CCA looks forward to supporting this important new Senate legislation and to promoting the real truth about wellness programs, using evidence and research rather than speculation and fear tactics.

—Tracey Moorhead, President & CEO

Federal Prevention Fund: Two Steps Forward, One Step Back

When President Obama signs payroll tax cut legislation today at a White House ceremony, with him will be working Americans who represent the 160 million taxpayers the bill will benefit. Based on best estimates, a third of the men and women expected to be at Obama’s side are at risk for diabetes and have two or more risk factors for heart disease. Two-thirds will be overweight or obese and a third will have high blood pressure. In that light, the payroll tax cut extension loses much of its luster, as the bill also will cut $5 billion from the Prevention and Public Health Fund to help avert a scheduled 27 percent drop in Medicare physician reimbursements.

It’s a penny wise pound foolish approach to Medicare’s dysfunctional sustainable growth rate (SGR) that kicks the can down the road at the expense of programs to fight the very conditions that drive most health care spending. We fully support fair payment to physicians and understand the magnitude of the threat they face with the scheduled SGR adjustment. But gutting badly needed federal support for wellness and prevention isn’t a solution. It’s an exclamation point on the short-sightedness of this legislation and a disheartening step back just as the federal government appeared to be moving firmly forward toward supporting workplace and community health promotion initiatives.

We wrote recently about the “glaring disconnect” that remains between the strong evidence base for programs targeting diabetes and other chronic conditions and the broader application of those care strategies. Throttling back federal spending on wellness and prevention robs us of a promising opportunity to close that gap. Yes, we must find payment strategies that satisfy providers and promote greater quality, value and accountability in care—and there are lawmakers working toward this sensible goal, such as Rep. Allyson Schwartz, D-Pa. But until we’re there, let us not dig the spending hole deeper with stop-gap solutions that diminish our best chance to climb out: wellness, prevention and care management.

Nailing the Coffin Shut?

Lots of buzz this week about disease management. First, Archelle Georgiou, MD, proclaims the “The Death of Disease Management (Finally).” Archelle’s arguments seem reasonable enough if you don’t consider that her post-mortem describes a DM model so outdated that today’s providers likely wouldn’t recognize it. Al Lewis reinforces that point with his excellent rebuttal – one with which I actually agreed. (I will, ahem, set aside for another day my thoughts on his position regarding outcomes methodology.)

Then, today, the Congressional Budget Office weighs in with a report on all the Medicare demonstration projects testing “disease management, care coordination, and value-based payment” models. Guess what? CBO says DM didn’t reduce Medicare spending in any of the Medicare demonstration and pilot programs. Really? This is news? Not at all.

The eight-page CBO Issue Brief released this morning summarizes a 30-page report, and I direct your attention to it: It contains a wealth of information that backs up much of what we, the population health management industry, know and that reflects program models being implemented today, in 2012.

Certainly, news reports will proclaim this yet another nail in DM’s coffin. Yet, the full report contains much about which we should crow – and loudly. The full report details the individual strategies upon which each demo or pilot was built and which of those strategies had more success than others. In addition, the report discusses the potential for success and the weaknesses of the studies due mainly to sample size. News flash: Many of the strategies that were more successful are the exact strategies that form the foundation for today’s programs. Further, (and here’s the really wonky part) the report correctly points out the confidence intervals for each study and suggests that, due to the large size of these CIs, we really don’t know how successful or unsuccessful each of these programs really were.

Bottom line: Today’s CBO report is a clear road map on how to build effective programs for Medicare populations. Remember that we can learn as much from what works as what does not work. This is a great road map for our industry and one, frankly, we’ve followed turn-for-turn in recent years.

A final point: Archelle noted, “At the end of the day, DM that does not achieve a net savings is not successful.” It’s an astonishingly cynical conclusion, especially juxtaposed with her “About Me” commitment to “health care projects, initiatives, and causes I believe are most meaningful to making a difference for people.” So, saving money is the only way to make a meaningful difference? Consider this counterpoint, published in the January 2008 American Journal of Managed Care and penned by former Care Continuum Alliance Chair Gordon K. Norman, MD:

“Let us return to the question of whether the current excess of $1 billion spent annually for DM is a good investment. Let us suppose that it is eventually shown by replicated RCTs that, in aggregate, DM programs consistently improve clinical outcomes, quality of life, functional status, and worker productivity but do not invariably produce cost savings. Might it still be the case that DM is consistently cost-effective? If that were the case – and many DM experts believe that it is plausible – it would be noteworthy because little of what physicians do to patients is ever cost saving (albeit life saving). Medicare is not allowed to consider cost-effectiveness in approving new technology for reimbursement, and the US Food and Drug Administration must approve any new drug shown to be safe and effective regardless of cost or comparative effectiveness. Few would question whether health plans should conduct case management, whether hospitals should provide discharge planning, or whether physicians should educate patients about prevention and healthful lifestyles, but none of these accepted health interventions have been shown by replicated RCT evidence to be consistently cost saving or cost-effective, to my knowledge.”

Bingo. Few health care interventions have been shown to save money, yet no rational person would suggest, for example, an office visit with a physician is “not successful” or bypass surgery is “not successful.” A more responsible measure of success might be whether the intervention creates value – in other words, whether you get your money’s worth. It’s the same yardstick we hold up to most other transactions, from a grocery store purchase to a new home. In that light, the evidence is clear that the right disease management intervention for the right population at the right time improves clinical outcomes (and, despite what disease management’s pallbearers would have you believe, can save money).

Where does that leave us? With a vibrant industry that continues to grow and evolve, as evidenced by the rapid pace of recent acquisitions and investments. There’s clearly value to be derived from current population health management strategies in new care delivery models – we see that in the quality improvement drive in the Medicare Advantage Star Ratings program. While I’m sure we haven’t yet heard the last post-mortem on these outdated demos and pilots, when they do crop up we can’t help but think of that memorable Saturday Night Live Weekend Update line, “Generalissimo Francisco Franco is still dead.”

—Tracey Moorhead, President & CEO

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