Health Risk Incentives

Increasingly, payors offer incentives to complete health risk assessments (HRAs) and/or interventions. Not to mention myriad quizzes in magazines, on Web sites ranging from Hoodia hawkers to the American Heart Association , but we'll focus on the MCO-sponsored HRAs today.

When a plan asks "clinical questions," expectations of benefit and/or negative consequences often arise. More transparency around how, when and why HRAs drive payor behavior would be welcome, as well as the role patients' clinicians should play.

Let's assume that inducements for completing a HRA are intended to accomplish some combination of the following:

1. Increase awareness of modifiable risks

2. Increase awareness of less modifiable risks, e.g. family history

3. Increase likelihood that modifiable risks will be addressed

4. Increase awareness of preventive health overall

5. Seek medical advice as HRA suggests appropriate

6. Increase payor awareness of high-risk members, and targeting of appropriate interventions

Studies assessing progress toward #3, 5 and 6 could be claims, survey and/or chart-based. We can track health outcomes, events like hospitalization and drug/medical trend. But there's more than ROI involved. What about unintended negative effects on members? Some possibilities:

--False reassurance, since HRAs cover only a few risk factors

--Catalyst for denial, since "bad news" may not have been delivered in that format previously

--Oppositional behavior, since lack of questions regarding members' known conditions may be seen as unresponsive to their needs

--Resistance to disease management stemming from HRA completion may arise, since the relationship between the two could be perceived as intrusive (careful message crafting can avoid this)

--As an automated tool rather than a one-to-one conversation, HRAs may induce or enhance a feeling of disassociation from the plan / health system

HRAs remain a good idea, but as yet they are a blunt instrument. Hopefully, we are heading toward baseline HRAs and tracking customized by member claims; integration into longitudinal patient data that includes survey and claims data; periodic chart audits to complement these data. Perhaps most importantly, such data can enable plans to act more proactively in partnership with clinicians and third party associations toward eliciting and helping to address health issues that are troubling the member.

For example, payors are generally not helping members with complex and concomitant chronic conditions find knowledgeable and coordinated care, which often would require no more than disciplined claims sifting. Patients often experience a trial and error process that costs both them and the plan extra money, with adverse health outcomes as well. Center of excellence programs are only the tip of the iceberg for optimizing inputs.

It’s strange that HRA data collection forms are less sophisticated than many "marketing research" surveys. For the most part, HRAs do not permit open-ended data collection, branching or piping, so everyone basically sees the same questions. Moreover, HRAs seem fairly far behind the literature. For instance, we are finding that not all LDL is created equal; multiple inflammatory /autoimmune conditions may be related, etc. The "goodwill investment" in HRA completion is fairly substantial and merits the most actionable questions possible.

Yes, the typical subject areas of BMI, depression, smoking, diabetes, cholesterol, HTN and MVAs all relate to health status and cost, but it is not always clear how in what patients, nor how HRAs can optimize care in the year(s) following this snapshot. An HRA may be one of the few plan touch points related to her health that a patient ever sees (EOBs and flu shot reminders notwithstanding). Many plan e-mails, which should be dynamic and personal, are somehow presumptuous, condescending and irrelevant all at the same time -- we can do better.

Industry/MCO collaborations are often based on the flimsiest of targeting algorithms, when the claims, charts, and the humans involved (clinicians, patients, payors) hold so much information that could improve those algorithms. As EHRs and PHRs are developed, how well are they integrating these data?

Incidentally, the methods paper for the first study of patient medication adherence to integrate claims, charts and surveys at the physician and patient levels is now in print (disclaimer: I am a co-author). This kind of project demonstrates that claims can be used for more than cost comparisons, surveys can drive more than product-specific marketing and chart audits can do more than fulfill HEDIS requirements.

Thoughts?