The silent middle

Traditional disease management programs target high-cost, high-risk patients. This is “low-hanging fruit” in terms of cost savings, but such patients represent only 5 percent to 10 percent of your population. Wellness programs benefit a larger cohort but don’t offer substantial savings.

Roughly 68 percent of most populations, however, are neither sick nor well. They’re in the middle. Many in this segment are quietly developing yet-to-be-diagnosed chronic conditions. Engaging with them is emerging as the holy grail in population health. Three strategies can help.

Strategy 1: Use more sophisticated analytics

Even if you know who's in the silent middle are, how do you know if they want help?

Population health programs use clinical analytics to identify where an individual is on the path from well to sick. Advanced analytics programs rely on more-robust information, which combines raw health care data such as claims, health risk assessments, biometric screenings, electronic health record information, and even census and financial data — aggregating more than 1,500 clinically relevant facts to develop a comprehensive profile of a person. The result is deep understanding of a person’s clinical needs, opportunities, risks and likely behaviors.

The best analytics can identify not only who is in the silent middle but also who among them would respond favorably to an intervention. Organizations struggling to engage the silent middle should explore analytic capabilities that can help them understand an individual’s receptivity to change and even how he or she would like to receive information, which is critical to engaging people on a path to disease prevention.

Strategy 2: Employ new technology to lower cost

Once you’ve identified and analyzed your silent middle, you can turn to new technologies, which offer easy-to-use and cost-effective ways to reach and interact with patients. Online health portals can connect individuals with information relevant to their needs and solutions tailored to goals that most interest the user. Portals aren’t new, but some have now matured significantly — they not only connect with individuals but also interact with them, delivering highly personalized content and support.

The best online portals exploit a combination of digital, telephonic and in-person channels to interact with individuals in a manner that works for them. Text, chat and video — as well as the tried and true telephone — present myriad ways for individuals to access health guidance, and choose how they want to receive it and apply it to their daily life. Some portals allow individuals to integrate hundreds of wellness devices and apps that go beyond popular fitness wearables.

For example, A 40-year-old woman who is overweight, leads a sedentary lifestyle and has a family history of diabetes can be informed of her risk factors and screened for diabetes or its precondition. As a newly diagnosed prediabetic, she can integrate specialized devices such as meal planners and step counters into her portal experience. She can also use a diet app and immediately link to a health coach to better understand how to work with her physician. The health coach can answer her questions and walk her through creating an online, customized health action plan that will allow her to register for notifications, reminders and incentives. User-friendly and mobile-enabled interfaces will connect her to the programs she needs to forge her own path to better health.

Strategy 3: Consider other wraparound services 

Convenient care clinics: Because many in the silent middle don’t have a primary care physician relationship, convenient care clinics offer a valuable way to engage them. Today, there are an estimated 2,000 convenient care centers across the country, in retail stores, supermarkets and pharmacies. A multiyear study, published in September 2009 in the Annals of Internal Medicine, found that these clinics are "more convenient for patients, less costly and provide care that is of equal quality.”

Large health care systems are partnering with convenient care providers to offer high-quality care at a lower cost. These partnerships offer provider organizations an efficient way to expand their primary care networks and unclog their busy emergency departments without building new facilities and recruiting new staff.

NCQA-certified nurse phone lines: Nurse lines are well suited for people in the silent middle, who often lack a primary care physician. The highest-quality nurse lines feature registered nurses, who rely on evidence-based clinical data to rapidly assess health situations and direct members to the appropriate level of care. High-quality nurse lines can also help individuals learn about a new condition, prepare for a doctor’s visit or manage the side effects of a new medication. Organizations should seek a nurse line that is certified by the National Committee for Quality Assurance and includes bilingual nurses, access to live interpretation services, health information in multiple languages and at appropriate reading levels, and TDD/TTY accessibility for hearing-impaired patients.

Shared decision-making: Shared decision making informs patients about their condition and the risks and benefits of evidence-based treatments. SDM can better engage people in their health care choices. It also helps them evaluate the treatment options that best fit their preferences.

SDM is especially helpful for surgical conditions that have more than one viable treatment option. Examples include knee and hip osteoarthritis, back pain and surgeries designed to alleviate angina. Such costly conditions often affect this subpopulation of otherwise well people. Patients who use these tools tend to choose less-invasive care and report being more satisfied with both their care and their health plan.

Choose wisely when selecting SDM aids. Government programs may soon require aid certification, a process that requires a very high-quality aid. The best SDM programs extend the reach of their tools by combining them with support from licensed nurse coaches trained in shared decision-making. This approach can vastly expand the reach and effectiveness of the program.

Advanced analytics have taught us the importance of servicing the needs of the silent middle. Identifying and engaging this large and costly segment will help you serve this new holy grail of population health management.

Peter Goldbach, M.D., is the chief medical officer of RediClinic and Health Dialog in Boston.

The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.