can you find the people you can help? can you help the people that you find?

Can You Find the People YouCan Help? Can You Helpthe People that You Find?Julie A. Meek

Indiana University School of Nursing and The Haelan® Group, Indianapolis, Indiana, USA

Abstract Because of recent upsurges in medical costs, health plans, employers, and thegovernment will increasingly demand solutions that stretch performance bound-aries with regard to quality of care, provider and member satisfaction, and nearterm cost benefits.

The health management industry is awakening to three trends that will revo-lutionize the way we provide healthcare: (i) what we look with and what we lookfor determines how we view health and subsequently how we choose interven-tions and solution sets; (ii) finding the people we can help requires us to broadenour thinking to include non–disease-based factors as drivers of care-seeking be-havior; and (iii) the convergence of new knowledge and new technologies setsthe stage for disruptive innovation in the way care is delivered, thereby providingan unprecedented opportunity to extend performance boundaries.

This article details the rationale behind the three trends listed above, whichare shaking the traditional foundations of health management and which, takentogether, will usher in a dramatic improvement in quality of care and financialoutcomes for entities that manage the health and care of populations.

CURRENT OPINION Dis Manage Health Outcomes 2001; 9 Suppl. 1: 13-191173-8790/01/0001-0013/$22.00/0

© Adis International Limited. All rights reserved.

1. The Opportunity

Health plans and employers have experienced areturn to significant increases in medical costs, de-spite the implementation of managed care and nu-merous other utilization management strategies.[1]

As they run out of ideas, and with limited resourcesand an even greater requirement for near term re-sults, health plans, employers, and the governmentwill demand solutions that stretch performanceboundaries with regard to quality of care, pro-vider/member satisfaction, and near term costbenefits.

2. Awakenings

The Holy Grail of managing the health and as-sociated medical cost of a population is this:• Can you find the people you can help?• Can you help the people that you find?

The industry’s traditional thinking about howbest to answer these questions is being shaken. It’stime for those of us who expend considerable pro-fessional effort focused on population health man-agement (PHM) to consider that how we currentlyperceive, think about, and solve the problems asso-ciated with PHM provides the opportunity to

stretch performance boundaries further than wehave ever thought possible.

The PHM industry is awakening to three emerg-ing trends that will revolutionize the way we pro-vide healthcare:1. What we look with and what we look for deter-mines how we view health and subsequently howwe choose interventions and solution sets.2. Finding the people we can help requires us tobroaden our thinking to include non–disease-basedfactors as drivers of care-seeking behavior.3. The convergence of new knowledge and newtechnologies sets the stage for disruptive innova-tion in the way care is delivered, thereby providingan unprecedented opportunity to extend perfor-mance boundaries.

3. The First Awakening:A New View of Health

How we view a phenomenon – such as the do-main of health – greatly influences how we sub-sequently think about and approach solving prob-lems. Pearsall[2] suggests that ‘we see what we lookfor and create what we see by how we see’. Con-sider the revolutionary changes that occurred in theworld of Newtonian physics in the early part of the20th century. Farraday, in his discovery of forcefields, i.e. seeing energy as waves versus particles,and later Einstein with his theory of relativity, andthen later the evolution of subatomic physics shat-tered all the deeply held beliefs about Newton’sparticle theory and the separateness of space andtime.

Think about this with respect to health. Table Idemonstrates that, as different providers within thedomain of health, what we look with and what welook for determine how we view health and sub-sequently how we choose interventions and solu-tion sets. None of these views are wrong. However,it’s important to be aware of how we might be ex-trapolating the clinical/medical model of health tothe domain of care seeking, which is primarily abehavioral versus a clinical phenomenon, and sub-sequently to PHM. Medicine’s contribution tohealth is the diagnosis and treatment of disease andinjury. When the medical view of health is adopted,it only follows that to find the people you can helpdemands a predictive model that looks for peoplewith chronic disease and then provides care to pro-actively manage those members of a population toimprove compliance behaviors, lower the numberof acute episodes, and thus lower costs. The mor-bidity/mortality-based approach to care wouldwork well if cost were exclusively associated withthe presence of disease and injury, but how signif-icant in terms of encounters and costs are the mem-bers of a population who do not have a diagnosabledisease or injury, yet continue to seek and usehealthcare resources?

Physical discomfort resulting from stress is oneof the more common reasons people seek medicalcare. A 20-year study at Kaiser-Permanente byCummings and VandenBos[3] concluded that morethan 60% of all medical visits were by those withsymptoms for which their physicians could find nodiagnosable disorder. Barsky[4] reports that, whileonly 10 to 20% of patients presenting in a primarycare setting have a diagnosable psychiatric disor-

Table I. Different views of health

Provider What we look with What we look for Health as:

Exercise physiologist Submaximal cycle ergometer V.O2max Optimal cardiorespiratory

endurance

Cardiologist Echocardiograph Heart wall motion; stroke volume Optimal stroke volume

Health plan medical director Claims database analysis ofencounters/costs

Length of stay, cost per DRG, clinicalguideline compliance

Optimal quality of care atoptimal cost

Disease management vendor Claims database analysis forcertain ICD-9s

Compliance with treatment regimens;prevention of acute episodes

Optimal management ofchronic disease

DRG = diagnosis-related group; ICD-9 = International Classification of Diseases-Ninth Revision; V.O2max = maximum oxygen uptake/con-

sumption.

14 Meek

© Adis International Limited. All rights reserved. Dis Manage Health Outcomes 2001; 9 Suppl. 1

der, upwards of 80% show evidence of significantpsychological distress. Consider another study:Kroenke and Mangelsdorff[5] analyzed the recordsof more than 1000 patients from an internal medi-cine clinic who were followed-up for over 3 years.The 14 most common symptoms were investi-gated. The probable etiology was established asorganic in less than 16% of symptoms, while 74%were of unknown etiology. Only 10% of symptomswere identified as psychological.

The previously mentioned studies show that themedical view of health may work well for thosewhose care seeking is a result of disease or injury,but may not work well for those with other factorscontributing to their care seeking. The industry isawakening to a new view of health that relatesmore closely to care seeking as a behavioral phe-nomenon with associated costs. This new view ofhealth is called the Perceived Health Model and iscontrasted with the traditional view of health intable II. The Perceived Health Model, as concep-tualized by Lyon,[6] defines health as a person’scomposite evaluation of how he/she is feeling anddoing. People experience health as either somelevel of wellness or illness. If a person is experi-encing unpleasant or uncomfortable physical sen-sations and/or emotions, in addition to not func-tioning up to their perceived level of capability, theperson perceives some degree of illness. Some de-gree of wellness, on the other hand, is perceivedwhen the person experiences pleasant/comfortable

physical sensations and emotions combined withan acceptable level of self-evaluated functioning.The critical difference between the PerceivedHealth Model and traditional views of health is thatthe Perceived Health Model recognizes that a per-son can experience wellness in the presence or ab-sence of disease. For example, a person who hasdiabetes can experience wellness, i.e. from his/herperspective may be feeling and doing well. Con-versely, many a clinician has been frustrated in theeffort to help a person experiencing illness in theabsence of discernable disease. From a practicalviewpoint, people seek care when they have fallenbelow their normal levels of feeling and doing.Because this gap between how a person feels andhow they perceive they should be feeling is moreclosely associated with care-seeking behaviorthan clinical diagnoses, the Perceived HealthModel provides higher predictive power when tar-geting those at risk for high near term healthcareuse.

It’s important to note the increasing evidencethat perception is also a powerful predictor of careuse and eventual care outcomes even with patientswho have known clinical disease. Salaffi et al.[7]

conducted a study where they examined the degreeof disability and pain in those patients with osteo-arthritis of the knee. They found that the patient’slevels of anxiety and depression were better pre-dictors of pain and disability than the extent of an-atomical damage to the knee, as demonstrated byradiographic studies. Sobol[8] provides an excel-lent review of studies which demonstrate the rela-tionship between psychological factors and clini-cal outcomes for cardiovascular disease, arthritisand those with chronic pain, and outcomes fromsurgical procedures and childbirth.

The point here is that the medical model ofhealth as treatment and prevention of disease/injury,while most useful when applied to those with clin-ical disease or injury, is limiting when the etiolo-gies of care seeking are multifactorial. Psychoso-cial factors, perceptual/attribution factors, beliefs,preferences, health practices, etc. are areas that re-ceive limited attention, yet have a powerful influ-

Table II. A new view of health: health perception science

Current view New view

Health Lack of disease A person’s compositeevaluation of how they’refeeling and doing

Illness Presence of disease The experience of somelevel of uncomfortable/unpleasant sensationsand/or emotions combinedwith functioning lower thanperceived capability level

Wellness Lack of disease The experience ofcomfortable/pleasantsensations and/or emotionscombined with functioningat/near perceived capabilitylevel

Disruptive Innovations in Healthcare Delivery 15


ence on health outcomes, levels of care seeking,levels of compliance, and frankly – cost. So a newview of health is the most important first step. Thenext step is to consider how our view of healthinfluences our ways of thinking about what we willinclude/not include in our box of tools to find thepeople we can help and then help the people wefind.

4. The Second Awakening: Finding thePeople You Can Help

Consider how a new view of health would trans-late into thinking outside the box with regard tofinding the right people to help – that’s the firstchallenge. Werner Heisenberg, one of the most bril-liant physicists of the 20th century thoughtfullyposits that, in the history of human thinking, themost fruitful developments frequently take place atthose points where two different lines of thoughtmeet.[9] This describes the second awakening goingon in our industry today – we are in the midst ofinnovative developments because two differentlines of thought are converging.

Can you find the people you can help beforethey present in acute crisis? If your view is thatonly those with particular chronic conditions costyou money, or that those who are at risk of earliermorbidity/mortality and those who do not complywith treatment regimens/lifestyle changes repre-sent high costs, then you will use either health riskassessments or claims-based methods to stratifyand target those individuals. Certainly, those meth-ods identify members of populations who trulyneed proactive care – but is there a way of expand-ing our thinking to capture not only those people,but also others whose care seeking-behavior isdriven by non–disease-based factors? Consider thefollowing studies, which begin to bring togethertwo lines of thought, predicting morbidity andcare-seeking behavior due to other factors.

The Health Enhancement Research Organiza-tion (HERO) study conducted by Goetzel et al. wasan analysis of both the Health Risk Assessmentdata and the corresponding claims of 45 000 peo-ple.[9] The authors of the study reported that the top

two predictors of near term care-seeking behaviorwere high levels of self-reported depression andstress. Terry et al.[10] conducted a cross-sectionalstudy in a group model health-maintenance organi-zation in Minneapolis using both adult (3825) andsenior (1955) populations, comparing responsesfrom a mailed survey with medical encounter andexpenditure data. Bivariate analysis and multivar-iate linear and logistic regression, controlling forage, gender, and health status were conducted toillustrate the relationship between selected risk fac-tors and healthcare use. The analyses demonstratedthat traditional risk factors such as smoking status,alcohol use, obesity, and lack of exercise wereweak and inconsistent predictors of short termmedical charges (12-month). Seniors who reportedbeing unhappy had significantly higher healthcarecharges and were also significantly more likely tohave had an inpatient stay. The conclusion of Terryand colleagues was that we might receive highershort term gains by focusing on improving mentalhealth status rather than by reducing classic riskfactors.

Meneades et al.[11] recently submitted a study ofcare utilization to The Institute for Health & Pro-ductivity which analyzed the inpatient and outpa-tient care use of individuals nationwide who werecovered by more than 160 non-capitated benefitplans offered by 61 large employers. The plans in-cluded the following: fee-for-service; point-of-service; and exclusive-provider organization/preferred-provider organization. The study dem-onstrated that two-thirds of the patients and three-fourths of the costs were not explained by the topten most costly disease conditions. With that inmind, it begs the question: how can we have a sub-stantial impact on cost if our current disease man-agement efforts are focused on just two or three ofthose top ten conditions? Do the math. Secondly,this particular study excluded symptoms, signs,other conditions, nonspecified symptoms, andother conditions from the data analysis, therebymissing an opportunity to explore the cost burdenof nonclinical drivers of care-seeking behavior.

16 Meek


To test the notion that perceived health factorsmight provide higher predictive power, Meek etal.[12] conducted a study to determine the predic-tive validity of a health perception assessment toaccurately predict those who would become highcare users in the near term (6 months). From a sam-ple of 4210 commercial enrollees of the health plan(ranging in age from 18 to 65 years), responses toan initial perceived health assessment were used tobuild a predictive model that employed healthcareencounters over the ensuing 6 months as the de-pendent variable.

A formula was developed from the resulting lo-gistic model and then tested on the first split-halffor levels of sensitivity and specificity. The chosenpredictive formula was then tested using data fromthe other half of the sample. The resulting predic-tive model included 39 health perception assess-ment variables, correctly predicting 68.1% of thehigh care users and 61.9% of the low care users.The final logistic model was converted to a for-mula, resulting in a probability score for eachmember, which indicated the likelihood the personwill become a high care utilizer in the near term.This formula was tested on both split-halves of thepopulation, yielding 66.7% sensitivity, 63.4%specificity on the first split-half, and 59.4% sensi-tivity, 53.3% specificity on the second split-half.This study demonstrated that easily ascertainedself-reported factors predict an adult’s probabilityof becoming a near term high care user. Use of apowerful self-report survey overcomes many ofthe limitations of less predictive traditional healthrisk/status models or cumbersome claims stratifi-cation methods.

In summary, the industry is awakening to newways of thinking outside the box – of discoveringbetter ways of finding the right people to help.Now the next challenge – can you help the peopleyou find?

5. The Third Awakening: Helping thePeople You Find

In a recent publication, Christensen et al.[13]

suggest that in healthcare we’ve focused our dol-

lars and energy so highly on curing complex andadvanced diseases that we’ve missed the opportu-nity to provide simple, more convenient, and lesscostly solutions that would appeal to, and make adifference in, a broader section of the population.They point out that the majority of our healthcareinstitutions are in a ‘lockstep march toward themost scientifically demanding challenges’. Theyalso point out that, while our medical schoolschurn out specialists and sub-specialists with ex-traordinary capabilities, the vast majority of us suf-fer from relatively straightforward disorders thattap a mere fraction of what our medical schoolshave prepared physicians to do. Similarly, the Na-tional Institutes of Health are funding research tocure disease, while spending much less on learninghow to provide systems of care management thataddress the factors causing the majority of us tofeel ill from time to time and thus potentially con-tinue to seek non-beneficial care. Christensen etal.[13] call for disruptive innovation in the funda-mental ways we deliver care that would enable alarger group of less skilled individuals to act inmore convenient, less expensive settings, to pro-vide services previously available only throughspecialists working from centralized locations.

So, in the context of PHM, what would a dis-ruptive innovation look like? And if such a disrup-tion could be created, could you manage it in a waythat would produce quality of care and cost effec-tiveness? Let’s take an example that we’re familiarwith and create an analogy to healthcare (see tableIII).

Christensen et al.[13] discuss the disruption thatpersonal computers (PCs) created in the computingindustry. In the 1960s, when people needed com-puting help, they had to take their punch cards tothe corporate or university mainframe and wait inline for the data-processing specialists to run thejob for them. PCs were regarded as disruptive tech-nologies by mainframe makers. At the outset, PCswere not as capable as mainframes (rememberwhen we all carried around our floppy discs withour programs on them?) and, as a consequence, theprofessionals, who operated the sophisticated



mainframes, and the companies that suppliedthem, discounted the value of PCs. But PCs en-abled people to solve problems for themselves thathad required centralized computing facilities andcaused inconvenience. Thus, PCs enabled themasses to compute on their own time and in theconvenience of their own homes and workplaces.Some other examples: George Eastman’s cameramade amateur photography widespread; Bell’stelephone helped people communicate without theprofessional telegraph operators; photocopyinghas now replaced what used to be sent to printers;and on-line brokerage has our college-age childrenmanaging their portfolios online. Disruptive tech-nologies have improved the quality of our lives tre-mendously. Our system of delivering care to pop-ulations needs to be transformed in the same way,and this is now possible because of new knowledgeand new technologies.

Firstly, recent findings show that there are shortterm interventions with an excellent impact on nearterm care-seeking behavior. A variety of studiesdemonstrate the beneficial effect that brief situa-tional mental health counseling,[14-15] group train-ing in stress management,[16] and self-managementtraining[17] can have on care seeking, with associ-ated cost savings. Sobel[8] states that there appearsto be a biology of self-confidence, a core set ofattitudes, beliefs, and moods that predispose to-ward a sense of wellness in general. Whether calledhardiness, optimism, self-efficacy, coherence, senseof control, connectedness, happiness, or pleasure,these core factors are related to a wide range ofoutcomes: improved physical and mental symp-tomatology, onset of disease, mortality rates, andhealthier behaviors. So the lesson is that interven-tions that target a specific disease or condition, orfor which behavior change is the desired goal, will

have a broader impact if these underlying attitudes,beliefs, and moods are also included as part of theintervention pathway.

Secondly, we have new technologies that makeit possible to provide highly customized, timely, andeffective interventions. A variety of new technolo-gies, including innovations in interactive voice re-sponse technology, home monitoring devices,hand-held devices, touch screen technology, vari-able data printing, and all of the recent innovationsin web-based technology now make it faster, easier,and cheaper to deliver what was once too cumber-some or too expensive to consider for the entirepopulation. These innovations will enable peopleto access the care they need from their homes andwork stations, at a time that is most convenient andwhen they are most ready to receive help from careproviders, and at a cost that will make it viable forvendors to innovate and compete in the market-place. Intervention modalities that were once onlyavailable through visits to specialists and sub-spe-cialists will become widely available throughwebsites, where content is widely accessible andparticipants may communicate online with healthadvocates. The best behavioral and situationalstress counseling techniques will be embedded inonline interactive health counseling services, pro-viding short term mental health treatments pre-viously only available through individual visits tomental health counselors, lifestyle change counsel-ors, or group support programs. Home monitoringdevices will automatically screen vast numbers ofpeople with chronic disease and provide follow-upto those with significant changes, a service pre-viously requiring a doctor or home nurse visit. Insummary, we are rapidly moving to an age wheretechnology is transforming the way we delivercare.

Table III. Disruptive technology as it relates to healthcare

Disruptive characteristics Computing industry Healthcare industry

Enable a larger population of less-skilledpeople to act...

The end user with online and softwarehelp guides

The member/employee/consumer with helpfrom online help and nurse health advocates

In a more convenient, less expensive setting... In their own home In their own home or from their workstations

Doing things that historically could only beperformed by specialists in centralizedlocations...

Versus computing using dataprocessors and mainframe computingcenters

Versus receiving non-beneficial care fromdoctors/specialists in office/inpatient/outpatientsettings

18 Meek


6. Conclusion

The convergence of new knowledge and newtechnologies sets the stage for true innovation inthe way care is delivered. Industry awakeningswith regard to the way we view health, build solu-tions, and approach care management provide anunprecedented opportunity to stretch boundaries interms of quality of care, provider and member sat-isfaction, and financial performance.

Acknowledgements

The pilot results reported in this manuscript were sup-ported in part by work performed under contract withChoiceCare, now owned by Humana Insurance Company,and Proctor & Gamble, in Cincinnati, Ohio. The design,conduct, interpretation, and analysis of the study as well asthe writing of the manuscript were completed solely by theauthor.

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Health Care Expenditure Projections: Table 2 [online]. Avail-able from URL: http://www.hcfa.gov/stats/ [Accessed 2000Nov 2]

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3. Cummings NA, VandenBos GR. The twenty year Kaiser-Per-manente experience with psychotherapy and medical utiliza-tion: implications for national health policy and nationalhealth insurance. Health Policy Q 1981; 1 (2): 159-75

4. Barsky AJ. Hidden reasons some patients visit doctors. Ann IntMed 1981; 94: 492-8

5. Kroenke K, Mangelsdorff AD. Common symptoms in ambula-tory care: incidence, evaluation, therapy, and outcome. AnnInt Med 1989; 86: 262-6

6. Lyon B. Stress, coping and health: a conceptual overview. In:Rice V, editor. Handbook of stress, coping and health: impli-cations for theory, research and practice. Thousand Oaks, CA:Sage Publications, 2000: 3-23

7. Salaffi F, Cavalieri E, Nolli M, et al. Analysis of disability inknown osteoarthritis: relationship with age and psychologicalvariables but not with radiographic score. J Rheumatol 1991;18: 1581-6

8. Sobel DS. Rethinking medicine: improving health outcomeswith cost-effective psychosocial interventions. PsychosomMed 1995; 57: 234-44

9. Goetzel RZ, Anderson DH, Whitmer RW. The relationship be-tween modifiable health risks and health care expenditures:an analysis of the multi-employer HERO health risk and costdatabase. The Health Enhancement Research Organization(HERO) Research Committee. J Occup Environ Med 1998;40 (10): 843-54

10. Terry PE, Fowler EJ, Fowels JB. Are health risks related tomedical care charges in the short-term? Challenging tradi-tional assumptions. Am J Health Promot 1998; 12 (5): 340-7

11. Meneades L, Stewart M, Ozminkowski RJ, et al. Industry-spe-cific medical care utilization and expenditures. Houston,Texas: Institute for Health and Productivity Management, Oct1999. Internal Report (Data on file)

12. Meek JA, Lyon BL, May FE, et al. Targeting high utilisers:predictive validity of a screening questionnaire. Dis ManageHealth Outcomes 2000; 8 (4): 223-32

13. Christensen CM, Bohmer R, Kenagy J. Will disruptive innova-tions cure health care? Harv Bus Rev 2000 Sep-Oct; 78 (5):102-12

14. Mumford E, Schlesinger HJ, Glass GV, et al. A new look atevidence about reduced cost of medical utilization followingmental health treatment. Am J Psychiatry 1984; 141: 1145-58

15. Pallak MS, Cummings NA, Dorken H, et al. Effects of mentalhealth treatment on medical costs. Adv Mind Body Med1995; 1 (1): 7-12

16. Hellman CJ, Budd M, Borysenko J, et al. A study of the effec-tiveness of two group behavioral medicine interventions forpatients with psychosomatic complaints. Behav Med 1990;16: 165-73

17. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggestingthat a chronic disease self-management program can improvehealth status while reducing hospitalization: a randomizedtrial. Med Care 1999; 37: 5-14

About the Author: Julie Meek, DNS, is founder and CEOof The Haelan Group. Her research interests focus onpredictive modeling, health management and outcomesmeasurement.Correspondence and offprints: Julie A. Meek, Chief ScienceOfficer, The Haelan® Group, 748 E. Bates Street, Suite 103,Indianapolis, Indiana 46202, USA.E-mail: [email protected]



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