WASHINGTON, D.C. – Although nearly half of the nation's premature deaths are linked with such things as unhealthy diet, inactivity or substance abuse, few managed care plans routinely use proven strategies to help their enrollees change these behaviors. A new report from the Center for the Advancement of Health (CAH) shows that while most health plans offer some services to help members better manage chronic conditions or modify health risk behaviors, the majority of these efforts consist of handing out brochures or pamphlets -- a practice known to be ineffectual in producing sustained change.

The report, Health Behavior Change in Managed Care: A Status Report, is the first of its kind to assess the degree to which proven behavior change strategies are integrated into medical care. The report is based on a 1999 survey of HMO medical directors in five states and the District of Columbia, interviews with public and private health care purchasers, and an extensive review of the scientific literature on behavior change interventions in medical settings. The study focused on the attitudes and actions of both HMO medical directors and purchasers with regard to ensuring that evidence-based health behavior change services were offered to their members or beneficiaries. Specifically, both the HMO survey and purchaser interviews inquired about the provision of services to reduce risk (smoking, physical inactivity, unhealthy eating habits, and substance abuse) and to manage chronic diseases (asthma, back pain, heart disease, depression and diabetes).

The report finds that most HMO medical directors believe health behavior powerfully influences health outcomes. Behavioral health risks are tied to higher ambulatory care and hospitalization costs and account for as much as 70 percent of all medical care spending. However, health plans said they were reluctant to incorporate behavior change interventions into their systems of care, in part because the cost impact of doing so is unclear.

The survey also found that services to help patients better manage chronic diseases are treated and viewed differently than risk reduction services. While most health plans offer programs to help patients manage chronic disease as part of routine care, risk behavior change programs tend to be offered off-site and often result in out-of-pocket costs to patients. According to the report, behavior change efforts appear to be "fragmented within plans" with one set of policies and standards in existence for disease management and another in place for behavioral risk reduction services.

Interviews with health care purchasers found that they also recognize the important role that behavior plays in health. Nevertheless, few purchasers negotiate with health plans for specific behavior change services. "We found that health care purchasers expect that when they buy a comprehensive health benefit from a managed care plan it will include effective strategies for controlling risky behaviors and managing chronic diseases," says CAH Executive Director Jessie Gruman, Ph.D. "Most employers or purchasers are unwilling to offer behavior intervention services directly to employees or negotiate for them separately with a health plan for fear of paying for these services twice," she adds.

Although there are many examples of evidence-based interventions that work, the Center's analysis shows that incorporating these interventions into medical practice remains a "limited and piecemeal" effort. Part of the problem, according to the findings, is that managed care decision-makers, health care purchasers, providers and consumers have had difficulty distinguishing effective behavior change approaches from unproven ones. Gruman says this needs to change, particularly since both health plans and health purchasers now recognize that the health of individuals is highly influenced by behavior. "Well designed and widely available behavior change services could -- if fully implemented -- make a significant contribution to improving health outcomes as well as reduce costs," says Gruman. Other highlights of the study:

• Access to health behavior change services is primarily tied to medical need or provider referral rather than on any systematic outreach to all those at risk within a health plan.
• Although they see the value in health behavior change services, most purchasers don't feel they have any leverage or ability to negotiate for the type and quality of services plans offer their beneficiaries.
• The majority of purchasers report they do not have access to or make regular use of clinical and cost effectiveness data when making coverage decisions

The report was supported by a grant from The Robert Wood Johnson Foundation.

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The Center for the Advancement of Health, a nonprofit organization, promotes the science underlying the relationship between mental and physical states that influence health and illness, and works to turn that knowledge into practical health care solutions. The full reports from Health Behavior Change in Managed Care can be obtained by calling 202.387.2829 or sending e-mail to cfah@cfah.org.