TOOLS FOR PROGRAM EVALUATION
Using a health risk assessment (HRA) questionnaire.One way to begin your program is by having employees and dependents complete a health risk assessment questionnaire. The HRA serves three important functions. First, it identifies those individuals who are eligible for the program. 3M and Caterpillar both used an HRA to identify individuals eligible for the program, but participation is, as always, voluntary. Second, by seeing where they need improvement, individuals can set their own health goals that they would like to accomplish while participating in the program. Parker Hannifin administers an HRA twice a year for the purpose of determining whether goals set at the time of the last HRA were in fact met. Third, the HRA results, when sorted and reported as an aggregate set, gives a company a good indication of its level of wellness. At the end of the program time frame, usually one year, the employer can assess whether participants have been able to meet their goals. This information can then be used as a way to promote the program to both upper management and other potential participants. Overall, the HRA is a valuable tool for measuring specific health outcomes.
Establishing performance guarantees.In working with health plans or other outside vendors, employers have the option of asking the vendor to incorporate performance guarantees into the original design of the program. Performance guarantees can be used to measure both financial and health outcomes. For example, Anheuser-Busch Co., Inc. whose health plan administers its diabetes management program, worked out an agreement to establish a performance guarantee in five networks in which the company has the greatest concentration of employees. The performance guarantee, which measured a financial outcome, is that the claims savings of the diabetes management program would have to be equal to or greater than the programs costs. By comparing claims data from the previous year with that of the year the program was in place, it was then possible to calculate savings. Other performance guarantees that employers can consider requesting of their vendor include those related to clinical outcomes, such as reduced emergency room visits and hospitalizations.
Using goal-setting strategies.In programs where participants work individually with a health care professional, setting individual goals is a good way to assess progress in improving health incomes and financial outcomes. AT&Ts program, administered by a PBM, has a goal-setting component. For example, if an individual has determined that his or her goal is to keep blood glucose levels under control or to keep short-term, acute complications to a minimum, these can be measured in terms of per capita costs for diabetes patients. If participants have met these goals, then their costs that year have probably decreased as well, because they did not have to go the emergency room or spend time in the hospital. Perhaps, too, their overall health has improved because they have gone to see their physician on a more regular basis. In this way, all three outcomes can be measured. You can see an improvement in a process outcome by the increased number of doctor visits, an improvement in a health outcome by lower blood glucose levels, and an improvement in a financial outcome by a decrease in per capita costs for diabetes patients, based on a decrease in emergency room and/or hospital stays. Although there may be increased costs associated with higher frequency of physician visits, these are outpatient rather than inpatient costs. Those costs are not as expensive as those incurred through hospital stays.
Measuring participant satisfaction and increased understanding of the condition.Surveys measuring improved self-advocacy are also frequently used to evaluate the program. Self-advocacy results in a stronger relationship with the individuals physician, decreased risk of complications related to the condition, and increased knowledge about the condition. These factors can be assessed before the program is initiated and at a designated interval into the program (i.e. 6 months) to measure the following health outcomes: improved ability to manage the condition; increased knowledge, resulting in more effective self-advocacy and empowerment; and an improved relationship with the physician.
Using data from the pharmacy benefits manager (PBM).If you are working with your PBM to develop and implement your diabetes management program, the PBM will probably have access to data on use of medications by program participants. If baseline data are available on medications taken and level of compliance before program implementation (a process outcome), then your PBM can give you information comparing results at designated intervals such as 6 months or after the first year of the program. For example, if participants in the program are filling their prescriptions on a more regular basis, there is a good chance that greater compliance will result in fewer complications, ultimately leading to greater savings over the long term. In the short term, however, there may be an increase in pharmacy costs. Savings from a decrease in more costly emergency room visits and hospital stays generally offset this increased cost. Throughout the duration of the program the PBM submits quarterly reports to the employer. The reports have such information as the number of HRAs returned, the number of participants, the participants broken down by age and gender, and the number of calls the toll-free number received from both participants and their physicians.
Using medical claims data.If you are working with a disease management company or a health plan, both of which have access to medical claims data, then it is possible to compare hospitalization rates both before and after program implementation (both a process and financial outcome). Ideally, having access to both pharmaceutical data and claims data could yield the most convincing information about the success of the program. In some cases, a PBM is willing to give information about pharmacy use to the health plan, as was Anheuser-Buschs experience.
Designing your own study.Some employers design their own controlled study to measure the impact of the worksite diabetes program. As mentioned earlier, this is the ideal way to get accurate information about the effectiveness of a program, but it can also be the most difficult tool to implement. However, Southern Company, in Atlanta, Georgia, did design a study with intervention and control groups. At the beginning of the six-month study, each group was given education information, a blood pressure check, a weight check, a urine test, a fasting blood sugar, an A1C test, a lipid profile, kidney function tests, and one-on-one counseling. The intervention group was given nutritional information at special lunch programs and additional one-on-one counseling sessions. At the end of the six-month period, both groups were given all the tests again. Study results showed that while both groups improved, the participants who received interventions showed greater improvement, thus demonstrating (for this company) that more involvement with participants yielded a greater return on investment.
While all these tools are helpful, each has its strengths and weaknesses. Even the most conscientious attempts may or may not yield results. This is simply because measuring outcomes, or isolating the cause and effect factors, is extremely difficult to do. The easiest kind of outcome to measure is a process outcome, such as tracking and comparing the number of hospital visits before and after program implementation. But the information that you would really like to have improved health and financial outcomes is much harder to assess. The reason for this is that changes take a long time to show up, can be caused by a number of factors, and can be subtle and hard to detect.
A new tool being developed by the Biomathematics Unit, Care Management Institute at Kaiser Permanente shows promise as a way to provide employers with information about the effectiveness of a proposed program. Called Archimedes, the program is a mathematical model that uses existing information to predict the value of a program. The database has a tremendous capacity and can factor in a wide range of information to determine results. For example, if you input information about the people participating in a program and any data available about costs, as well as knowledge about clinical trials, disease management programs, population epidemiology, and desired outcomes, the model can give you information about the pros and cons of a particular program. While the model cannot give you hard and fast answers about what to do for people with diabetes in your particular setting, it can give you more data to use in making critical decisions.