Entries in Gelb, Laurie (22)


Can decision support consist of more than threats, promises and stiff upper lips?

By Laurie Gelb

Can decision support consist of more than threats, promises and stiff upper

Here's where domains, measures and thresholds come in.

Here's where the rubber hits the road.

In one study, sufferers, clinicians and payors were asked how they would
measure the value of a drug for a condition for which disease- modifying
therapy did not yet exist. The same methodology works whether options are
plentiful, mediocre, whatever.  But in this case--

Physicians highlighted clinical results in one or more domains, all of which
have a demonstrable impact on quality of life.
Patients focused on being able to experience things they have not been able
to experience recently.
Payors wanted to see statistically significant differences from placebo on
some objective measures, not really caring which -- the FDA's job.

Every stakeholder was able to specify domains (pain being one, just so we're
clear on what a domain is) that were relevant to him, and whether or not an
improvement in that particular domain would in itself justify
prescribing/taking/reimbursing therapy. Obviously, not all domains were
salient to every stakeholder.

Every stakeholder was able to specify how improvements in salient domains
would be measured (numerically and/or categorically) as well as her
threshold for that improvement -- what number or value or outcome would
constitute sufficient reason to act.

But the answers were different for everyone.  (So were the questions, of
course -- computer-assisted interviewing uses previous answers to frame
relevant questions).

So, when you're doing stakeholder research, instead of dragging out a stack
(real or virtual) of static scenario cards for tradeoff analysis and
sorting, instead of asking about abstractions like preference and
satisfaction that aren't used in real life, what if you asked about:

Domains that are salient
Measures that are used to measure change or value in those domains
Thresholds applied to those measures to justify action

Bear in mind, these are studies that run (very) low five figures and a few
weeks, all told -- this is a framework for frequent studies, not once a
decade. So you can track how the findings change as the environment does.

What next? You might design decision support that makes very clear...

What domain(s) are affected by the intervention you recommend or wish
considered What measures show change when the intervention is used, in whom,
and how frequently. how predictably To what extent any particular threshold
of change can be predicted, guaranteed or even hoped for

Of course, you update this as the data come in and time goes on.

Presto! User-centric decision support can be yours.
And it can be theirs.
If you do all this on the Web, kiosk or CD-ROM, you can develop a "wizard"
that enables the user to "buy in" to their choice using their own criteria.

The decision that's owned is the result that's achieved.

We're not just talking about justifying or avoiding therapy -- this is about
staff/physician recruitment/retention, open enrollment and a thousand other

Effective decision support reduces and supports the burden of choice.
How is yours doing?
Any stories to share?


“Personal” is more than a word

By Laure Gelb
In my last post, I speculated as to whether 2008 might be the year that disease management communication from MCOs finally got personal. The next one-page MCO piece I saw (an EOB insert) offered the following snippets:  


“We think getting personal is a healthy idea.”
“We know that nothing is more personal than your health.”
“Do you take a healthy interest in good health?”
This piece of paper attempts to induce enrollment in the personal health coach program. But where are the benefits offered for this proactive behavior?  


“If you qualify…one person to call for answers and advice. It’s confidential and it’s free.”
o      OK, so you want me to transfer the expectation that my physician will offer answers and advice, to a nurse whom I’ll never meet.

o      You want me to believe that it’s confidential, when I’m reading every week about health insurance data privacy breaches.

o      And you want me to celebrate that it’s “free,” when my premiums and copays have never been higher.

 Health coaching should ideally align with the patient’s medical home. Can we more strongly link that proposition to premiums and copays? Talking points could include:


  • The relationship between OOP costs, medical errors and drug interactions
  • The higher risk of unidentified ME/DI among patients with multiple conditions/polypharmacy
  • The opportunities for improved outcomes that multiple conditions can obscure
  • The importance of a “medical home” in reducing ME/DI
  • What a health coach actually does, and indications that having a coach might help; how the coach and the medical home can support each other
 Although managed care has been “doing” disease management since the 80’s, a patient’s “buy-in” to disease management, with the time, effort and emotional costs it entails, will be short-lived unless it’s obtained through honest discussion of its potential benefits, rather than demanded or condescendingly waved in front of someone with many conflicting priorities. And I haven’t seen an EOB insert yet that addressed questions like:


  • Why I am on two drugs that are supposedly “contraindicated” in combination?
  • Does anyone at the MCO know or care about all that treatments I’ve had?
  • Isn’t a health coach going to refer me to a doctor for the tough calls anyway?
  • How will a stranger get me to do all the things I already know I should do?
  • Why can’t the health plan just find me a better physician?
There’s a real shortage of health content in member communication, and it’s no wonder that members find it difficult to read, let alone remember (or act on) any of it. The next time you want to change a member’s mind or otherwise influence behavior, you might want to check your communiqué for a few basic points:


  1. Is it clear what you are asking members to do?
  2. Is a coherent value proposition for them to take this action presented and are potential objections addressed?
  3. If members to whom your request is directed are not appropriate candidates, how will they know?
  4. Is there a high ratio of important content to buzzwords like “personal,” “healthy” and “wellness”?
 All this is no more than Marketing 101, of course. When disease management diverges from marketing exchange theory (equal value achieved by all parties to a transaction), it is less likely that any transaction, change or improved outcome will result. And, at the end of the day, the evidence suggests that clinical outcomes are more durably and significantly improved by self-imposed than externally-imposed change. Yes, the MCO (and the physician, nurse, et.al.) can help present the rationale for change, a means for implementing it and incentives for doing so. But only the patient “pulls the switch” each and every day. Every day brings new health decisions (like self-dosing qd), challenges and opportunities. It takes more than a few clichés to frame and support optimal choices. And there has to be a balance between “happy talk” and the certain knowledge that some “good” decisions and intentions go horribly wrong.
Next month: domains, measures and thresholds -- the keys to behavioral change.

Can 2008 be the year that health communication gets personal?

By Laurie Gelb

It's safe to assume that your organization's 2008 objectives include some combination of member/clinician behavior change and cost containment. To that end, consider the following. 

Scenario 1: An organization sends you snail mail and e-mail that obviously is the same for everyone. It references products you don't need, ignores your previous transactions, frequently repeats the same message and offers you no way to personalize its communication to you.

Scenario 2: (a la Amazon.com) An organization sends you snail mail and e-mail that clearly has entailed an analysis of your pre-existing relationship with the organization. Future purchases are recommended, reminders are tailored to the interval at which you made previous purchases, etc. You are also offered the opportunity to personalize the offers and reminders you receive, and to update this information when you see fit.

Which organization are you more likely to do more business with? Recommend?

Now consider what last year was like for one of your members (every example below is from actual MCO communications). He is male and receives a letter that clearly recognizes that fact (it's addressed to Mr. Smith). The letter references the fact that he might be pregnant. It also invites him to call a "local number" to reach a health coach, for which the area code is an hour away and actually a toll call. The signature on this invitation is a typewriter font.

Does any of this seem personalized?

He receives two successive letters "from his doc," via a joint initiative, that encourage him to get an A1c and includes a form wherein he can have a lab tech sign off on the test, send in the form, and receive a trivial incentive. This is right after the visit at which he and the doc went over the results of his recommended interval A1c test.

He receives an EOB with an insert encouraging him to get a flu shot.  The EOB is for his recent flu shot. Every EOB he receives over a six month period includes the flu shot insert, long after he has received the shot. 

He tries to order rx refills from his PBM over the Web. He finds out by trying to do this (over a half hour with increasing frustration) that his former user ID is no longer valid. When he tries to create a new one, he gets repeated, incomprehensible error messages with no information as to how to resolve the issue. Ultimately, he has to call the refills in, but after explaining the issue to the representative, he receives no information on how to fix the log-in.  The member hangs up still unsure whether he will ever again be able to refill rx on the Web, and with no incentive to pursue the matter.

Do personalized mail merges and sorts cost more? You be the judge.  One thing is sure -- if we stipulate that the "informed health consumer" expects a win/win relationship with her payor, it's hard to see how that relationship is fostered by "one size fits all" communication. Consider how easy it is to complete a transaction on amazon.com (or at any one of thousands of Web sites) that actually begins and maintains a personalized relationship, as opposed to the feedback members receive from an MCO or PBM transaction. It's not just a matter of behavioral change; think of all the goodwill you're losing, and all the adversarial baselines you're creating, by seemingly refusing to treat members as people.

It's easy to say that health communication is a two-way street, that patients need to take responsibility for ontrollable risks and lifestyle factors. It's more difficult, but ultimately more rewarding, to walk the walk from a payor standpoint. Tools that support plan design choices came into being several years ago. Have tools to support health decisions and encourage appropriate behavior matched that early promise? Not yet.

Need evidence that any of this matters? A modest proposal would be to run some pilots that compare "one size fits all" messaging with something that takes previous information into account. Pretend that you're at an organization where "one size fits all" communications simply aren't done.  What would you do to stratify your members? You might begin with gender...

Happy 2008 to all, hopefully a year in which all of our initiatives increasingly facilitate appropriate prevention, screening, diagnosis and treatment.


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.



Health Literacy and the Misplaced Mantra, part 2 of 2

Health Literacy and the Misplaced Mantra, part 2 of 2

The Dilemma

Web-based decision support and concierge health services are on the rise, yet most people still believe (with considerable justification) that the most complete and objective advice remains reserved for the rich or well-connected. Meanwhile, system integrators believe that the best consumer is informed and would rather, for example, link her BMI to cash than evaluate plan designs. So, while incentives to “do the right thing” are coming into play, when/how to do it is still a very real issue for the consumer receiving constant, often contradictory, stimuli.

At the point of care, the patient, who still lacks access to much of her medical record, is told at one visit, "I can't decide for you," and acted for paternalistically the next, in both cases with the best of intentions, under a system that rewards speed, test orders and upcoding more than outcomes.

The Reality

The ability to limit health information stimuli to self-initiated searches no longer exists. What if you were as besieged with information about lawn mowers (which you may not even need) as you are with health information? How soon would you turn off and drop out? Now, what makes health information so compelling? At its root, it’s a catalog of ways to die. There are ways to dress it up, but charging ahead under the assumption that living’s easy is not the way. High utilizers are often the most likely to have at least one uncontrollable risk factor. How well are you illuminating what’s controllable and what’s not? And when you put together your health/disease education modules, shouldn’t you overlay all the content with incentive to actually use it?

We need to address the barriers to optimal decision-making head-on, rational or not. These include lack of self-efficacy, emotion/information overload and a perception that inputs relate poorly to outputs (everyone hears about the runner who dies of an early MI). P4P and CDHC designs in and of themselves cannot drive outcomes and may even make things worse. So we need to address the most pressing patient questions head-on:

  • How important is making this decision? What are the risks and benefits of doing nothing vs. acting?
  • How controllable is the risk of acting? Can the risks be spread out by making a series of decisions over time?
  • What are the best and worst cases?
  • How achievable is a positive outcome?
  • How predictable are the positive and negative consequences?

In short, we can help deciders prioritize their decisions to optimize the achievable delta. Rather than agonize over which multivitamin to buy this month, what if I can spend that energy on overcoming my addiction to sweetened fruit drinks? The reason that so many people read Prevention, a monthly digest of often contradictory information, is that when its authors make a declarative statement, they are usually fairly good about telling readers how to implement it in their own lives. How well do your Web site, direct mail, brochures and e-mails do that? And no, “it’s easy to eat 5-7 vegetable servings per day” doesn’t count, because it’s not easy!


Today, tests for the extent of health literacy (e.g. the ability to read a product label) don’t measure the propensity to follow the label’s instructions, take it seriously, extrapolate it to other health decisions, etc. These are where motivation to spend time on the key decisions and wade through all the extraneous and repetitive information comes in.

Now imagine it’s 2017, and there are robust question batteries that reliably predict the capacity for and propensity to use health literacy. When rating or treating a group or individual, wouldn’t you want to combine this assay with medical underwriting and the patient’s past ratio of achieved to achievable health improvement, since the three together have a more direct effect on costs and outcomes?

So what is your organization putting into place today, to prepare you to develop, implement and/or integrate this algorithm in 2017? And underlying this entire fantasy has to be real-time access to claims and/or chart data, with the clinical and communication savvy to use these data intelligently. How close are you there?

Next…what self-administered risk assessments do and don’t do…and what might work better.