Medical Group Management Association

Fall,1996 Meeting (October 14, 1996)

Increasing Revenues By Integrating Wellness And Health Promotion Services Into The Practice Of Medicine.

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 practice newsletter.

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 computer.

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 public facility.

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 program.

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 individual risk.

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 life.

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 as follows:

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 such programs.

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 desirable.


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 desirable.

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 data.

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.