Medical Group Management Association
Fall,1996 Meeting (October 14, 1996)
The American public has been spending billions, that's
Billions with a big "B", of dollars each year for health
promotion products and services. Unfortunately, most of these
dollars are not being spent in traditional medical care environments.
Simply scanning the ad pages in large city newspapers will give
you an idea how many services are being offered to the public.
Services such as: weight control, smoking cessation, beginning
fitness, diet therapy and massage therapy are just a few. Some
of the more traditional programs being offered by hospitals, YMCA's,
and fitness centers include lifestyle appraisal programs, stop
smoking programs, weight loss programs, stress management programs
and beginning fitness programs.
Ironically physicians are often asked by their patients
to certify that it is safe for the patient to participate in one
or more of these programs. The average physician sees hundreds
of patients per month who would benefit from participating in
health enhancement activities. Yet some physicians are hesitant
to refer these patients to such programs. Their concern is that
the quality of the program may not meet the same standards as
their clinical practice or that they may lose the patient because
of some continued referral activity from the health promotion
providers. The time has come to expand the role of the physician
to include the provision of health enhancement services. One of
the early definitions of physician is "teacher." These
activities will complement the health restoration services that
have been the main activity for most physicians.
Unfortunately, most physicians have had little exposure
to the operation of health promotion activity. Most physicians
would be amazed at the limited academic preparation earned by
the average health promotion provider. Many diet and fitness services
are run by entrepreneurs who have little if any training in health
education/health promotion or fitness.
The physician is in a unique position to provide
high quality health promotion services to his or her patients.
The most important step is to overcome the inertia that many of
us have when it comes to trying something new.
Listed below are some of the potential gains.
Helping the physician get started.
Many physicians begin to offer health promotion services
by sending a letter to all of their regular patients. In this
letter they outline their commitment to total quality care. They
indicate that they are offering a health appraisal service to
provide a starting point from which suggested health programs
might ensue. Planning a health appraisal service involves many
variables. It is an interaction between the patient, groups of
patients, a computer, and the environment. All of these aspects
must be taken into consideration when creating an appraisal system.
The patients need to be informed, groups may be created
to discuss the system, information needs to be entered into a
computer system, and the results of the appraisal are put into
practice by altering the traditional activities of the physician/patient
relationships. The following questions may be helpful in planning
the first step of your health promotion program.
When do I start?
Give yourself time to identify staff and prepare
materials. Many times you can find those on your own staff who
would love the opportunity to diversify their duties. Other members
of the staff may need to contract with people who have the expertise
needed to bring the program to fruition. A good source for finding
people is in educational institutions. Colleges and universities
often have people who are offering these services on the campus.
How do I notify my patients?
The best method is a short letter to each of your
patients explaining what services you plan to offer and why. Let
them know who will be helping you with the new services. Another
opportunity is at each office visit. A small referral notice in
the form of a prescription is another possible innovation. Others
may choose to use a small notice in their waiting room or in a
What equipment do I need?
If you plan to offer lifestyle assessment services
it is often desirable to have a microcomputer with printer available
in the office. I recommend a Windows-based system and a laser
printer. Frequently the office will already have the equipment
that is used for billing, scheduling, or other practice management
functions. If you are starting from scratch the total cost of
a computer, monitor, printer, and some software should be under
$5,000.00. Few offices would need anything larger than one multimedia
Most programs that you will offer will not require
any equipment not already in the office. You may wish to add a
blackboard or flipchart or some other types of audiovisual equipment.
The classes and group activities can often be conducted in your
waiting room area after normal clinic hours. Though it may be
more appropriate to conduct some of your sessions in some common
By using the office for more than one shift per day
you can increase the revenue per square foot for your facility.
How can I establish a fee structure?
The price for health appraisal assessments can range
from a low of $10.00 to a high of $50.00. The price usually does
not include lab work that might be offered as an adjunct to the
There are a number of computer appraisal software
packages available. They assess such areas as patient's diet,
stress management skills, wellness appraisals, fitness levels,
and health hazard appraisals. The cost for diet counseling, stress
management, stop smoking, and guided fitness programs will have
to be competitive with existing programs in your community. You
could have your staff or other colleagues check prices. You will
be surprised to see how much money is being charged for various
programs conducted by people with much less training and experience
than your staff.
How do these health appraisal systems work?
Most risk assessment systems are based on a method
first developed by Dr's. Robbins and Hall. After the standard
or average risk of morbidity and mortality is determined, factors
that may increase or decrease the standard risk are used to estimate
Complex mathematical equations are used to compute
the impact lifestyle choices have on an individuals' total risk
of death from certain causes. The results are printed on a simple
format that can be easily explained to a participant.
The printout can be customized to include referral
to specific programs that might be helpful to the participant
who is interested in reducing their total risk. Many users can
increase their compliance rates if they are offered an opportunity
to sign up for lifestyle change/self-help groups. The best time
to recruit people for these self-help groups is at a time when
you are giving back their health appraisal results.
How often can risk appraisals be done?
Generally it is useful to conduct a risk assessment
on at least a once a year basis. For those who are living a healthy
lifestyle this may be one of the few times they get positive reinforcement
for their healthy behaviors.
For those at a higher than average risk, at least
once a year is a reasonable frequency. Actually, any visit to
a health care provider is a good time to reinforce the tremendous
impact that lifestyle choices have on the quality and length of
Interactive versions of risk assessment software
can be made available to patients in the waiting room or lobby
areas. Recently a number of risk appraisal systems have been placed
on the Internet so that people in the comfort and privacy of their
home can do lifestyle assessment activities.
You can offer followup letters to participants at
predetermined intervals. Computer generated reminders can be just
the nudge that some people need to maintain an initial change
that they have made.
The following two charts have been reproduced from
a 1988 article published in Medical Times.
These charts show that a tracking system can be included as part
of your medical record to identify behavioral change objectives
that would be indicated for your patients.
Quality health and patient education
In the 1988 article written by Don W. Bradley, M.D.,
he identifies the criteria that ought to be used by physicians
to ensure quality care. Dr. Bradley refers to some criteria that
were developed by Paul Frame in 1986. Frame's criteria for the
inclusion of a condition in a health maintenance protocol are
1). The condition should have a significant effect on the quality of life,
2). Acceptable methods of treatment must be available,
3). The condition must have an asymptomatic period during which detection and treatment reduced
morbidity and mortality,
4). Treatment in the asymptomatic phase must yield therapeutic result that is superior to that
obtained in delaying treatment until symptoms appear,
5). Tests that are acceptable to patients must be available at reasonable costs to detect the
condition in the asymptomatic period,
6). The incidence of the condition must be sufficient
to justify the cost of the screening.
Many physicians are hesitant to begin offering services
that are not covered by traditional insurance plans. This is unfortunate,
because often the insurance plans are too restrictive in what
types of preventive health services they will cover. It is time
for physicians to not be timid but to be willing to compete on
the open market for people's time and money. So much patient money
is being spent on less than high quality health promotion pursuits
that surely physicians can risk the occasional refusal by a patient
who will only do things that are covered by insurance. A recent
buzz phrase that has emerged is "personalized health management."
There is actually a major conference being held in November sponsored
by a number of national organizations addressing the issues of
personalized health management. The subtitle of the event is Integrating Prevention, Wellness and Fitness Within Managed Care.
Now that managed care has created a system in which the health
care providers get the money up front they are much more creative
in their use of disease management strategies that include education.
Some of the major topics being discussed at this workshop are
"Prevention, Wellness, and Fitness: The Foundation for
Women's Health Services in a Managed Care Market," "Systematic
Approaches to Effective Weight Management," "Integrating
the Hospital Mission with Health and Fitness: Leverage
the Relationship," "Managing the Unmanaged: Bridging
the Gap with Fitness Therapy," "Use of Computerized
Health Risk Appraisal for Conveying Risk Information to Diverse
Clients," "Partners in Prevention, Putting Cardiovascular
Disease Prevention to Work." These and numerous other
titles indicate a significant change in the attitudes by major
health care delivery systems as it relates to offering health
promotion services as part of the practice of medicine.
The Society of Prospective Medicine is concerned
with encouraging high standards in the application of programs
of health risk appraisal and reduction. Accordingly it has set
forth attributes which are considered essential to such programs.
The Guidelines are intended to assist not only individuals
and organizations who are providing risk appraisal/reduction programs,
but also individuals and organizations who are seeking to utilize
The Society does not intend to impose the Guidelines;
rather it is hoped that they will be accepted voluntarily. The
Society believes that their use will encourage providers to strive
for excellence in the delivery of health risk.
The Guidelines will be presented in two parts, and
will be updated periodically. The first part, immediately following,
covers the minimum guidelines, or essentials; the second, now
under development, will include those attributes considered strongly
Health Risk Appraisal/Reduction
is the art and science of identifying an individual's present
and potential health hazards and of helping him/her reduce those
risks so as to extend useful life expectancy, improve the quality
of life, and reduce morbidity and disability.
Health Risk Appraisal
evaluates an individual's lifestyle/health behaviors, estimates
his/her risk of death and/or illness, and estimates potential
reduction in risk based on epidemiological data, mortality statistics,
and actuarial techniques. Feedback is given to the individual
based on his/her current and achievable risks.
Risk Appraisal Instruments
are printed or computer-assisted questionnaires used to identify
an individual's health risk.
Risk Reduction Programs
are organized activities to reduce risk through sustained behavior
change. These programs can be of long or short duration and of
a broad or categorical nature.
Providers are the individuals,
institutions or organizations providing risk appraisal/reduction
programs to individuals or groups of individuals.
Participants are the individuals
whose health risks are being appraised and who may, if appropriate,
participate in some components of a risk reduction program.
Essentials are the basic
attributes that should be present in any program of risk appraisal/reduction.
They remain the same for all programs, whether institutionally
based or free-standing, whether limited to a one-month community
cardiovascular risk program or as extensive as an industry-wide,
ongoing health risk appraisal program.
The following should be present in every program:
1. The Written Statement of the Objectives of the Program, and Limitations
The statement should include a concise, realistic
definition of goals; the scope of the program (general health
vs. Categorical efforts); duration (ongoing vs. Short term); target
audience; affiliation or sponsorship; and limitations.
2. Evidence of a Scientific Base for the Risk Appraisal Instrument.
Evidence should include references to morality and/or
morbidity data bases from which the risk appraisal instrument
is constructed; to the methodology for quantifying the risk factors;
and to any studies regarding the relevance and validity of the
risk appraisal instrument. An effort should be made to incorporate
current "state-of-the-art: data and methods.
3. Evidence that Appropriate Risk Reduction Resources are Available to Participants.
Risk reduction resources should have a scientific
basis, to the extent possible, and should be culturally appropriate
for the target participants. Resources should be made available
consistent with the risk indicators appraised. For example, if
lifestyle stress risks are included in the appraisal, resources
should be available for stress reduction. The provider may offer
its own programs or may identify community resources that serve
the purpose. An effort should be made to incorporate current "state-of-the-art"
data and methods.
4. Demonstration of Staff's Capability to Organize and Conduct Risk Appraisal/Reduction Programs in Accordance with Stated Objectives.
Each program should be able to meet its objectives
in terms of budget, facilities, staff, and consultants. The latter
should have the experience and/or training needed to promote the
program, administer risk appraisal instruments in a valid manner,
and interpret the results to participants so as to encourage optimal
risk reduction activity. Providers should exemplify positive personal
lifestyles coupled with professional commitment.
5. Evidence that Participants Receive the Results of Their Appraisals in a Form They Can Comprehend, Including Recommendations to Consult an Appropriate Health Provider When Needed.
Existence of an operating feedback loop is critical
to the integrity and success of the program. The risk appraisal
instrument must be understandable enough to get meaningful responses.
The reporting of results and recommendations for risk reduction
must be individualized, relevant and understandable. If a medical
or other serious health problem is detected, the participant should
be notified and encouraged to consult a physician or other health
provider. Followup to monitor risk reduction compliance is also
6. Mechanisms to Protect the Confidentiality of the Data on Individual Participants.
Only the participant, and health professionals authorized
by the participant, should receive a copy of, or otherwise have
access to, his/her own risk appraisal or results of risk reduction
activity. If there is any need to reveal participant's identities,
written consent should also be obtained before releasing aggregate
7. Evidence of Efforts to Evaluate the Program Periodically In Relation To Objectives.
Evaluation is a judgment about the program and its
effectiveness in identifying and reducing health risk. It assesses
the extent to which the program objectives have been met, for
example, to observe whether the program has had an effect on the
lifestyle of the participants. Evaluation also implies a review
of program objectives in light of research in the field. There
should be a plan for periodic evaluation, communication of the
results, and action based thereon.