Power to the Patient

Coaches can help employees become more accountable for maintaining and improving their own health.

Friday, May 2, 2008
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If rising rates of diabetes are any indication, this country is getting sicker.

In 2005, the Centers for Disease Control reported that nearly 21 million Americans were afflicted with diabetes. That was an increase of 2.6 million from 2002, making the disease -- a leading cause of blindness, kidney disease, heart attacks and strokes -- the sixth-highest cause of death in America.

And it gets worse: 6 million of those diabetics don't know they have the disease, meaning they're not treating it. In the remainder of the population, another 41 million are estimated to be pre-diabetic, meaning they're at significant risk of developing the disease soon.

The total cost of diabetes in the United States, as reported by the American Diabetes Association, was $174 billion in 2007. And that's just one chronic disease afflicting people and costing their employers huge sums of money. Add to that the toll taken by hypertension, chronic obstructive pulmonary disease, asthma, lower-back pain and others.

To top it off, study after study shows that Americans are becoming more overweight -- bringing the potential for even more health problems, and more health expenses.

Fortunately, there is something that can improve or alleviate these conditions, and get patients healthier. And that is the patients themselves.

"There are a handful of conditions where the patient is a key part of success with management and avoiding problems," says Helen Darling, president of the Washington-based National Business Group on Health. For this very reason, she says, more than one-third of NBGH's member companies now offer health coaches who -- via mentor-like ongoing relationships -- work with employees to uncover, discuss and alleviate their health risks, and keep them on track health-wise.

A recent NBGH/Watson Wyatt study revealed that 44 percent of large employers offered health coaching in 2007, with an additional 13 percent planning to offer it this year. Coaches work with employees (usually over the phone, but sometimes in person) to set goals for the treatment of their conditions and to keep them informed of potential risks.

In the case of diabetes, one simple step might be reminding patients to test their blood sugar more often. A coach's insight could lead to some of those latent diabetics getting diagnosed and treated before further damage is done. Some of the pre-diabetics might be shown negative consequences at the end of their current path and opt to change course -- potentially adding years to their lives. The potential savings for the companies they work for could mean millions of dollars.

"If the condition you're working with has very high costs, and what you're coaching on has a direct impact on those costs, [then coaching] can work," says Darling.

The challenge is that coaching can be a bit of a black box, which is one reason Darling includes that provisional "can." Privacy restrictions mean a company cannot know who's using the programs -- only that X number of employees are being coached for condition Y. Employers know what they spend on coaching, but can't correlate that with individual health improvements.

They cannot count the dollars they never had to spend on hospitalizations or on the treatment of hypertension that coaching managed to prevent from manifesting. All they can do is track participation in the programs and limit estimates on return-on-investment to comparing pre-coaching healthcare costs to those that occur after implementation.

The Right Questions


Andy Greenberg, principal for HR programs at St. Louis-based investment firm Edward Jones, admits to a somewhat nebulous financial inspiration for his company's new coaching programs, which were launched in January of this year.

Edward Jones does anticipate that the programs will save money -- using that same logic that keeping people out of the hospital has to save money -- but Greenberg says current ROI expectations tend to be more on the "soft" side.

"There seemed to be a lot of cases, talking to colleagues, of programs helping to save people's lives or dramatically improve the quality of their lives," he says. Healthier employees are more likely to be at work and more likely to be productive. Plus, the program is, in part, intended to be a value-added benefit for employees -- with better benefits translating into happier employees.

"The nurses and coaches are there to educate our associates, to help them ask the right questions of their physicians and to make sure they're following the recommended guidelines for their condition," says Greenberg.

Rather than calling employees and simply asking if they've taken their medication, good coaches build rapport by tailoring their approach to each individual, according to him. They gather information from the health record and from each employee, and gauge their apparent knowledge and motivation.

Some people are motivated by how much better they might feel if they did change. Others may be motivated by what might happen if they don't change. A good coach should weigh all of these factors in deciding how to work with an individual patient.

Prior to beginning the coaching program, Edward Jones conducted a health-risk appraisal among its employee population and passed the results on to health-management provider CareAllies, part of Philadelphia-based Cigna.

CareAllies combed through claims data and the HRA results to identify employees who currently present a disease condition or whose HRA results indicate risk factors such as obesity or smoking. When coaches contact these employees by phone, they can discuss the HRA findings, determine how they're managing any current conditions and suggest course corrections, if needed.

"[The employee] and the coach may set a manageable goal," Greenberg says. "If someone has 80 pounds to lose, the first goal may be to lose five or 10 pounds." The plan might be to walk around the block several times a day or eat better. Later, coaches check back to see if employees managed to shed those pounds and discuss what they're doing in terms of diet and exercise, suggesting alterations as necessary.

While it's too early to report results from the programs, Greenberg says, employees are "excited," especially about the weight-loss programs. It's similarly too early to see any ROI, but Greenberg says that over the first three years, Edward Jones expects coaching to cost several million dollars. The hope is that healthcare costs for chronic diseases will go down by at least that much to compensate.

A "Waste of Time"

When it comes to what form -- telephonic versus face-to-face -- the coaching sessions will take, differences arise. Telephonic coaching, while having a lot of potential, also has its limitations. The Disease Management Association of America reported in its journal Disease Management that telephonic engagement rates hover in the range of 10 percent to 15 percent, meaning that for every 100 people identified as presenting a "coachable" condition, 10 to 15 are successfully contacted and enrolled in a program.

Tracking the effectiveness of these programs can be difficult. For this reason, some companies have decided to integrate coaching with their on-site primary care facilities, to establish a face-to-face relationship between coaches and employees.

San Diego-based Qualcomm began offering coaching through its on-site health center in late 2007. Manager of HR Dave Beadle says the arrangement lets the company eschew the usual approach -- conduct an HRA first, then call high-risk employees and urge them to contact a doctor.

"That's the traditional way of doing things, and my personal philosophy is that it's a waste of time," says Beadle. "When you send out a blanket HRA but don't follow up with someone who sits down and proactively deals with these people, the HRA isn't worth the paper it's printed on."

The on-site center allows coaching to segue immediately into medical follow-through, rather than relying on coached employees to contact a doctor later to undergo a diabetes screening, inquire about medications or obtain further advice, he says.

Beadle says the company widely promotes the health center (which offers primary care, physical therapy and other services) as a convenient place for employees to use instead of going to outside physicians. The co-location of doctors with coaches from Cleveland-based Whole Health Management takes the need for medical follow-through largely out of employees' hands.

"When a patient comes into the Qualcomm Health Center and sits down with one of the clinicians, [the clinician is] going to pull up the electronic medical record of that person, which is linked to the HRA information, and will be able to have a conversation right there while the patient's in the office," says Beadle. "We're not relying on the employee to follow up on the HRA with another physician, or on a callback from a nurse line."

If an employee never visits the on-site clinic but his or her health record or HRA indicates he or she could benefit from coaching, then coaches must contact the employee by telephone. However, says Beadle, employees are familiar with the health center and its staff, who attend Qualcomm events, give flu shots throughout the offices and conduct a "Know your Numbers" cholesterol campaign. When an employee gets a call from a coach, Beadle says, it's better received because the caller is from "a known entity."

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"When you're right there on-site, you see a higher engagement rate," says Chuck Reuter, president of Marathon Health in Burlington, Vt. Reuter says his firm, which provides on-site coaching services, engages about 70 percent of the people it identifies as having a chronic condition or presenting a moderate-to-high risk of developing one.

"Engaging" means getting that person in for an initial face-to-face session to complete a health review, set goals and agree on an action plan (medicine, lifestyle changes or both), as well as generating at least one follow-up session within six months.

On-site coaching also has its downsides, however. Many companies simply can't afford an on-site center, and the model doesn't work well with a dispersed employee population. "The vast majority of [employers] still require telephonic coaching to allow program access for 100 percent of their employees and dependents," says Elizabeth Nota-Kirby, program-design manager for disease management and wellness at Hartford, Conn.-based Aetna.

Aetna, like many other insurance companies, has thrown its hat into the coaching ring with a variety of models that include face-to-face coaching, but which primarily take the form of a telephonic program supplemented with online tools.

Confidentiality Concerns

The presence of insurance providers in the health-coaching arena raises another question: Should employers get coaches from insurers, or from niche coaching providers?

Beadle says Qualcomm chose Whole Health Management over its insurance company (United Healthcare) because Qualcomm wanted in-person coaching. Edward Jones' Greenberg says his company decided to contract with a specialized coaching provider instead of its insurer to alleviate employees' privacy concerns.

"Sometimes when people talk to someone about a problem, they're scared that they'll be denied insurance later," Greenberg says. "So we used a third-party that we don't use for our insurance plans so people will feel more comfortable getting help."

Any provider of coaching must comply with privacy regulations as spelled out in the Health Insurance Portability and Accountability Act, so concerns about coaching via an insurance provider being "less private" are groundless. Still, says Greenberg, the perception of a conflict of interest remains. Edward Jones wanted to make clear to its employees that their privacy is a serious concern, he says.

The veil of privacy makes determining cost versus benefit difficult, but Darling says coaching is effective -- so long as it's done right. "Done right," she adds, entails a few key ingredients.

First, the company must widely promote the programs, their benefits and any incentives being offered for participation. The second "done right" component is trickier.

"The key is targeting," says Darling. "You have to find the people and the conditions that are costing you a lot because of failures in something that you can influence."

In other words, determine the chronic diseases within the population that cost the most to treat. Work with the coaching provider to set up clear selection criteria. Will you coach only current diabetics, or those who may be pre-diabetic as well? Criteria vary by case, depending on the size of the organization, the insurance structure, the amount spent on the condition and how far that amount could possibly be reduced.

Most organizations stop their targeting at this point, but Darling suggests going one step further. Not all employees presenting a disease will benefit the same from coaching, she says.

"If you have someone with diabetes who is illiterate in terms of health -- doesn't really understand, doesn't take care of their condition -- and gets hospitalized five times in a year because of that, then anything you can do to keep that person out of the hospital is going to save a ton of money," she says. "But if you're talking about someone who is highly literate, well-educated and has never been hospitalized for [that chronic condition], then coaching them isn't going to save any money."

Within a few minutes of talking to an employee, a coach should be able to determine if he or she is health-literate. If so, unless the employee specifically wants to be coached, the coach should bow out and save the company the cost of metaphorically preaching to the choir, says Darling.

If a coach can do what a good coach is supposed to do -- positively influence people to change their behavior -- then health coaching can be a true win-win. The company only benefits if the employees benefit.

"The main focus," says Darling, "is to jumpstart [employees'] thinking and get people to understand that this is really about their health. This isn't being done for the employer."

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