Manatee County Center for Health and LIfestyle Management
Manatee County, FL
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“Brenda”, a County employee for 20 years, is living with diabetes. After the inception of the “YourChoice” program, she recognized an improved level of focus and productivity, noting, “For the first time in 20 years, I know what I am doing at my job. . .Before the Diabetes Management Program, I did not have the knowledge of how to regulate my blood sugar or how I could feel so much better with exercise and diet.”
“YourChoice” addresses the issue at hand for many employers how to convert the present “Sickcare” System into a “Healthcare” System. The current “Sickcare” system addresses acute and chronic diseases which result in 20% of the people generating 80% of the costs. More than 95% of our nation’s health expenditures, including most of the billions of dollars employers spend on health coverage, are committed to diagnosing and treating disease only after it becomes manifest. Researchers have estimated that preventable illnesses make up approximately 70% of the burden of illness and the associated costs. Research also shows that poor health and preventable illnesses significantly contribute to elevated employee absenteeism, poor work performance, worker compensation claims and short and long term disability claims.
Previously, the practice at Manatee County Health Plan was to provide “Sickcare” benefits in the typical manner provided by employers. We offered a PPO/HMO look-a-like plan, paid 100% employer contribution for employees, administered it in-house and contracted directly with providers. There was dissatisfaction with the system, and costs and chronic conditions continued to rise. Mr. Goodman approached senior management with a plan for broad change; specifically, he sought permission to design a new medical benefit plan that paid benefits according to evidence-based qualifying events that would make employees and their families accountable for their lifestyle choices.
The problems that Manatee County Government addressed are similar to those facing all employers. For example, how do we make employees more accountable for their lifestyle choices and reduce medical benefit costs? How does an employer address the root of the problem as opposed to simply shifting costs? How do we educate employer and employee that improving the health of employees is important in controlling medical costs, not only for the employee, but also for the employer through increased productivity and reduced absenteeism, both of which impact an employer’s “bottom line”? How, as a public employer, do county officials and employees demonstrate to the community the need to build a better workforce and provide excellent customer service?
To answer these questions, in 2004 Manatee County created an alternative “Accountable Health Care Model” with their employees, holding them accountable for their lifestyle choices. Critical to this effort was altering plan design so as to prioritize accountability over paternalism.
By developing a “YourChoice” plan design, the county provided medical benefits based upon the completion of evidence-based qualifying events. Manatee “YourChoice” offers three plan levels (“Best,” “Better” and “Basic”) to members. All plans have identical coverage, including identical prescription and behaviors health benefits and only differ in the levels of reimbursement which are determined by members completing the plan’s evidence-based qualifying events:
- The “Best” Plan has a $25.00 co-pay per office visit with no deductible or coinsurance. Hospital, surgery and out-patient services are covered at 100% up to $1,400 annually.
- The “Better” Plan has a $500 deductible and a 75/25% coinsurance up to $3,600 annually.
- The “Basic” Plan has a $1000 Deductible and a 50/50% coinsurance up to $5,000 annually.
All new enrollees must qualify to be enrolled in a plan and from that point forward their qualifying years are age-based: 20, 25, 30, 35, 40, 43, 46, 49 and 50 and older. The qualifying events consist of the following evidenced-based practices:
- Comprehensive Biometric Lab work, including A1C (diabetes testing) and Cotinine (nicotine testing)
- Completion of an on-line Health Risk Assessment (HRA)
- A wellness exam that is a comprehensive physical exam with a review of systems as well as lifestyle choices and behaviors and includes recommendations for programming to assist with health improvement.
- Age based screenings, including, at appropriate ages, prostate exams and testicular exams for men; colonoscopies and skin screenings for men and women; and mammograms, pelvic exams, pap smears and clinical breast exams for women.
- Tobacco cessation programs for all tobacco-using members.
- A diabetes management program, including A1C value and lipid profile, annual foot and eye exam and physician visit. If a member has an A1C of 7.0 or above, there are additional qualifying events required: (i) a two-day diabetes workshop, (ii) online learning and a face to face visit with the diabetic educator, (iii) a six hour workshop addressing preparation for lifestyle change, and (iv) structured exercise program at our fitness center.
To be eligible for the “Best” plan adult members must do all the qualifying events listed above, including tobacco cessation and diabetes management if applicable. For the “Better” plan the adult members must complete specified health risk assessment, biometric lab work and the wellness exam, and for the “Basic” plan adult members have no qualifying events to complete.
Each adult member – employee, spouse or dependent age 19 and older – is enrolled in an individual plan based upon their own qualifying event choice. Regardless of age, the tobacco and diabetes qualifying events are required annually if applicable. All children in a family must complete a wellness exam, dental exam and have their immunization up to date to be in the “Best” plan. Over 93% of our members participate in all of the qualifying events and are therefore enrolled in the “Best” plan.
Some of the qualifying events are provided on-site. For example all of the events for tobacco cessation and diabetes management are provided on-site. In addition, throughout the year, we have Quest Laboratories do worksite lab draws for the qualifying events so members can get their qualifying lab draw done at a worksite as opposed to going to a local Quest Patient Service Center. The health risk assessment is an on-line tool and we provide help sessions throughout the year to assist them in completing their assessment. The other qualifying events such as the wellness exam, the age-based screenings (mammogram, colonoscopy, pelvic, etc) are all conducted at in-network providers in the community as a medical service. However, members are not charged for any of these qualifying events despite being conducted at their physician’s office.
“YourChoice” provides financial rewards or “Health Bucks” to members who are willing to make healthy, on-going lifestyle choices. Examples of programs and health/lifestyle conditions that earn “Health Bucks” include being a non-tobacco user, particpating in our exercise and diabetes management programs, achieving and maintaining a healthy weight, and particpating in our healthy baby program, and Cardiac Health for Life. The participation in these programs and the “Health Bucks” awarded are provided by the staff under the Center for Health and Lifestyle Management (described below). These “Health Buck” rewards can be applied to reduce medical and dental premiums or can be placed in the employee’s Healthcare Spending Account. In 2008, the County’s plan paid in excess of $900,000 in “Health Bucks” to covered members.
Health & Lifestyle Management – Moving from “Sickcare” to “Healthcare” Management
The Center for Health and Lifestyle Management is the division of the “YourChoice” Health Plan that creates and operates the various programs. The Center’s staff is provided by independent contractors and are full time local employees. The staff works as an integrated team reporting directly to the County Benefits Manager.
The team has grown significantly over the past few years. What started in 2002 with a health advocate (RN) and diabetic coach has now become a team of 12 multi-disciplinary professionals dedicated to the health and well-being of our members. The Center’s team is designed to create integrated, outcomeproducing and evidenced-based programming. Originally the plan provided just voluntary HRA and biometric testing. Now, eight years later the plan has a comprehensive and integrated approach to health management. Programs are in place and being continuously re-evaluated to give members the opportunity to be more educated about and improve their health status. Both the HRA Aggregate Report and the plan’s data warehouse (D2 Hawkeye) are demonstrating improved outcomes and substantially lower cost trends than the national average.
In 2007, based on the success of a pilot program provided specialized mental health counseling sessions to members who were undergoing cancer treatment, the County developed a new model for an employee assistance program (EAP), focused on, among other issues, stress, parenting, financial needs, motivation to change, tobacco cessation and behavioral health (mental health and substance abuse). The reasons for the new behavioral health program were that depression is four times greater in people with chronic pain; depressed people are 60% more likely to develop Type II Diabetes; and employees experiencing depression and stress utilize health care at a rate 250% higher than other employees.
This new integrated EAP and behavioral health program, known as LAMP (the Lifestyle Assistance and Modification Program), has become the cornerstone of the County’s programs, allowing the County to incorporate behavioral health and change process concepts into all of its medical management and weight loss/nutrition programs.
Four LAMP in-house, contracted practitioners specialize in behavioral health and provide individual, family and group mental health counseling and psychiatric services in addition to tobacco cessation counseling and motivation to change workshops. LAMP does more than encourage members to make healthy choices: the program offers specialized and individualized programming related to stress, anxiety, depression, parenting, etc. Because the services are all provided in-house and integrated with medical management and fitness/nutrition, we can effectively incorporate concepts of behavior change and preparation to change into all aspects of health and well-being.
Manatee’s model is to provide all plan members disease, medical, health, preventive and wellness management plus education and advocacy resources using a “people to people” approach rather than a telephonic one. Manatee’s program design is based on the knowledge that change is a process and that in order to create lasting change and a “culture of health; people need ongoing advocacy, support and resources in a face to face environment where opportunities to engage members in a relationship of support and respect can occur.
As Kim Stroud, Director of Health and Lifestyle Management, notes, “Change is difficult. We have found that incorporating the individualized behavioral aspect into all of our health management programming is most important in creating a ‘culture of health’ which results in lasting change. Specifically, we… [recognize] that people need a diverse menu of opportunities to change based upon their stage of change. By assisting members to prepare for change after understanding their own barriers and potential relapse triggers, advocates and coaches are seeing significantly improved outcomes within all of our programs.”
The County provides employees with a variety of integrated work-site based health and lifestyle management programs, in great part developed with information from HRA, biometric testing, claims, lab and pharmacy data. The County has found that integrating benefit plan design and health management programming yields significant outcomes and that these outcomes have stabilized employee health costs and given more credence to “return on investment.”
The following are some statistical outcomes for various programs, many of which have been written up in national and international professional journals. Weight loss and fitness and exercise programs yielded the following results:
- Bariatric Surgery Program: Patients averaged a loss of 157 pounds 24 months after surgery and a reduction in Body Mass Index (BMI) greater than 10 points; most participants discontinued or reduced medications for hypertension, Type II diabetes and cholesterol; this population’s PMPM drug costs dropped 40%; and PMPM claims dropped 20% post surgery.
- Lighten Up Weight Management: 134 people participating, 998.0 total pounds lost
- Medical Weight Loss Program (6 months intensive). 2007: 128 members participated. BMI decreased by an average of 5 points, body fat by 77.2%, weight by 29.4 lbs per person. 2008: 150 members participated. BMI decreased by an average of 6 points, body fat by 81.5%, and weight by 33.7 lbs per person.
- Medical Weight Loss Maintenance Program (6 months in duration): Once completing the initial 6 months of medical weight loss, participants work with a fitness coach to assist with their continued goals. Outcomes show that after one year of enrollment in the program, participants continued with their weight loss goals and achieved an average of 40.3 lbs lost per participant.
Pharmacy Outcomes were as follows:
- Generic utilization went from 59% in 2007 to over 67% in 2008
- PMPM amount paid for pharmacy has been reduced by over 7% since 2006
- 2008 pharmacy costs were less than 3% with no reduction in compliance due to the economic conditions.
Medical Spending and Outcomes:
- Only a 2.9% change in total (medical and pharmacy) costs from FY 06-07 to FY 07-08.
- Improvement in modifiable spending from 2007 to 2008 was $406,342.
- Average length of a hospital stay is down 37% from 2007.
- High Risk for chronic disease is 6% below the national average.
Heading into the Future
The Manatee staff is implementing the following changes to quantify outcomes and to hold members more accountable for their lifestyle choices. To start, the staff is adding a fourth (“Ultimate”) tier to the benefit plan effective January 2011. To be eligible for the new tier a member will have to be a nontobacco user (verified by lab testing). The “Ultimate” level of reimbursement will be identical to the present “Best” plan.
In addition, that same year the “Health Buck” Incentive Program will be tied more closely to approved, evidence-based biometric tests for minimum participation in the “Ultimate” plan. Participants will have to show measured improvement to be paid Health Buck incentives. As a result of this change, the programs offered by the Center for Health and Lifestyle Management will become more intensive and integrated, all incorporating the concept of “change is a process”. We will have the opportunity to teach more of our members about the process of change and the preparation to make it lasting, ultimately achieving a more productive employee and employer population who understand the need for and have a desire for a culture of health.
Finally, personal health records (PHR) and wellness electronic medical records (WEMR) will become effective by Fall 2009 to ensure that the best quality of care is provided to members. The plan’s PHR and WEMR systems are state of the art pre-populating information systems for members and physicians and are automatically updated with HRA, lab, medical and prescription claim data. Providers and members will be paid incentives to use the system.
Since inception, the program has reduced cost trends by more than 63% of the national average. Currently the plan’s cost is trending below the prior year and in the current economic times there has been no reduction in prescription utilization, indicating that members are remaining compliant with their plans of care. See the Trend Comparison Chart for outcome detail.
In rolling out the program, Manatee County underestimated the willingness of employees’ and families’ desire to change. 93% of the members completing qualifying events for the “Best” plan. We also lacked automation for qualifying event enrollment and calculating incentives. Finally, we needed to restructure the health and lifestyle programs to meet the needs of our members and their changing health statuses. In particular, the incorporation of a behavioral health component (LAMP) in our programming was vital to supporting positive outcomes among our members.
The HRA and biometrics reporting is demonstrating incremental progress and the plan trend is consistently reporting below national trends. In fact, 2009 prescription utilization is not reporting a decline due to the economy (as has been evidenced with other health plans and insurance companies), and costs are still down 3.8% from the previous year. Also, the plan is trending monthly between 5.3% and 8.3% below the previous 12 months. Our total administrative cost is approximately 18% below other plans.
Massachusetts faces the same problem that all Governments face: increased health care costs, reduction in staffing and funding and increased stress among employees. Our value-based, integrated approach holds employee and all state residents accountable for their lifestyle choices. By applying lessons from Manatee County, Massachusetts could reduce costs and improve employee retention, recruitment, absenteeism, and overall work performance.
“YourChoice” plan and its approach to health and lifestyle management are becoming a proven model to address the issue of controlling healthcare cost and to build a new, healthier workforce. The Manatee “YourChoice” plan design and the Center for Health and Lifestyle Management could play a relevant role in Massachusetts by reducing the cost of medical insurance for state and local governments, employers and individuals by providing incentives based upon accountable plan designs.
By adopting the “YourChoice” plan design, Massachusetts could develop incentivebased multi-tier plans for plan sponsors and individuals to provide medical insurance that would hold their employees and families accountable for completing evidencebased testing, screening and health and lifestyle programs. By tying the preventative/ wellness benefit to the level of reimbursement, it creates an incentive in itself to make positive choices.
Equally as important is the Center for Health and Lifestyle Management. Its integrated “people to people” approach for educating lifestyle change, is important for providing an ongoing support system rather than the impersonal telephonic approach used by traditional disease management organizations and insurance companies. Community-based centers for employers, local institutions such as community colleges or local or county governments are logical choices for centers. Pairing a value-based plan design with a Center for Health and Lifestyle Management, with professionals who desire to work in an “out of the box” environment where creativity and change is not only encouraged, but expected, can benefit Massachusetts on a multitude of levels.
The Manatee model will help communities build healthier, vibrant individuals who are invested in improving their own quality of life. Equally as important, employers will become more competitive through decreased absenteeism and improved productivity.