Making the Case for Consumer Health Education in Managed Care

Moderator: Gail H. Knopf, Vice President and Chief Information
Officer, Humana, Inc.

David Cochran, M.D., Associate Medical Director for Clinical
Practice Systems, Kaiser Permanente, Mid-Atlantic

Edward Bergmark, Ph.D., President, OPTUM Division, United Health
Care Corporation


* Dr. David Cochran *

I'm here to talk about managed care's comfort with technology.

What I would like to do is talk about how managed care looks at
itself.  There's been a lot of discussion during the past two days
about the role of information and how we can use it to help our
patients.  But there has to be some bottom line analysis.

We need to understand how we look at the evolution of our industry
and we need to look at how we view our own industry and the role of
self-care and information technology in the evolution.  How it can
be used in helping our patients.

I'd like to talk a bit about an analysis that was presented by Jeff
Olstead (?) of the Public Health Association about two years ago. He
was a University of Chicago policy analyst who looked at managed
care as a new industry.  He wanted to find the driving forces in the
growth of the industry and predict where the forces would be as time
goes forward.  The analysis divided up the evolution into 3 stages.

1.  The stage in which managed care companies are trying to find a
nice in a market dominated by government insurers.  Companies could
be successful by simply shadow-pricing government insurers.

2.  Managed care companies are marginally computing with managed
care companies.   Companies are successful by changing the delivery
system left over from the fee-for service model.

3.  Development of managed care industry.  managed care companies
are still the primary insurers and companies will not be successful
if they fail to offer what the patients want.  Some of the tools
that we've been talking about can be applied

Basically, in stage one, mainly people are focused on the price of
service and the availability of hospital beds.  Managed care
organizations are successful simply by shadow pricing fee-for-
service in that environment.  But, as you move across that continuum
there are 2 main differences that create focal points.  One of the
focal points is a new emphasis on directly working with the patient.
The other is that simply bargaining on price is of limited short
term value

In the second stage, where most of the developed markets are now, we
find an increased emphasis on controlling resource intensity --
improving the delivery system.  In this area the focus is on working
to improve the system and particularly on improving the perception
of the experience of care.  Buyers are buying in part based on
customer satisfaction.  You need to get feedback from buyers, taking
the high cost areas and trying to reduce the cost.  Looking at the
variables,  we need to monitor the outcomes and get feedback from
employers.  In this stage we need to focus on building off the
public rather than building off the disease.

In the next stage -- development -- we see consolidation of managed
care companies, and a company is successful if it has a lower cost .
What's been happening in most of our markets is consolidation.

There is no doubt that our patient population looks like the
community in which it lives.  And we're trying to sign up the
healthier patients -- whether that's a conscious effort, or an
unconscious manifestation.  And we need to recognize our communities
so that in practice we can compete on networks. We need to compete
on designing programs that will make our customers healthier than
our competitors' networks -- in the end we'll have a healthier
population.

At that point, that's where we use tools to link up to connect that
population.

Then we look at sub-populations.  We start looking at whether
there's some sub-populations at risk.  We need to take our managed
care programs that were hospital based and extend them into the
community.

We also need to make an effort to identify early on the services
required to maximize the "moving up" stream -- the early prevention,
the low intensity, preventative care -- to be sure the components of
those programs are linking together and integrating.  We look for
cracks, that's where are programs suffer.

So instead of looking vertically down into the program --  we look
at "what are the experiences for this person..." -- and we try to
fix it from there.

We need to build prevention strategies for the community -- we go to
healthy people 2000, surveys, we collect data sets, strategies for
screening, our solutions and our problems from the perspective of
the solutions and problems of the larger medical community

How do we help patients understand their role in managing their
conditions early on?  How do we help them become active and involved
in treatment?

The provider way of focusing on lifestyle health risks is to attempt
to teach them to understand  what they do-- give them information
and understanding of what the options are -- people are engaged in
taking care of themselves.

To summarize -- as we've evolved, we're evolving toward different
types of tools.  If we don't understand the patients needs for care
than we won't be successful in the information age.


* Edward Bergmark *

The issue here is actually changing behavior and information is only
a tool to get the desired behavior out of the people we're trying to
reach.

There was a direct question earlier in one of the sessions: "do you
think people will make better decisions if they have more
information?"  I think that we need to carefully evaluate that
question.   Making a decision has been viewed during this conference
as a rational process but the decisions we're asking people to make
are tremendously emotional but there are no attractive alternatives.
We talk about how we provide information, but we also need to think
about how we help people make decisions with that information.

In making the case for managed care in this process -- in a sense,
if we look at the current situation, it's the physician who's really
the salesperson -- it's not hard to see why that's an economic model
that will not last over time.  It lacks checks and balances.  But if
you stop looking at economic incentives, we see it can't be
sustained.  we have to figure out where education fits into the
process

What do we see companies doing today?  Defined contribution plans.
What are we finding?  People don't manage their retirement well.
They have the information, and it will catch up to them sometime.
But less than 10% of the baby boomers are taking advantage of the
possibilities.  we're trying to make a transition into a new system.

When we look at managed care, we need to drive incentives to that
all increases are in the same direction -- right now the payers have
one incentive, the physicians have another, and the patients have
another.  We should, in theory, be able to come up with a far better
process.

There are a range of incentives for us to examine as we look at the
unsustainable economic medical system.  If we don't line up all the
incentives, ultimately, the system will become more and more out of
whack and unstable.

It is the system that is providing the care -- and the system is
made up of many, many people, not just doctors.  They (consumers)
are evaluating the entire system as a whole -- does this system give
the kind of care that I want?  As a managed care provider, one of
the things that we do is provide information.  But if you look at
the distribution channels available today --  books, magazines,
pamphlets, information over the phone -- we can assist with a broad
range of problems in a manner that works for them.  We want to be
able to provide information when it's needed and in a format that
helps the patient.  In the current system, the production costs are
high, the distribution costs are high, and we are always searching
for better ways to get information to the patient.

We know from surveys that news services are very useful -- 99% of
those surveyed say that the news services are important -- but it's
hard to target that service.  we're interested in introducing a low
fixed-cost system rather than a high variable-cost system -- to
present information more efficiently.

We also know that the way to change human behavior is through
repetition.  You have to have it in front of people over and over.
As a medical provider, we have no way of getting the information out
to patients in that way.  New technologies give us a way to do this
on a very targeted basis.  It offers a lot of potential.  It's also
very efficient for the consumer if we design it effectively.

There are three important components to an effectively designed
system:
navigation,  credibility,  and volume.

Volume is important because there are two separate groups which we
need to give information.  The first group, has medical problems
that we know how to treat (ex. pregnancy).  There aren't a lot of
difficult decision points along the way.  The new technology allows
us to take the people through the process incrementally, little by
little.  The second group is the people that have to make extremely
difficult decisions.  It can be very hard to overcome emotional
hurdles and process the information that's given to us and make good
choices.  The second group is very different from the first in that
they're more likely to want an enormous wealth of information.  If
we can target this need, we'll be one step ahead.

It's important to recognize that the most important characteristics
of individuals that we serve are intelligence, education, and
reading levels.  These are the characteristics that will best tell
us how able a patient is to make choices using the information given
to them.  Some of us are better at decision making processes and
some of us aren't.  We need to be sure that there are simple systems
in place so that people aren't frustrated by the system.

The goal is constructive change.  That means packaging information
and thinking of it as packaged information and making sure that it
can be used as packaged information.


* Gail H. Knopf *

John Dewey is unable to join us -- so I will give a little
information on what we're doing at Humana.

Humana started in the early 60's in the hospital business.  We are
purely a managed care company now.  We now have 2.9 million members.
We also have a large Medicare/WIC population.  We own National
Prescription Services.  We have a lot of members in HMO plans.  The
most recent thing we've done is created a data warehouse for primary
care providers.  We've also started physicians on-line.