By Barbara Bronson Gray, MN, RN
Demand management--giving people information that helps them use medical care appropriately--is playing an increasingly important role in the efforts of hospitals, HMOs, and health organizations to create informed consumers.
Some say demand management is the only promising route to reforming health care and toppling the more-is-best philosophy that has fueled the rising demand for health care since the advent of Medicare legislation in 1964. "It's about reforming health care from the bottom up," said Molly Mettler, MSW, senior vice president of Healthwise, a nonprofit health education organization in Boise, Idaho.
Experts say the goal of demand management--some prefer the term shared health management--is not to reduce the demand for services or to restrict access to care. Rather, it is to provide resources to help people make better decisions about self-care. One way it does this is by helping consumers decide whether to seek medical attention for illnesses or injuries or to treat themselves. Proponents say that demand management often has the fortunate effect of voluntarily reducing the demand for professional health care.
"Eighty-five percent of the care in this country is already self-administered," said Wendy Lynch, PhD, senior scientist with Health Decisions International in Golden, Colo., a company that specializes in demand management products and services. "About 30 percent of all emergency department visits are not necessary, and two out of 10 visits to the doctor are not required."
Some market analyses have projected that at least 200 million Americans will have access to demand management services within the next few years; the total market is estimated at more than $2 billion.
When Lynch started in health promotion a few years ago, she was discouraged to discover that claims data showed that healthy behavior did not necessarily result in decreased healthcare costs. "People had patterns in how they sought care," Lynch said. "Research shows that what predicts whether you'll seek health care has little to do with how sick you are."
The medical model has typically ignored the key period between the discovery of a problem and assessment by a health provider, according to Lynch. "We forgot that there's this process people go through that involves their perceptions, their fears, their feelings about how good medical care is, and what their mothers and friends say they should do."
Some firms have developed systems to better predict who will be most likely to use high-cost services. The goal of such systems is not to disqualify such individuals from health coverage, but to identify who is likely to benefit from education about what needs to be evaluated professionally and what can be managed from home, Lynch said. "We say that if we identify those people most likely to bump into health services, we can help give them support in making a medical decision," she said.
The University of Michigan Fitness Research Center in Ann Arbor has created a questionnaire to forecast who will be most likely to use higher-cost healthcare services in the next two to three years. The questionnaire is part of a broader demand management program and focuses on predicting short-term morbidity, costs, and utilization to estimate future demand.
Part of the demand management work at the Fitness Research Center involves 20-year longitudinal studies that track lifestyle behaviors to determine their impact on healthcare use and health. One study, involving workers at Steelcase Inc. in Grand Rapids, Mich., includes 4,000 employees who are being tracked over 20 years, beginning in 1985. The data obtained 10 years into the study showed that employees who were considered high-risk in 1985 but who shifted to low-risk behaviors by 1988 had much lower medical claims from 1988 to 1990 than did those who did not shift to low-risk behaviors.
"But fitness and health alone don't change an individual's utilization of health services," said Elaine Schnueringer, MA, research associate at the Fitness Research Center. Unless a consumer's fears, feelings, and decision-making style are addressed, data shows the actual use of health services may not change as health improves, she said.
Lynch's Health Decisions International provides comprehensive demand management that includes nurse counseling on a toll-free number, a program called Informed Choice. Nurses refer to Windows-based computer software and explain various care options to patients rather than recommending a single course of action. Nurses must have more than three years of clinical experience and be committed to encouraging patients to make decisions for themselves based on exposure to the necessary information, Lynch said.
Mettler said the mission of demand management is to teach consumers self-care and help providers adapt to the new philosophy. "Our belief is that if people are informed about what they can do for themselves and in partnerships with providers, they will get better quality care, be more satisfied with their care, and save money," she said.
Mettler is project director of the Healthwise Communities Project, funded by a $2.1 million grant from The Robert Wood Johnson Foundation and matching money from Healthwise, Blue Cross of Idaho, MSB Blue Shield of Idaho, and other employers and healthcare organizations.
The project, which involves the 278,000 residents of four counties, includes the distribution of The Healthwise Handbook, a 334-page self-help paperback that covers 180 health problems, to all residences and the Healthwise Line, a toll-free telephone service staffed by specially trained nurses who provide counseling and in-depth medical information. The project also includes seminars for physicians, nurses, and office staff on shared medical decision making; Healthwise information stations, self-care resource centers open to the public that provide books and electronic health information systems; and workshops for consumers on medical self-care skills and medical consumerism.
Providers are taught to support patients in their self-care efforts and to work within a shared medical decision-making model, offering real choices between treatments and approaches and allowing patients to decide whenever possible. The entire model is based on recognizing the consumer as a partner in providing health care, Mettler said.
Some organizations have purchased The Healthwise Handbook to distribute to their members and employees. Kaiser Permanente in California has distributed over 2 million copies to members throughout the state, according to Frayne Rosenfield, MPH, administrator for health promotion for Kaiser Permanente.
The handbooks are part of an attempt to spur member confidence and self-care capability and teach patients how to use time with healthcare providers more effectively, Rosenfield said. The text, a modified version of the one distributed in Idaho, includes an ask-the-physician checklist and advice for getting the most out of a medical appointment.
Some experts predict demand management will change the practice of nursing, eventually offering scores of new jobs that draw on a broad base of clinical and communication skills. Some predict the field will eventually encompass utilization review and case management responsibilities as much as health education.
Nancy Nadolski, RN, a health educator with Healthwise, spends her day arranging community workshops; talking to nursing, physician and other provider groups about the program; and teaching consumer workshops in an area that spans 9,000 square miles. She said teaching according to the Healthwise model is unique. "I'm asking people to come together and make decisions rather than looking to me as the expert," she said. For example, when Nadolski sets up information stations, she asks residents to decide which books will be the most helpful to them.
For Pam Weinberg, MPA, RN, director of operations for Healthwise, demand management differs from the typical approach to reducing healthcare cost. "Traditional health reform is based on what to do to make care cheaper and to limit access," she said. "Our approach is very different: All the focus is on the patient, and it allows patients to decide how much of the healthcare buffet they want to take advantage of. It's about allowing you to choose when you want to go to your doctor."
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