MedWorks Consulting recommends for the Center for Disease Control and Prevention’s (CDC) consideration changes in their effort(s) to introduce sustainable “lifestyle” change programs to the commercial marketplace. They include:
1. Define what is meant by “sustainability.” MedWorks understands the CDCs goal is to have the Community Based Organizations (CBOs) generate positive cash flow from the promotion, sale, delivery, and support of the lifestyle change programs to benefit plan buyers. But the definition of how to achieve that can include:
a. Achieved by the CBO offering multiple CDC-supported lifestyle change programs in different clinical areas or simply with one offering.
b. Achieved by the CBO offering a mix of CDC-supported and non-supported offerings.
c. The offerings can always be inperson onsite or it can include a multimedia mix.
d. Timeframe discussion as it can be expected to be achieved in a few months or a few years as well as last for twelve months or a decade.
e. The funding levels required are impacted by the expected path to sustainability.
2. Recognize commercial benefit design decisions are made slowly over an eighteen month to two year timeframe. And that is when the decisions to proceed are made in a timely fashion. Some organizations will take more time to decide. Plan to work in the same geographies with the same CBOs for several years.
3. Program design is important to commercial healthcare buyers. Lifestyle offerings need to be simple minimizing the employees time away from their primary job, fitting into a travel schedule, and producing a reasonable return on the investment. Not all clinically effective programs will fit into the workplace. In selecting programs to review for clinical effectiveness, these other design concerns should be included to speed commercial adoption.
4. Operational scale matters for the delivery organization to achieve longer term sustainability. A sustainable delivery organization will need to support new functional areas and aquire expertise beyond what has been required in a project-driven grant environment. The greater the number of program classes offered, the more likely the delivery organization will experience economies of scale reducing their costs. Therefore, larger CBOs are better positioned to support higher class volumes and achieve profitability than smaller CBOs.
5. Focus on introducing several related lifestyle efforts through the same organizations in the same geography. Commercial buyers want integration and would like to avoid content duplication. There is a recurring structure to a lifestyle change programs. The process always starts by defining the targeted population, planning how to engage eligible individuals, delivering the program, and capture information to assess outcomes and identify how to enhance the offering. There are also recurring lifestyle themes across different clinical areas. Diet and exercise are prime examples. Programs for different conditions, especially when those conditions are frequent patient comorbidities, should be designed to minimize redundancy.
6. Larger organizations can grow in part by building local “delivery networks.” Affiliate relationships already exist in the public health space. Creating a regional ‘Hub” from a larger CBO gives the smaller CBO the opportunity to participate as well as leverage the larger organizations’ infrastructure.
7. Plan to have the larger CBO Hubs use common components. These can be developed by a third party and provided to the CBOs (NACDD?) or shared as they are developed internally. But the sharing expectation needs to be set in the beginning. This will result in a National CBO Network over time.
8. characteristics. Identifying the right Coalition partner(s) to achieve maximum early results builds a model that can be adopted by the other coalitions.
MedWorks recognizes the CDC is experimenting with many if not all of these ideas. Our recommendations are designing an overall solution based on what is working now.
Background
Clinical studies consistently show healthy lifestyles provide a significant clinical benefit for individuals with reduced spending on healthcare services. The Centers for Disease Control and Prevention (CDC) and the Federal Agency for Community Living (ACL), various State Governments, and not-for-profit foundations have funded academic organizations to develop such programs in a variety of clinical areas. Currently, tens of thousands of Community-based Organizations (CBOs) participate in innumeral ways to deliver these offerings. Commercial buyers of health care, including self-insured employers and health plans, are also involved including a wide variety of lifestyle change programs in their benefit program offerings. A variety of businesses are developing and distributing these programs across a number of clinical and informationa areas to commercial buyers.
As a result, a large number of offerings are in the healthcare market with overlapping content (i.e., diet, exercise, and regular sleep are examples) as well as inconsistent quality and outcomes. Practicing physicians, well aware lifestyle change can be important therapy, are overwhelmed and do not know how to proceed. Patient use of these offerings is low due in part to the physicians’ uncertainty. Without the physicians’ involvement, program delivery organizations spend considerably to identify, engage, and retain eligible patient participants.
The CDC is supporting multiple disease specific efforts to improve the availability of clinically validated offerings (i.e., Arthritis) as well as developing standardized solutions where there are underserved needs (i.e., Diabetes Prevention). The CDC is likely to introduce additional lifestyle change programs in other clinical areas. Their goals are:
1. Ensure the programs on the market are clinically effective.
2. Convince self-insured employers and health plans to buy the CDC-reviewed offerings and include them in their benefits designs. As a result, the CDC will be ensuring the quality of the offerings and reducing the program variation in the marketplace.
3. Increased standardization and effectiveness make it possible for physicians to become engaged to the point they start identifying qualified patients and prescribe these solutions.
4. Patients identified by their physician in this environment can select the same or similar offering from CBO or commercial delivery alternative that are most attractive to them. Patient choice is expected to achieve improved patient participation and retention.
5. CBOs involved in this process will generate revenues based on their ability to attract paying patients to their program(s), which increases their ability to sustain their delivery capabilities beyond cyclical grants.
In summary, the result would be integrated clinically-proven lifestyle change programs available to the traditional healthcare delivery system.
The Challenge
Changing the immense healthcare ecosystem is difficult. There is a great need to engage physicians, ensure lifestyle change program quality, increase participant choice to enhance participation and retention, and reduce a variety of administration costs but the marketplace is about product differentiation. Stakeholders do not want their current business models disrupted, and not all will benefit from the changes.
The CDC is the right place to create necessary change. The CDC is buildt on the foundation of clinical exactness for citizens. It is important to promote health lifestyles across all ages and not just to those in need of care. It is hard to identify any other organization better suited to take the lead. But changes in the current processes are needed.
The current efforts are funded by specific legislative acts in specific clinical areas. In addition, the political nature of a Governmental organization requires that funds be spread broadly over many geographies and organizations including rural and urban settings. This funding process fragments the developing lifestyle change efforts within the CDC. The funding that is distributed is generally focused on getting as many people into the program sessions as possible with an open ended requirement to make the effort “sustainable.”
CBOs, historically funded by grants, are also project oriented. They want to have commercial revenues but within the scope of their ongoing activity. Few organizations have a clear business model for these activities. The Y is the best example of those that do, and given it size and overall resources they have been pursuing infrastructure development necessary to streamline support for these offerings. Few CBOs are collectively as large as the Y. And smaller CBOs do not have the resources or the existing experience in marketing and supporting their offerings. Many CBOs do not have a desire to change their grant-based financing model. Many groups have focused on underserved members of our society who need help. They see their mission as serving the many individuals in this population who are older, have existing disabilities, and are often financially constrained. These organizations need a simple path to help them use their existing capabilities in the commercial setting.
Self-insured employers and health plans are committed to maintaining a healthy workforce. Because their employees have jobs, they usually have a lower average age with fewer disabilities that public health plans. While there are significant variations in these organizations (i.e., white collar or blue collar), all commercial buyers expect to ensure their spending is achieving measurable clinical and financial results. They majority of these organizations are built with a recurring, not project oriented, infrastructure to sustain their business(es). They seek simplicity when they are selecting, contracting, and delivering their benefit offerings to their members. As buyers, they seek business partners that clearly demonstrate the capability to meet their expectations and support their corporate image.
The current CDC project focus on traditional CBOs does not work well in the commercial marketplace. Most employers are cautious about promotional efforts from local organizations with limited contracting experience and operational infrastructure. Commercial buyers want to have an infrastructure that supports more than one lifestyle change offering across their whole population. There are legal as well as practical reason to seek a standard benefit offering as it simplifies contracting (one deal) and makes it easier to communicate the plan to their overall population. They have been moving to integrated offerings for more than a decade for this reason.
The typical CBO requires major organizational restructuring to meet these expectations. CBOs have to be able to support multiple programs while competing against commercial sellers experienced in providing strong customer implementation and ongoing support.
It is interesting to note some commercial lifestyle change program vendors are adopting the CDC’s solutions. These vendor freely modify the offering and do not comply with all of the CDC’s reporting and other requirements to reduce the cost of the program to the commercial buyer. Using the CDC templates actually reduces the cost of program development and the vendors use supports the assertion the CDC can help standardize these offerings to engage the physicians.
If the programs become included in the majority of public and private buyers of healthcare, the patient will have the ability to select his lifestyle care provider. More organizations would be communicating to the community about the opportunity for positive lifestyle change. More messages from more sources will improve the overall marketing. Even the small CBOs would have an opportunity to compete in this environment. And the individual patient will be more committed to completing the program of their choice.
Rationale for the Solution
Several specific recommendations were made earlier. Collectively, the recommendation is to identify larger traditional CBOs willing to establish infrastructure for commercial program promotion and create regional networks of smaller traditional CBOs to support their offerings. The larger CBOs would be linked to create a national network capable of contracting with national health plan buyers across multiple CDC recognized offerings.Some of this is already happening, but the larger players with limited exceptions are not developing sustainable infrastructure. They provide informational support, serve as project managers for the term of the grant, and report progress achieved by their subgrantees. .
