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Benefits Managers Can Help Health Coaching Find Its Niche

The health system isn't designed to help people manage chronic conditions

A man is using a laptop to make a video call to a woman.

Health coaches can support people who are living with chronic conditions such as diabetes or heart disease, health experts say, by helping them to follow prescribed drug regimens, eat well and get appropriate exercise. Their real value, however, may be in acting as intermediaries with employees' health care providers. 

Employee benefits managers, working with their insurance carriers or third-party administrators (TPAs), can help ensure that workers dealing with medical challenges have access to health coaches.

Coaching's Value

Thomas Bodenheimer, a general internist who spent 32 years in primary care practice in San Francisco, thinks benefits managers are overlooking the value of integrating health coaching into what has traditionally been a top-down doctor/patient relationship.

Employers with self-funded health benefits can work with their TPAs to design plans that include access to health coaches, for example, while fully insured employers can choose to work with carriers that recognize the value of coaching.

"We haven't really gone out and made [health coaching] a household word," said Bodenheimer, who developed health coaching guidelines locally at San Francisco's Center for Excellence in Primary Care and nationally for the American Medical Association. "Employee benefits plans could be a good place to encourage it to happen."

Those efforts got a boost in June when New York Times personal health columnist Jane Brody wrote "We Could All Use a Health Coach." Researchers at the University of Southern Maine, she reported, "found that patients aided by health coaches saved $412 per patient per month," based on the insurance claims of 1,161 high-risk health plan enrollees, such as those with chronic conditions, who participated in the study for six months or longer.

"Monetary savings aside, the value to patients is immeasurable," Brody wrote. "As leading causes of disability and premature death, chronic disorders are responsible for the majority of the trillions of dollars now spent on health care."

[Related SHRM article: Study Stokes Fresh Scrutiny of Wellness Programs' Value]

Trust Is a Must

Health coaching already exists within many health benefits plans, but coaching advocates say elements that can make it most effective—integration with "real-life" data such as food diaries and fitness trackers, the clinician's care plan, and an ongoing trusted relationship—are often missing in plan-sponsored coaching. The same issues hamper telehealth coaching from third-party providers.

Coaching often isn't related to patients' primary care and so trust is a problem, Bodenheimer said. "That doesn't mean that some of these coaches aren't really good," he noted, but virtual coaching usually is more effective after patients have "met the [health coach] face to face and established a relationship."

Danielle Heuseveldt, coaching program manager at Crossover Health, which provides direct contract medical care to tech giants Apple, Amazon and Facebook, among other clients, agreed that the disconnect between many coaching programs and a person's medical providers can be a problem.

"Insurance company-based coaching can be really disjointed," Heuseveldt said, "because there is no connection between the work being done with the coach and the work being done in the primary care model."

Insurers and other providers are trying to correct these issues. Cigna's telephonic and online coaching program, for example, does offer communication between providers and coaches, according to Joseph Thorpe, product strategy managing director at Cigna's Evernorth health services subsidiary. "Once the coaching relationship has been established, we will reach out to [primary care] providers to inform them about the customer's participation in coaching," Thorpe said.

In addition, with the patient's permission, the coach will inform the provider of any concerns related to that person's health, such as a mental health screening score, biometrics outside the normal range or fast weight gain for customers with congestive heart failure.

Reimbursement Headwinds

Employer support, while welcomed, isn't likely to be enough to make coaching commonplace within primary care practices, health experts caution, given disincentives within the health care system. Among those headwinds are no clear path for reimbursing physicians for working with health coaches as intermediaries with their patients, not to mention the doctors' own cramped schedules.

Crossover Health CEO Scott Shreeve, himself a physician, said he understands why it is difficult to add coaching to a fellow doctor's duties under the reimbursement system much of U.S. health care uses.

"I am a generally healthy guy," Shreeve said. "I don't have a medical condition, and in a fee-for-service world there is nothing [for a physician] to bill for. But there is so much to do for my health working with a health coach who is keeping me accountable and on track. The problem is, who will pay for that?"

The American Medical Association has assigned coaching three billing codes, but they are classified as category III, for which reimbursement is not required. In a statement announcing the codes' approvals, the National Board of Health and Wellness Coaching said payers typically wait until codes have category I approval to begin reimbursement.

"It feels like a very difficult position to be in," Heuseveldt said. "It's one familiar to dieticians, for whom this has been an issue forever. We're covered by insurance for a handful of conditions. Otherwise, it's self-pay to see somebody who could really be instrumental in helping you move forward in your health."

However, as digital platforms like fitness trackers, smartwatches and mobile apps capture more personal health data, coaching advocates say there is a need to help people use that data to advance their own health goals, which could lend support to needed health system reforms.

Social Barriers

Social factors are another hurdle to effective health coaching, said Dena Bravata, chief medical officer of San Francisco-based health navigation platform vendor Castlight Health.

Bravata co-authored a recent Castlight study on outreach shortfalls for people with health insurance who face social barriers to effective health services, such as difficulty securing healthy food, child care and transportation.

As more employers become aware of how social determinants affect their employees' access to health care, outreach strategies that go beyond health provider or insurance carrier-based coaching will become more attractive, Bravata said.

"If you are asking somebody to call a coach, that's a pretty big hurdle," she explained. "It takes time out of schedules that they may not have. You may want to offer [a text messaging] chat or a link just to help them get started."

Flexibility is necessary to help people maximize health resources, Bodenheimer agreed, regardless of the method used or the title of the person giving assistance.

For effective health coaching, "instead of telling people what to do, you ask them what they are able and willing to do and meet them halfway," Bodenheimer said. "That's a big change."

Greg Goth is a freelance health and technology writer based in Oakville, Conn.


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