An enhanced care management program achieved lower health care costs through broader outreach, personalized health coaching, and engagement of higher-risk populations. A randomized controlled trial of 175,000 individuals found that the enhanced program led to a $7.96 lower average monthly medical cost per member and over a 4:1 return on investment. Key aspects of the enhanced program included targeting a wider range of chronic and preference-sensitive conditions, more frequent outreach, and deeper health coaching relationships.

1. A promising new method to managing health care costs has emerged
from the consumer-driven health movement with proven results for
employers and health care consultants. The key is reaching just
beyond standard practices to enhance member engagement in
wellness and care management programs. This leads to additional
opportunities to improve member health outcomes, increase
satisfaction and sustain healthy behaviors.
Population health programs typically focus on high volume and high
cost chronic conditions such as coronary heart disease, heart failure,
diabetes, asthma, chronic obstructive pulmonary disease, and related
co-morbidities such as chronic pain, obesity, depression, renal failure
and hypertension. But evidence is emerging that shows results can be
optimized when this approach is:
• Broadened to include preference-sensitive conditions that drive
high utilization and medical costs involving lifestyle factors.
• Built around frequent and intensive personalized member outreach.
• Designed to engage members through comprehensive health
coaching to provide the most effective interventions for diverse
populations.
Avivia Health From Kaiser Permanente delivers this ground breaking
program, which was developed by Health Dialog Services Corporation,
to employer groups nationwide. The efficacy of this program is
supported by a year long, randomized trial conducted by Health
Dialog of nearly 175,000 individuals that was published in September
2010 in The New England Journal of Medicine.1
The study, entitled
“A Randomized Trial of a Telephone Care-Management Strategy,”
was authored by David E. Wennberg, M.D., M.P.H., along with Amy
Marr, Ph.D., Lance Lang, M.D., Stephen O’Malley, M.Sc., and George
Bennett, Ph.D. It was the largest research of its kind ever conducted
to assess the effectiveness of enhanced telephone-based care
management on medical costs and resource utilization.
Coaching Employees
to Better Health
Broader, Deeper Population Outreach Generates 4:1 ROI
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2. A sound investment
High health care costs have dogged
human resource and employee benefit
professionals for years, but they are just
as worrisome to C-suite executives who
face mounting pressure to rein in spending
wherever possible—especially in a
sluggish economy or competitive business
climate. Consequently, they are looking for
compelling opportunities to accomplish
this increasingly important corporate
objective. The conclusion of this study is
that the average medical and pharmacy
cost per member per month (PMPM) was
determined to be $7.96 lower for health
plan members who received enhanced
support, including a 10.1% reduction in
annual hospital admissions and a greater
than 4:1 return on investment (ROI). A
deeper review of these findings illustrates
how organizations that are willing to
commit the necessary time and resources
to improving the health of their workforce
can substantially grow their investment in
human capital.
“This study shows that an analytically
driven, targeted, population-based
program can decrease hospitalizations
and surgical procedures and thereby
reduce total medical costs for the
population as a whole,” according to the
researchers. “The reductions in resource
utilization were within the categories one
would expect, given the intervention:
high-variation medical admissions and
preference-sensitive surgical admissions.
Although not a panacea, a scalable
intervention that substantially reduces
expenditures by supporting patient
involvement in the decision-making
process could be an effective component
of health care reform.”2
Historical disease management trends
have cast doubt about the extent to
which traditional outreach mechanisms
or standard industry measures can
make a substantive difference in an
organization’s bottom line. In using rigorous
randomized comparisons, the researchers
sought to address dissatisfaction with
current engagement and measurement
approaches and examine the impacts of
enhanced telephonic member engagement.
Enhanced care model
The enhanced intervention involving the
populations served by two regional health
plans exceeded traditional program support
in that a larger number of subjects were
targeted for outreach.
Individuals in both the enhanced care and
usual care groups were identified through
predictive models that calculated the
estimated total cost of services, identified
gaps in effective care, and forecasted
the likelihood of surgical intervention for a
preference-sensitive condition. However,
for the group receiving enhanced care, the
thresholds for predicted health care costs
or resource utilization among persons with
chronic or preference-sensitive conditions
were lowered to encompass a wider range
of individuals. Finally, these analytics
identified subjects for enhanced care who
were not diagnosed with certain specified
conditions but who according to the models
were at high financial risk.1
Proprietary predictive models were used to
determine the most effective level of support
for members based on their condition or
risk levels. These models were deployed to
broaden outreach, with claims-form codes
used to identify health plan members in a
health maintenance organization, preferred-
provider organization and point-of-service
plan with the highest financial risk3
. The
individuals who participated in this study had
group health insurance coverage through
one of seven employers (which received
Health Dialog’s services at least one to four
years prior to the study). That list included
a state university system, state employee
group, natural-resource extraction company,
public educational service agency, nonprofit
association of independent colleges and two
manufacturers.
Roughly 10% of the enhanced support
group received telephone-based coaching;
these individuals were contacted through
a combination of outbound health coach
and interactive voice recognition (IVR) calls.
The number of outreach attempts made
to those in the enhanced support group
was greater than the traditional support
group. The study’s health coach team,
which included registered nurses, licensed
vocational nurses, dietitians, respiratory
therapists and pharmacists, used
proprietary software to support treatment
decisions, guide discussions, provide
education, and make referrals to relevant
Web site links, medical encyclopedias or
other resources, plus videos, DVDs and
printed materials.
Total population health approach
Health care analytics are used in
conjunction with a total population
health approach to assess the risk of
high utilization and costs, as well as the
prospect of surgery and adverse clinical
outcomes across the entire member
population. Risk scores also incorporate
potential variation in care drivers, such
as the per capita availability of general
and specialty surgeons and acute care
facilities.4
This approach incorporates a
larger pool of health care information in
addition to information about individual
risks and treatment levels.
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Differences in
Average Monthly
Medical Costs
between Enhanced
and Usual Support,
According to
Service Category
Source: Wennberg DE et al. N Engl J Med 2010;363:1245-1255
-6.04
-0.05
-1.61
-0.78
0.52
1.00 –
0.00 –
-1.00 –
-2.00 –
-3.00 –
-4.00 –
-5.00 –
-6.00 –
-7.00 –
Inpatient hospital
Emergency room
Outpatient hospital
Outpatient office
Pharmacy
Service Category
DifferenceinAverageMonthlyCostsbetween
UsualSupportandEnhancedSupport($)

3. In addition to reaching more of the
high risk population, the enhanced care
model encourages a deeper one-on-one
relationship between each member and
their personal health coach over time.
Receptivity scores help guide resources
to the members most open to health
coaching and decision support. Health
coaching relationships empower members
to be more active in their health and well
being. This bond can create a greater
receptivity to coaching, which is invaluable
considering that there is a set of conditions
driving inpatient and outpatient utilization
that present a high degree of sensitivity to
health coaching activities.
Under an enhanced care approach,
health coaching and support services are
broadened to encompass 65 wellness and
condition management topics. The program
model also takes into account health-risk
assessments (HRAs), biometric screenings
and prior-authorization data. Another
component is the incorporation of a robust
provider communication, education and
engagement strategy.
Broader range of conditions
A major component of the enhanced
care program includes targeting a broader
range of health care conditions and
concerns beyond traditional core chronic
conditions. For example, additional high-risk
conditions that are identified include anxiety,
migraines, spinal stenosis, chronic fatigue,
tobacco use, joint pain, back pain, peptic
ulcer, chronic kidney disease, and cancer.
Outreach is also provided to members who
have frequent emergency room and/or
hospital admissions.
The telephone is a particularly effective
conduit for health care coaching on a mass
scale, serving as the hub on a wheel of
program engagement—with Web-based
tools, e-mail, multimedia presentations,
and direct mail serving as the spokes.
Calls can be tailored to pinpoint the needs
of members with high or moderate health
risks along the health continuum based on
a complete set of their information at each
health coach’s fingertips. Results show that
participation in enhanced support programs
was almost three times the engagement rate
in a typical arrangement.1
The power of personalization also
is reflected in corporate branding. IVR
technology enables caller ID to display
the name of an employer-sponsored
program—allowing members to press
certain prompts to learn more information
or speak with a health coach. This
consultation is built around a variety of
different tools and techniques to identify
opportunities where members can not
only eat better and exercise more but also
adhere to a prescription drug regimen
to manage a chronic illness or avoid
dangerous drug interactions.
While HRAs can serve as an effective
tool in determining each member’s health
status and assessing the person’s needs,
the nature of self-reporting is such that it
could skew a program’s recommendations.
The enhanced care model, mindful of this
pitfall, instead relies on an evidence-based
approach that uses medical and pharmacy
claims data to identify and stratify more
members in need of health care coaching,
as well as questionable health conditions,
relative to risk scoring. Patient claims data
can be leveraged for examining hospital
admissions, trips to the ER, specialist
visits, co-morbidity or pharmacy measures
for predicting adverse clinical outcomes if
one’s condition is not properly managed.
Various risk scores are applied to members,
who are stratified into high, moderate and
low risk groups to help manage obesity,
stress or even tobacco cessation.
Assessing key measures
A final piece of the puzzle for taming
health care costs in the workplace involves
how activity measures for key population
segments are documented. Reporting
under the enhanced care approach
includes operation metrics for health
coaching call centers that rate how quickly
a call is answered, hold time, call volume
and other critical information.
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Health Coach Activity and Outreach
According to Cohort and Study Group
Cohort and
Study Group1
No. of
Subjects
Subjects Targeted
for Coach Contact2
%
Coach Contacts3
no./1000
persons/yr
Subjects Contacted
by Coach
%
Videos
Sent
Coach
Mailings
all subjects
Usual support 87,243 7.8 79.3 3.7 3.8 35.3
Enhanced support 86,877 25.8 233.0 10.4 12.2 125.3
Subjects with selected chronic conditions
Usual support 8,515 34.4 331.1 15.9 16.8 194.2
Enhanced support 8,465 76.1 978.7 39.8 41.4 605.5
subjects with preference-sensitive conditions that put them a risk for surgical intervention
Usual support 9,161 18.2 113.1 6.3 11.4 55.4
Enhanced support 9,190 59.5 398.5 22.2 41.1 240.2
subjects with other high-risk conditions
Usual support 19,446 5.5 53.1 2.8 2.2 20.8
Enhanced support 19,364 30.9 183.5 10.8 12.7 105.1
all other subjects
Usual support 50,121 2.3 27.6 1.5 0.7 8.3
Enhanced support 49,858 9.1 57.5 3.1 1.6 23.9
1
Data are shown for cohorts at baseline: during the study year, subjects could move among the outreach cohorts (the largest number of moves was out
of the “all other subjects” cohort into the “preference-sensitive conditions” or “other high-risk conditions” cohort) but not between the two study groups.
2
Targeted subjects were directly telephoned by coaches or were called by an interactive voice-response system and given the option to transfer to a coach.
3
Contacted subjects included only those who spoke with a coach. All differences between the usual-support and the enhanced-support groups
were significant (P0.001).
no./1000 persons/yr
Source: Wennberg DE et al. N Engl J Med 2010;363:1245-1255
continued on back

4. Such reports are usually delivered on
a monthly and quarterly basis, with the
latter offering an in-depth analysis of
program effectiveness. They can be used
to compare intervention and control group
outcomes with regard to an array of PMPM
medical and pharmacy cost measures, an
analysis of utilization rates involving hospital
admissions and ER visits, as well as
primary and specialty care physician visits,
clinical quality indicators based on HEDIS
measures and member satisfaction.
Service providers need to offer a flexible
model that provides solutions to the various
challenges that employers and health
care consultants are facing. Enhanced
care offers a more in-depth approach for
employers seeking to improve member
health while simultaneously controlling
health care costs.
Conclusion
An enhanced care program provides the
answer to employers who are interested in
lowering health care costs, but are skeptical
about traditional approaches to measur-
ing financial outcomes of care manage-
ment programs. There is no easy answer
to achieving this major business objective,
but employers and health care consultants
can take heart in this emerging approach to
enhanced care management that is reduc-
ing medical and pharmacy costs, as well as
resource utilization, by broadening the scope
of traditional programs and delivering proven
results based on large randomized trials. n
References
1. New England Journal of Medicine, Volume 363(13):1245-1255, September 23, 2010
2. Catlin A, Cowan C, Hartman M, Heffler S. National health spending in 2006: A year of change for prescription drugs.
Health Aff (Millwood) 2008; 27:14-29. [Erratum, Health Aff (Millwood) 2008; 27:593]
3. International Classification of Diseases, 9th Revision
4. Foundation for Informed Medical Decision Making home page
For more information on Avivia Health, visit www.aviviahealth.com or call 1-877-4AVIVIA.
Avivia Health is a complete wellness and condition management service provider, powered by Kaiser Permanente’s 65+ years of population
care management expertise. We offer a comprehensive suite of health, wellness, and productivity optimization capabilities that help companies
better control their health care costs and give employees the resources they need to move toward a healthier lifestyle. We build our programs
on a whole-person philosophy, focused on preventing disease, maintaining a healthy lifestyle, deploying evidence-based practices, and
treating each member as an individual instead of a collection of symptoms. Our customizable services are available in all 50 states.
Health Dialog Services Corporation is a leading provider of healthcare analytics and decision support. The firm is a private, wholly-owned
subsidiary of Bupa, a global provider of healthcare services. Health Dialog helps healthcare payors improve healthcare quality while reducing
overall costs. Company offerings include health coaching for medical decisions, chronic conditions, and wellness; population analytic
solutions; and consulting services. Health Dialog helps individuals participate in their own healthcare decisions, develop more effective
relationships with their physicians, and live healthier, happier lives.
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