The Use of Incentives in Low-Income and Medicaid Populations to

Encourage Health Promoting Behaviors

Mary S. Manning, RD, MBAMinnesota Department of Health

January 24, 2014

We Can Prevent Diabetes

SAGE Program

Tobacco Quitline-Warm Transfer

SAGE Program

• MN version of the National Breast and Cervical Cancer Screening Program

• Serving approximately 18,000 low-income women in MN annually.

Phone Component

• MDH’s toll-free phone center– Staffed 40+ hours/week

– Computer automated intake system

– Callers screened for program eligibility

– Eligible women offered appointment at

300+ screening sites statewide

– Follow-up calls to ensure appointments made

Direct Mail Study:Women 40 – 64

• Target population: Sage-eligible women ages 40–64

• Sampling frame: Experian’s “Inforum” database

• Study groups:1) Mail2) Mail + Incentive3) Control (no intervention)

• Main outcome: mammogram within 13 months

Mail Intervention

• Two versions of folded cards– Attention-grabbing message– Free mammogram– Prompt to call Sage’s phone center’s toll-free number– Extension code

• MDH envelope

• Bulk rate (standard presort) postage

• Personally addressed

The Robinsons Mailer

The Beads Mailer

Mail + Incentive Intervention

• Two folded cards

• Toll-free phone line

• Monetary incentive– Incentive insert attached to inside of cards

– $10 American Express gift check

– Women must call back after mammogram completed to

claim incentive

– Mammograms not validated for incentive

Main Outcome Results

TreatmentGroup

N Calls Received

EligibleCallers

Appts.Made

Screened

Mail 

25,633 403 (1.6%) 169 (41.9%) 123 (72.8%) 342 (1.3%)

Mail+Incentive

 25,633 1622 (6.3%) 486 (30.0%) 369 (75.9%) 490 (1.9%)

Control 

94,201 NA NA NA 662 (0.7%)

Direct Mail Study Conclusions

• Both interventions significantly increased screening

• Coupling direct mail with incentive significantly enhances effectiveness

• Offer of incentive is important but receipt of incentive is not

• Direct mail should be considered as a recruitment strategy in other NBCCEDP states

Sage’s Use of Direct Mail Today

• State of MN agency and program lists

• Consumer lists

• Clinic medical record lists

• Sage’s internal lists: – Annual Reminders– Relapsers– Refer-A-Friend

Newer Direct Mail Pieces

Recommendations for an Effective Direct Mail Campaign

• Targeted mailing list

• Pre-tested direct mail materials

• Message that prompts women to act – most often a loss-framed message

• Large, readable text

• 8th grade literacy level

• White space

Recommendations for an Effective Direct Mail Campaign (cont.)

• Eye-catching photo or graphic

• Envelope (vs. self-mailer)

• Incentive offer attached

• Toll-free number with extension code

• First class or standard presort postage

Tobacco Quitline-Warm Transfer

• DHHS Centers for Medicare and Medicaid Services, Request for Proposal– Part 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

We Can Prevent Diabetes MN Research Study

• Collaborative effort to bring the Diabetes Prevention Program (DPP) to Medicaid recipients in St. Paul/Mpls. Metro

• Research study to test effects incentives have on program attendance and weight loss by assigning participants to one of three incentive groups

What is the Diabetes Prevention Program (DPP)?

• Lifestyle change program aimed as preventing diabetes• Delivered in a small group setting (10 – 15 people) by a trained Lifestyle

Coach from YMCA• 16-session core program – 8 monthly sessions

– 1 hour per week

• Sessions focus on– Healthy Eating– Physical Activity– Behavior Modification

• Primary Goals– Reduce body weight by 7%– Participation in 150 minutes of physical activity per week

• Program takes place at participating clinic locations, community centers or the YMCA

We Can Prevent DiabetesIncentive Structure

Study Design

• 13 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 incentives– DPP plus individual and group incentives

• MHCP 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 system

Target Population

Diabetes Prevention Program• 16 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”

Incentives• Overall incentive structures, individual or individual plus

group, may be up to $560 for achieving all attendance and weight loss goals– Frequent reinforcement– Tiered by achievement

• Participants in all groups receive DPP free plus supports to attend and increase success in the DPP– Transportation– Childcare– Weight loss tools

Roles

• DHS: 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 system

Clinic Roles

• Identify eligible patients– Electronic Medical Record identifies those with PDM or at risk– Test patients at high risk– Support screening sessions as needed– Promote 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

Study Support to Clinics

• Funds for study coordinator and patient navigator

• Clinic stipend for set up

• Training and technical support from study staff

Benefits to Patients

• Opportunity to prevent or delay onset of diabetes

• Free DPP classes • Support for attending DPP – Navigator– Transportation – Childcare

• Incentives for those in intervention conditions

Benefits to Clinics

• Free 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

Benefits to Minnesota

• Reduce 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