PREVENTIVE SERVICES AND COUNSELING

Keeping Members Well with Information and Incentives

Preventive care is at the heart of the primary care provider's work. Its importance in managed care is underscored by the very name health maintenance organization. The benefits of incorporating prevention into medical practice have become increasingly apparent over the last 30 to 40 years, as previously common and debilitating conditions have declined in incidence following the introduction of effective clinical preventive services. Services for the early detection of disease have been associated with substantial reductions in morbidity and mortality. [1] The most promising role of prevention in medical practice may lie in changing the personal health behaviors of patients. Growing evidence links leading causes of death in the United States, such as heart disease, cancer, stroke, COPD, accidents and HIV infection, to a handful of personal health behaviors. [2] Yet studies show that clinicians often fail to provide recommended preventive services. Common reasons cited include inadequate reimbursement, fragmentation of delivery and insufficient time. Even when these barriers are accounted for, clinicians fail to perform preventive services as recommended, suggesting that there is uncertainty as to which services should be offered. [3]

This health plan felt that preventive services and counseling rates would be likely to improve if every encounter was seen as an opportunity to address preventive care needs.

The plan had previously put efforts into improving individual preventive services such as mammography, Pap smears, cholesterol screening and immunizations. In 1996, they sought to include these measures, together with evaluations of counseling for tobacco cessation, dietary changes and improvement in exercise habits in a more comprehensive effort. By measuring whether a member's up to date status included all recommended preventive health services, they hoped to develop measurement, and subsequent improvement, that would be more meaningful.

The targeted population consisted of all members continuously enrolled during the one-year reporting period, regardless of age or gender.

To collect baseline data, two measures were selected. These were carried out through chart review of a stratified random sample of 88 charts from each of the 20 largest medical groups.

MANAGING MEDICAL RECORD REVIEW The process of reviewing medical records for a large number of clinical indicators can be extremely variable, and can consume a large amount of resources. This plan used a staff of 18 to visit medical groups and audit charts on-site. The plan worked extensively to develop inter-rater reliability among these 18 people. One tool used to ensure consistency was a set of detailed instructions for abstracting a medical record (included in Appendix 47). The plan's MIS department developed audit tools that indicated, for each patient in the sample, the services that were age and sex appropriate, and pre-populated the tools with any services documented on claims and other sources.

The first measure was based on the percentage of members up to date with recommended age/sex appropriate services. These included:

• Immunizations:
• DTP vaccine
• Tetanus boosters
• Pneumovax
• Flu vaccine
• MMR boosters
• Cholesterol, total and HDL
• Colon cancer screening
• Mammography
• Pap smear
• Blood pressure check
• Exercise assessment
• Nutrition assessment
• Smoking documentation and counseling

The second measure was the percentage of all the recommended services (for the sample of members reviewed) that were up to date.

In the second (and subsequent) year(s) of the activity, counseling components of the measure (exercise, nutrition and tobacco use) were broken out from the preventive service measures, and two separate measures of preventive counseling were developed. The first of these measures was, again, a medical record review, looking for evidence of counseling. This was subsequently abandoned in favor of a patient telephone survey performed by a market research firm that asked three basic questions:

• During the past year, did any health professional at your clinic advise you about the importance of being physically active or exercising?
• During the past year, did any health professional at your clinic advise you about the importance of healthy eating?
• During the past year, did any health professional at your clinic advise you to quit smoking or stop using tobacco products?

The survey was conducted among more than 8,000 patients, once again based on a stratified random sample from the major medical groups.

Baseline measurement, using 1996 data, showed that 44.1 percent of members were up to date with recommended preventive services, meaning 44 percent of all members received all applicable preventive services. Of all recommended services that should have been rendered, 65.3 percent were rendered. The plan also did a drill-down analysis on individual services (Table 1).

The plan set a goal of 75 percent of members up to date on preventive services.

A steering group made up of a mix of plan staff and providers managed this activity. Member focus groups were used to assess the barriers that existed from their perspective. Representatives of the major medical groups worked to determine barriers from the groups' viewpoint.

Barriers identified included:

• Lack of medical group systems to consistently deliver preventive services
• Some staff do not initiate preventive services even when empowered to do so, e.g., with immunization standing orders
• Providers feel that member expectations differ from guideline recommendations
• Not enough time during acute care visits
• Providers unfamiliar with current recommendations
• Providers uncomfortable with changing current practices
• Conflicting recommendations

The plan participated in a federally funded statewide initiative with another health plan and 44 medical groups. The focus of the project was the implementation of preventive services guidelines. The project provided facilitators to medical groups, developed a forum for groups to share implementation strategies, and revised and distributed a number of guidelines.

The plan used its existing telephone triage service to provide preventive counseling. A "prescription pad for a healthier lifestyle" was developed to formalize goals for lifestyle behavior changes, and as a link to the telephone service. Members were mailed information about the phone counseling service.

The plan generated "at risk" lists that identified members with needs for specific preventive services. These "at risk" lists were provided to medical groups. The groups used the lists to reach out to members, including "silent members" who had not accessed medical group services.

An existing program that provided financial recognition to medical groups that achieved superior performance was revised to include the measures of mammography screening, tobacco advice and Pap screening. (An outline of the program is included in QP Tool .) The clinical indicators themselves were made available to consumers through the health plan Web site.

Member newsletters and media campaigns focused on preventive services, tobacco usage and exercise.

The health plan developed a medical group profile report. This report included information about site survey results, quality improvement initiatives, guideline implementation and clinical indicators (including those for preventive services). These reports were updated annually, and discussed with the groups during the site survey process. If a group's rates of preventive services were not at or above the plan average, this was discussed with the group. The plan offered assistance and resources where appropriate.

The first remeasurement, based on 1997 data, documented that 52.1 percent of members were up to date with preventive services, with 71.6 percent of required services up to date. These measures demonstrated statistically significant improvements compared to baseline.

HEALTH RISK APPRAISALS This activity dovetailed with another initiative that performed telephone health risk appraisals for an employer's work force. Employees received personal summaries of risks and recommendations. Information obtained from the surveys was forwarded to each employee's PCP. Aggregate health risk information was used to develop a work site-specific health improvement strategy. Employers paid for this service with a set fee for each completed health risk appraisal.

The first measure of preventive counseling using a medical record audit showed 26.8 percent of members to be up to date. The survey of members concerning counseling showed a higher rate: 43.2 percent.

The plan continued its measurement of preventive services using the medical record, and of preventive counseling using the survey. It focused on previously identified barriers, as well as some newly discovered ones:

• Providers had not traditionally viewed counseling and assessment of health risk behaviors as their responsibility
• There was no common health risk assessment tool
• Incentives were inadequate
• Medical groups lacked systems for furnishing patients with expectations and education materials, and for furnishing staff with protocols, procedures, materials and expectations
• Changes to guidelines caused inefficiencies in implementation
• Assessment of passive tobacco exposure was poor
• Barriers of time, staffing, reimbursement and the supportiveness of clinicians existed at medical groups

The plan continued its forums for sharing implementation strategies among groups. It continued to update and distribute a variety of preventive service guidelines. It added a discrete measure of preventive services to its incentive program with a goal of 75 percent of members up to date and it expanded its use of the "at risk" lists, using a company intranet.

Measures from 1998 showed that improvement plateaued with 61.5 percent of members up to date with preventive services, and 73.5 percent of all recommended services rendered. The survey of preventive counseling also showed improvement, with 51.3 percent of members reporting the receipt of exercise, nutrition and tobacco advice. In 1999, data showed continued incremental improvement with 63.6 percent of members up to date with preventive service. In addition, 76 percent of recommended services were performed and 52.9 percent of surveyed members reported up-to-date counseling.

The plan continues its refinement of efforts to improve the health of its members. It continues to deliver medical-group-specific feedback on these important measures.

[1] - Department of Health and Human Services, Guide to Clinical Preventative Services Second Edition (Washington, D.C.: Department of Health and Human Services, 1989), xxv.

[2] - Ibid, xxvi.

[3] - Ibid.