The Use of Incentives in Lower Income and Medicaid Populations to Encourage Health Promoting Behaviors.

The Use of Incentives in Low-Income and Medicaid Populations to Encourage Health Promoting Behaviors

Mary S. Manning, RD, MBAMinnesota Department of HealthJanuary 24, 20141We can Prevent Diabetes

SAGE Program

Tobacco Quitline-Warm TransferSAGE Program CDC funded program Mammography screening for low income uninsured/uninsured women.

We Can Prevent DiabetesMedicad Innovations Grant to test use of incentives

2SAGE Program

MN version of the National Breast and Cervical Cancer Screening ProgramServing approximately 18,000 low-income women in MN annually. Phone ComponentMDHs toll-free phone centerStaffed 40+ hours/weekComputer automated intake systemCallers screened for program eligibilityEligible women offered appointment at 300+ screening sites statewideFollow-up calls to ensure appointments made

4Developed a sophisticated phone system to handle all types of callers and situations.

DAS computer automated intake system it is a screen driven system (similar to a CATI system) that the phone agents type all information directly into at the time of the call so all data is captured directly in a database.

Most important goal in setting up this system was to make appointments through a 3-way call (fast and easy) with the clinic during the call. We knew that if we left it up to the woman to make an appointment on her own or if she or us had to call back, then that would decrease the likelihood of a completed appointment.

Direct Mail Study:Women 40 64Target population: Sage-eligible women ages 4064Sampling frame: Experians Inforum databaseStudy groups:MailMail + IncentiveControl (no intervention)Main outcome: mammogram within 13 months

5RCT

Although there were two parallel studies, today I am primarily going to discuss the younger womens study (those 40 64). This has been published for you to review (provide manuscript).

Mailing list used: Inforum db consumer list; also contained NCI PRIZM Clusters that were designed to

Mail InterventionTwo versions of folded cardsAttention-grabbing messageFree mammogramPrompt to call Sages phone centers toll-free numberExtension codeMDH envelopeBulk rate (standard presort) postagePersonally addressed

6Today I will not go into detail on how we developed the mail pieces, except to say that we devoted a year with a marketing agency to help design and test them. We conducted pilot tests to determine the most effective pieces. Focus group results were not helpful at predicting actual effectiveness of mail pieces.

Envelope vs. Self-mailer (pilots showed envelope was much more accepted and got a better response) Self-mailer looked more like junk mail!

Bulk rate vs. First class.

Personally addressed vs. addressed to household.

The Robinsons Mailer

71st piece sent to all women

This has a loss-framed, fear-based messagewhat you can lose if you dont get screened!

Although we got some feedback from women that the message was harsh, it was noticed and continues to be one of our most effective pieces used today!

Our pilot tests indicated that the pieces needed to be brief and that you had to get the message across immediately. Women did not want to spend the time wading through text.

The main purpose of the pieces was to prompt women to call--a simple, easy action to do. The majority of what they needed to know would come from the phone call and not the mailing.

The Beads Mailer

8Second piece which all women received about a month after the Robinsons piece.

FRONT:Orange plastic bead about 1 cm in diameter on a string

INSIDE:Orange bead about 2 mm in diameter on a string.

Learned that women liked the novelty of this piece, that it was very educational and had a long shelf life because women had a tendency to hang on to it. Its very interactive and tactile.And again, the same prompt -- to call!

Mail + Incentive InterventionTwo folded cardsToll-free phone lineMonetary incentiveIncentive insert attached to inside of cards$10 American Express gift checkWomen must call back after mammogram completed to claim incentiveMammograms not validated for incentive

9Identical to Mail+Phone interventionpieces were the same (Robinsons and Beads)

Difference was a card insert that offered a monetary incentive for completing a mammogram.Main Outcome ResultsTreatmentGroupNCalls ReceivedEligibleCallersAppts.MadeScreenedMail25,633403 (1.6%)169 (41.9%)123 (72.8%)342 (1.3%)Mail+Incentive25,633

1622 (6.3%)486 (30.0%)369 (75.9%)490 (1.9%)Control94,201NANA

NA662 (0.7%)

10Main Outcome Analysis:Outcome = CBE and/or mammogram between May 24, 2000 and June 30, 2001Link Inforum database with Sages tracking and follow-up database

Newly EnrolledOverall, 479 women enrolled in the program for the first time (179 (52.3%) M+P, 300 (61.2%) M+P+I).

Direct Mail Study ConclusionsBoth interventions significantly increased screeningCoupling direct mail with incentive significantly enhances effectivenessOffer of incentive is important but receipt of incentive is not Direct mail should be considered as a recruitment strategy in other NBCCEDP states

11Both interventions increased screening.Interventions more effective among cluster women than non-cluster women.Cluster women also more likely to enroll in the program without any intervention (based on control group).Obtaining incentive not important for most women.Incentive may be motivator for calling but not primary reason for getting screened. Perhaps free screening was enough compensation. Receipt of incentive seemed unimportant. Only 31% of women in Mail+Incentive claimed their incentive.

NCIs CHPs can help target interventions.

Medicare population study also showed that women in the trt group were significantly more likely to have a mammogram than the control group replicated

We believe dm done correctly can motivate an individual to move through stages of behavior change (define the TTM Precontemplation: not ready; Contemplation intending to start healthy behavior in next 6 mos; Preparation ready to take action in next 30 days; Action changed their behavior in last 6 mos; Maintenance changed their behavior more than 6 months ago).

Sages Use of Direct Mail TodayState of MN agency and program listsConsumer listsClinic medical record listsSages internal lists: Annual RemindersRelapsersRefer-A-Friend

12Direct mail brings an average of over ____ new participants and ______ rescreeners every year. We conduct many different types of mailings every year. From working with other state programs to conducting our weekly and monthly rescreener mailingsdirect mail is our most effective and cost-effective recruitment strategy we use. We track and evaluate every direct mail activity we conduct and know what works. When we conducted our last test to determine effectiveness of newly designed pieces, we were able to determineNewer Direct Mail Pieces

Recommendations for an Effective Direct Mail CampaignTargeted mailing listPre-tested direct mail materialsMessage that prompts women to act most often a loss-framed messageLarge, readable text8th grade literacy levelWhite space

14Site Kim Wittes work for fear-based (loss-framed) messagesRecommendations for an Effective Direct Mail Campaign (cont.)Eye-catching photo or graphicEnvelope (vs. self-mailer)Incentive offer attached Toll-free number with extension codeFirst class or standard presort postage

15Graphic/photo - Envelope less like junk mail in comparison to self-mailer

Incentive insert card should include the Program toll-free number

EASILY REPLICATEDDM has also been translated to be used by Blue Cross/Blue Shield and the ND B & C Program; Stratis Health

ND B & C program replicated our direct mail strategy a couple years ago and we provided technical assistance.

BC/BS designed a piece to use to a few years ago and directed their clients to our program to receive a free mammogram. (Should scan this piece)

Tobacco Quitline-Warm Transfer

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18DHHS Centers for Medicare and Medicaid Services, Request for ProposalPart of the Affordable Care Act

Authorizes grants to states to provide incentives for Medicaid beneficiaries who participate in prevention programs and demonstrate changes in health risk and outcomes, including behavior change

We Can Prevent Diabetes

Background about the study.19We Can Prevent Diabetes MN Research StudyCollaborative effort to bring the Diabetes Prevention Program (DPP) to Medicaid recipients in St. Paul/Mpls. MetroResearch study to test effects incentives have on program attendance and weight loss by assigning participants to one of three incentive groups

If shown to be effective the program may become a covered benefit to Medicaid recipientsStudy funded by CMS through MN DHS

20What is the Diabetes Prevention Program (DPP)?Lifestyle change program aimed as preventing diabetesDelivered in a small group setting (10 15 people) by a trained Lifestyle Coach from YMCA16-session core program 8 monthly sessions1 hour per weekSessions focus onHealthy EatingPhysical ActivityBehavior ModificationPrimary GoalsReduce body weight by 7%Participation in 150 minutes of physical activity per weekProgram takes place at participating clinic locations, community centers or the YMCA

21We Can Prevent DiabetesIncentive Structure

22Study Design13 organizations (24 clinics) with high MA populations recruited using a RFP process

Patients are enrolled in a DPP group at their clinic that meets their scheduling preferences. Groups are then randomly assigned to condition:DPP only DPP plus individual incentivesDPP plus individual and group incentives

23MHCP enrollees 18-75 years with prediabetes or at high risk

Project conducted in 7 county metro area

Patients identified, recruited and enrolled in the DPP through their clinic or health systemTarget Population

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Diabetes Prevention Program16 weekly sessions (core)

8 monthly sessions (post-core)

Taught by trained lifestyle coach (YMCA)

All DPP classes free to eligible patients

DPP offered at their clinic or nearby site

All patients in a DPP group in the same study condition

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IncentivesOverall incentive structures, individual or individual plus group, may be up to $560 for achieving all attendance and weight loss goalsFrequent reinforcementTiered by achievement

Participants in all groups receive DPP free plus supports to attend and increase success in the DPPTransportationChildcareWeight loss tools

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RolesDHS: Study design and administration

MDH: Study design and coordination; recruit clinics; train and support clinic staff

Health Partners Research Foundation: Study design; collect data and evaluate study results

YMCA: Offer the DPP to all clinics

Diabetes Prevention and Control Alliance: support data collection through MyNetico data system27

Clinic RolesIdentify eligible patientsElectronic Medical Record identifies those with PDM or at riskTest patients at high riskSupport screening sessions as neededPromote DPP in clinic

Recruit and refer eligible patients to clinic Study Coordinator for enrollment in DPP classes

Enroll 60 or more patients in the DPP over 2 years

Support patients throughout study period

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Study Support to ClinicsFunds for study coordinator and patient navigator

Clinic stipend for set up

Training and technical support from study staff

29Benefits to PatientsOpportunity to prevent or delay onset of diabetesFree DPP classes Support for attending DPP NavigatorTransportation ChildcareIncentives for those in intervention conditions

30Benefits to ClinicsFree DPP classes for eligible patients

Training and support for identifying, recruiting and enrolling patients with prediabetes in DPP

Clinic systems to enhance detection and treatment of prediabetes

Training for two clinic staff to be DPP lifestyle coaches when study ends

31Benefits to MinnesotaReduce new cases of diabetes in high risk population

Build infrastructure for offering the DPP in clinics

Expand CHW/navigator role in clinics

Increase awareness about diabetes prevention among patients and providers

Increase capacity to prevent diabetes

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