The health whisperer: A help or a hindrance?

Businesses and insurers hire health coaches to make sure their employees or members stay healthy, thus cutting costs. So where does that leave doctors?

By Pamela Lewis Dolan — Posted March 5, 2007

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There is a growing likelihood that when it comes to health advice, your voice is not the only one that is bending your patients' ears. Large employers and insurers increasingly are calling on health coaches to prod employees and members to healthier living -- and cut their health costs.

A health coach is a registered nurse, dietician or social worker who works with patients one on one to improve a patient's health or help manage a chronic illness.

A recent survey by Watson Wyatt Worldwide, a Rochelle Park, N.J.-based consulting firm, found that more than 50% of the nation's largest employers already offer health coaching programs or plan to add them sometime this year. Those companies are looking to cut the 22% of payroll represented by health and productivity-loss costs that Watson Wyatt's 2005-06 "Staying @ Work" report found for 2004.

"When we look at total [health] costs to employees, if you get higher quality care with less unnecessary care and less wrong care, you save more," said Alan Spiro, CEO of Anthem National Accounts, a subsidiary of Indianapolis-based WellPoint.

"It's not just a financially based decision," said Larry Lewellen, associate vice president of human resources for The Ohio State University, which started a health coaching program last year. "But the financial outcome is an important piece of it." Lewellen said this and other wellness programs also help make employers a choice workplace for talented job seekers.

Despite the rapid growth of health coaches, however, few physicians know what they are or do. In part, that is because health coaches often operate outside the realm of the physician's office and don't always inform an employee's or member's physician of what they are doing.

"We all need a little help," said Richard S. Frankenstein, MD, a pulmonologist from Garden Grove, Calif. "But I want to make sure it's help that really helps and it's not just a bureaucratic function of this behemoth we call the insurance industry."

But health coaches aren't just focused on the health of the nation's work force. The Centers for Medicare & Medicaid launched a pilot program in 2003 called Medicare Health Support that provides health coaches for members with chronic conditions such as heart failure and diabetes, with the hopes of keeping those members healthier and reducing the number of unnecessary doctor or hospital visits.

Filling in a gap

So why a health coach instead of relying on physicians? Peggy Wagner, PhD, a professor at the Medical School of Georgia's Dept. of Family Medicine, which offers a health coaching class for medical students, said the services provided by health coaches are services the physician can, and should, provide to the patient without involving a third party.

But because reimbursement is so low or nonexistent for these types of services in the primary care setting, the health coaches are used as a helping hand to the physician, she said.

Insurers also think of the health coach as a way to augment what the physician does as well as a way to help patients become better patients.

Relationships between health coaches and patients are always voluntary, say those familiar with the industry. In most cases, the health coach would make contact with employees, alerting them to the service, because of information volunteered through a self-reported health profile. Others use claims data, including prescription history and physician visits, to identify at-risk employees who could benefit from a health coach.

The programs can be as basic as offering support groups for employees who want to quit smoking. Or they can be as intimate as having a registered nurse closely monitor every health aspect of someone with chronic disease.

Health coaches help with diet plans, suggest topics to discuss with physicians and provide support for those who want to lose weight. Mainly, their goal is to help make sense of information pertaining to their clients' health, insurers say.

"Modifying someone's behavior is much harder than writing a prescription," Dr. Wagner said. That's the lesson she is hoping her students will take from their experience in the health coaching class her school is offering.

Allen Woolf, MD, senior vice president and national medical director for health advocacy for Cigna Health Partners, said many of the things health coaches do are things insurers also look at when gauging pay-for-performance quality measures for physicians. But the health coach acts as reinforcement to ensure that patients are compliant with the doctor's orders, he said.

Dr. Woolf gave the example of a health coach-patient encounter he recently witnessed at which a cardiac patient was told by his physician to go on a low-sodium diet. The patient received a one-on-one consultation at the physician's office on a low-sodium diet and tips on reading food labels, which would be a quality measure for which the physician would be paid a bonus, Dr. Woolf said.

But the health coach realized when speaking with the patient afterward that he still did not grasp the concept of a low-sodium diet. The health coach designed a diet that would be phased in through stages. She and the patient agreed to talk once a week.

When asked if physicians' quality measurements eventually could be gauged by what patients tell a health coach after a visit to their doctor, Dr. Woolf called that an "interesting idea" that might be considered at some point. But the perception of Big Brother watching would be a concern, he said. The company rather would put forth measures that "physicians are enthusiastic about."

"Our strategy is clearly shifting toward becoming a health service company," Dr. Woolf said.

The physician's role

Dr. Frankenstein, who is also president-elect of the California Medical Assn. said the best examples of health coaching programs are ones that operate with a "physician-designed protocol" in which the primary care physician is always kept in the loop.

E. Lee Rice, DO, medical director and CEO of the LifeWellness Institute, a practice in San Diego, said he prefers a team approach, in which the physician is head coach.

Dr. Rice's medical group employs both primary care physicians and health coaches. With all the parties under one roof, it's easier to coordinate the care, Dr. Rice said. But he said he still likes having the primary care physician involved, even if he or she is outside the medical group. He said the relationships between physicians and health coaches have been positive, and the physicians have been grateful for the help the coaches provide.

With medical advice coming from so many outlets, including media, friends and family, the patients enjoy having someone they can call at any time to help make sense of all the information, he said. And physicians are happy not to have to carve out time in their busy schedules to have those conversations, Dr. Rice said.

But because some health coaches require more communication with physicians, especially when they are working with the chronically ill, coordinating the communication can be time-consuming. Dr. Rice said insurers should offer incentives for physicians to work with health coaches.

Because Ohio State, which started a health coaching program last year, is self-insured and has its own medical center, it had to construct its program carefully not to compromise patient and employee confidentiality.

Lewellen said that because the university contracts with a third party -- CareAllies, a Cigna subsidiary -- for its health coaching services, conflict-of-interest fears he otherwise would have had were negated.

These are the same concerns some in the medical community hold.

Fred Sanfilippo, MD, CEO of the Medical Center at Ohio State, said the physicians at the medical center aren't sure of the role they will play yet, but the extent of a health coach's involvement will depend on why the patient wants the health coach, he said.

For example, someone with the goal of general improved wellness would need less structure and less contact with a primary care physician, compared with someone managing a chronic illness, he said.

Dr. Sanfilippo, who, with Lewellen, co-sponsored the initiative to bring health coaches to Ohio State, said concerns among physicians included loss of autonomy, that the health coach would recommend things not advised by the physician and that the health coach's interests would be guided more toward cost savings rather than best practices. "We want to make sure we deal with those concerns," Dr. Sanfilippo said.

No stepping on toes

The insurers say the health coach would never, under any circumstances, recommend a specific treatment method. They only would encourage patients to discuss specific treatments or tests with their physicians.

"Health coaches are not in the business of interfering or getting in the way of the physician treating the patient," Dr. Spiro said.

Likewise, officials from Ohio State say health coaching activities never should impinge on someone's employment status. The university does not know who uses a health coach, and the relationships are formed only after employees indicate on a voluntary health survey that it's something in which they might be interested.

The surveys do not go to the university or its health plan. "We want that degree of separation," Lewellen said.

As more employers look for ways to reduce absenteeism, reduce health care costs and improve productivity, Dr. Rice said he sees health coaches as "the wave of the future."

"People love the fact that someone cares enough about them to look after them and all the wellness components of their life," Dr. Rice said.

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A well work force

About half of large employers will offer health coaching services in 2007, Watson Wyatt Worldwide estimates. Employers also are promoting wellness in other ways.

Programs Employers who offer them
Employee assistance programs 94%
24-hour nurse line 77%
Online health and prevention education information 76%
Health promotion programs 75%
Health-risk appraisals and screenings 72%
Preventive care reminders 69%
On-site fitness center or subsidized health club memberships 66%
Self-care guides 63%
On-site medical clinics 33%

Source: Watson Wyatt's 2005/2006 "Staying @ Work" survey, which included 275 U.S. organizations with a minimum of 1,000 employees, for a total of more than 4.9 million workers

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Corporate health clinics keep on growing

Before health coaches, large employers were experimenting with another cost-saving approach to keeping employees healthy: the on-site corporate clinic. While other initiatives have been added, corporate clinics are still around and growing -- not just in numbers, but also in scope.

Toyota recently opened a $9 million full-service health facility for its 4,100 employees and their dependents at its San Antonio plant. The company said its health care costs had doubled in the past five years and that the clinic was a cost-effective way to bring health services to its employees. Another recent opening was a clinic by Silver Dollar City, serving 2,300 employees at the Branson, Mo., tourist attraction.

According to the consulting group Watson Wyatt Worldwide, 33% of the nation's largest employers had on-site medical clinics in 2006.

A 2005 report by health care technology firm Cerner Corp., which runs its own in-house corporate clinic at its Kansas City, Mo., headquarters, said employers are choosing the corporate clinic so that employees can get care more quickly instead of waiting until they are too ill to come to work.

The new corporate clinic model offers several specialties all under one roof, saving patients from visiting -- and paying -- for individual appointments at various locations.

Generally, companies contract out the physician services and don't see patient files. But companies do provide incentives to get employees to use the clinics, usually with lower co-pays.

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