HMOs and Health Education IRVING S. SHAPIRO, PhD
The role of health education in the structure and functioning of health maintenance organizations is examined.
Introduction Health maintenance organizations (HMOs), by name, by organization and operation, by social philosophy, and by economic logic must integrate health education into their structures. The label itself, health maintenance, proclaims a focus on behaviors which one is educated toward, rather than which are assured by medication or surgery. The organization and operation of an HMO is today variously defined. If its general purpose is "to assure responsibility for the total health care of defined populations on the basis of fixed annual contracts," there remains the variation possible in financial support, services, population coverage, patterns of delivery, sponsorship, safeguards, and implementation.' The specific characteristics of a particular HMO will, of course, determine its health education potentials and affect the realization of health education goals within it. Health education is also variously defined. In essence, it is generally seen as being concerned with the knowledge, feelings, and behavior of people in relation to health. Within the context of a health services delivery system, or the HMO concept, health education can be viewed as an active process aimed at providing and strengthening influences and experiences for both staff and covered population which will encourage health maintenance and recovery from illness. The rationale for health education effort can be expressed in both philosophical and pragmatic terms. Philosophically, hominid evolution-the culture which Dr. Shapiro is Director, Health Education Program, School of Public Health, Columbia University; Adjunct Professor, Institute of Health Sciences, Hunter College, New York, New York; and an educational consultant. He was formerly Director, Health Education Division, Health Insurance Plan of Greater New York. This article is based on a position paper prepared for the President's Committee on Health Education, of which Dr. Shapiro was a member.
makes man human-has in all societies revealed traditions which express man's concern for health, whether labeled magico-religious-supernatural or secular-scientific. Thus, each has a "need" to know, to be educated in health, which is fulfilled in various ways. One's "right" to know is an ethical expression of our own particular culture. There is also our stated preference for education over manipulation, free choice over force, respect for individual dignity and integrity over contempt and exploitation of others. Pragmatically, particular activities and goals also mandate health education. Thus, the practicing physician writes a prescription he hopes the patient will take. A health department offers immunization it hopes mothers will bring their children for. Schools hope students will learn to handle drugs appropriately as well as to read. And other agencies hope people will eat less or stop smoking. All health-related activities have educational or teaching-learning components. Some are major or crucial, requiring large, conscious effort. Others are minor or incidental, occurring with no interest or awareness. A significant number of health-related goals are simply not attainable without appropriate behaviors-all of which are learned. The justification for health education may also be expressed in economic terms. Do its benefits match its costs? Does it reduce costs beyond its own expense and thus actually save money? Attempts to answer these questions in a rigorous fashion have been few, although a growing interest in the area is evidenced by recent publication of summaries of such studies and of evaluative designs for patient education programs.2 ,3 * However, some data generated in health education programs are of a special nature. They do not lend themselves as readily as others to traditional methods of counting up and costing out.4 Within the context of an HMO, it is obvious that appropriate and efficient use of its facilities and personnel, * Avery et al. comment, "A cost-benefit analysis of these data will likely yield a compelling argument in favor of patient education in many medical care settings"3
HMO AND HEALTH EDUCATION
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cooperatively determined individual and joint efforts by patients, doctors, nurses, and others during treatment, a shift to demands for services earlier in illness, and a lessening in demand due to better health maintenance all mean cost savings.
Within an HMO To examine in greater detail how health education may be integrated into the structure and functioning of HMOs, it is necessary to examine specific organizational characteristics. While the label, HMO, may indeed cover many different kinds of organizations, the fact is that relatively few already exist with a history of "providing a full-range of medical care services to a defined or enrolled population in return for a fixed annual fee paid in advance."5 These few include the prepaid group practice plans, which have been referred to by governmental officials as one model for HMO development. The Health Insurance Plan of Greater New York (HIP), the Group Health Cooperative of Puget Sound, and the Kaiser Foundation are often named. These particular prepaid group practice plans have also developed health education programs which have unique as well as common characteristics. Obviously, among HMOs of a similar type there is room for variation, flexibility, and growth. It is also true that the differing internal characteristics of other types of HMOs will be reflected in the kinds and qualities of the health education activities they may initiate. HIP
Of the three organizations named, HIP has had a health education unit the longest, dating back to 1945 when it was in its planning and organizing stage. Characteristics of the plan which are relevant to its health education potential and developments include its stated purposes, which find expression in its medical and administrative standards,6 and its specific financing method and organizational structure.7 Included in its range of comprehensive services are periodic health examinations, immunizations, and other measures for the prevention and detection of disease. There are minimal extra charges which only a few enrollees are occasionally apt to face. Thus, for their prepaid premiums, subscribers can turn to full and continuous care, free of cost inhibitions. The 27 HIP medical groups, with a total of about 1,000 physicians, provide services to 750,000 people. The groups are legal medical partnerships, comprising family physicians and specialists representing at least 12 of the recognized medical specialists. Each medical group contracts with HIP to provide comprehensive services to every member it serves in return for a yearly capitation fee. The medical group partnership utilizes this income, which is based on the number of its enrollees and not on the numbers or kinds of services rendered, for staff remuneration and other operating expenses. Other features relevant to health education potentials 470
AJPH MAY, 1975, Vol. 65, No. 5
include close working relationships among physicians and allied health personnel, the provision of unit medical records, the principle that necessary care is rendered only by physicians qualified by training to do so, and a broad orientation toward illness and health expressed in staffing by nutritionists, social workers, and mental health workers, as well as health educators. The administrative separation of finance management from the practice of medicine makes it easier to allocate funds for educational activities. The fundamental of true team service for an identifiable and stable group of individuals and families makes possible a joint effort and the sharing of educational responsibilities. It encourages growth of mutual understanding. It taps a pool of human resources for a variety of educational objectives. In any health care system, the physician is central. Consequently an operational guide for all health education activities in the HIP medical groups has been that the physicians in a particular medical group agree to endorse, sponsor, or participate in educational efforts for their patients. Through the years, a wide variety of health educational activities has been developed. These include large and small meetings, classes, and continuing group discussions; regular mailed bulletins, internal newsletters, leaflets, welcome letters, interpretive booklets, the screening and distribution of materials produced elsewhere; subscriber committees; special immunization and check-up cards, exhibits, bulletin boards; in-service training courses; liaison with community organizations; field and residency programs for students; orientation for visitors; consultation and guidance; evaluation. These activities have embraced a far-ranging content, focusing on: health maintenance (human biology, nutrition, health hazards, mental health, preventive medicine, etc.); the use of available services (how to recognize need, the value of prompt action, specific steps to take, the reasons for medical and administrative procedures, etc.); medical care (national and historical trends, the nature of medical practice, why group practice is organized and works the way it does, etc.); special planwide campaigns (polio and measles immunizations, tonometry screening for glaucoma, expectant parent group education, etc.); face-to-face contacts between staff and patients (in-service training sessions in interpersonal relations, study of how well the patient understands the doctor, study of how Spanish-speaking members may view health, illness, and medical treatment, etc.); particular subjects (health needs and problems for different ages and sex groups, addictions, food fads, radiation, menopause, child care, diabetes, allergy, chronic illness, mental health, headaches, the doctor's instruments and procedures, etc.); and the development of special clinics and services (adolescent clinics, family planning, counseling, cooperation with nutritionists and social workers, consultation with students and outreach workers, etc.).8'1 l This listing of educational activities in HIP may be extended considerably. Recent developments calling for health education activities have been HIP's new Multiphasic Health Testing Center and its first hospital. There is interest in the problem-oriented medical record, whose main
proponent has himself stressed the necessity for health education. * While many of these activities continue today, some are intermittent, some have been transferred to other units, and some have ceased. What is noteworthy is the extent and range of activities realized. They have involved hundreds of physicians and dozens of key administration personnel. They reach all subscribers through the regular mailing of individualized medical group bulletins and thousands of members through the other activities. Evaluation of achievements in the program has included measurements and observations such as special studies, attendance at meetings, reader response to bulletin articles, written questionnaires, personal interviews with subscribers and physicians, evaluative comments at meetings, subscriber committee activity, the nature and quantity of questions asked at meetings, the number of physicians and administrators participating, the response by individual physicians and group administrators to subscriber comments and suggestions, subscriber reaction to medical group information, suggestions, advice, or directive, and community response.
Group Health-Puget Sound The Group Health Cooperative of Puget Sound in Seattle, Washington, is an outstanding model of a prepaid group practice plan developed and owned by a consumercooperative. It shares many organizational characteristics with HIP. For at least 15 years, its health education unit has guided activities involving the membership, the medical staff, the employees, and the community.' 3 As in HIP, there have been large meetings of members and small group discussions; newsletters, reports, leaflets; consultation and guidance for staff; the development and use of questionnaires and audiovisual material; special in-service training conferences and workshops. These efforts have focused on orientation of members to the Plan, health maintenance, preventive procedures, improved understanding between patient and staff and between staff units, and cooperation with community organizations. For a time, member complaints were received and processed by a health educator. More recently, in response to the enrollment of poverty groups, the health education unit has trained outreach workers recruited from this population to function as auxiliary health educators, nurses, and social workers. In another direction, a health educator has organized and guides a task force of staff nurses, social workers, physicians, and administrators to study and install family planning services for members.' 4 *
"Plans for education of the patient have been seriously neglected by the medical profession.... They should not expect the patient to grasp, after one exposure all the implications and details of the management of his disorder.... Advantage can be taken of that resource (patients and potential patients) through education of the 11 2 patient. .
Kaiser-Permanente In 1967, at the Kaiser-Permanente Medical Group in Oakland, California, the use of nurse-instructors in an ambulatory care unit was started. The objective was to "(1) improve care by positively influencing patient motivation and compliance, and (2) conserve physician time and increase the efficiency of medical care delivery."'' With educational staff members as resource people, the nurseeducators use many teaching methods and audiovisual tools to reduce patient confusion and anxieties and to guide patients in self-care and the use of services. The concept of conserving physician time within the Plan was elaborated into a suggested system which would regulate the flow of patients who might be identified as well, worried well, early sick, and sick.' 6 These members would follow different routes as they received necessary services. Thus, "With health testing as the heart of the system, the entry mix is sorted into its components which fan out to each of three distinct divisions of service: a health education service, a preventive maintenance service, and a sick care service."1 7 A Health Education Research Center has been established in Oakland which contains a popular Exhibit Theatre, with displays on a variety of subjects. Open house programs are planned. A health education library for patients has been established, where different teaching aids may be used. Topics covered include baby care, back pain, diabetes, family planning, nutrition, sex education, and adult immunization, among others. Patients are referred to the Health Education Center for advice and counseling in many areas.' 8
Potentials The programs in these three organizations demonstrate that a health education program in an HMO can serve as an efficient mechanism for providing patients with scientifically accurate information and reassurance about illness, for improving cooperation during treatment and recovery, and for encouraging the maintenance of health. It can reduce friction, misunderstanding, annoyance, and delay by explaining medical group practice and administrative functions and by describing specific procedures to be followed for medical care. It can contribute to the creation and improvement of certain health services. It can establish, maintain, extend, and encourage the use of channels of communication between patient and doctor, and between all members and the HMO. It can also help build a larger reservoir of good will between patients and staff, and between the community and the HMO. There are many other types of HMOs, only some of which are being patterned after the prepaid group practice structure exemplified by the three plans mentioned here. Interested in HMO programs have been physician groups, community hospitals, neighborhood health centers, medical schools, private corporations, medical societies, and state HMO AND HEALTH EDUCATION
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and local health departments. Blue Cross and Blue Shield plans and major commercial health insurance carriers are considering or actively developing and supporting HMOs. The new HMO law, despite specific criteria for certification, permits a wide range of HMOs. It also includes the injunction, "Each health maintenance organization shall encourage and actively provide for its members health education services, education in the appropriate use of health services, and education in the contribution each member can make to the maintenance of his own health" (Sec. 1301-C-9). The potential and need for health education exists in every HMO. But however it may be assayed, and whatever the results of particular efforts, best success is not achieved mechanically, nor does it flow automatically from the distribution of information to a covered population. The fullest realization of teaching-learning potentials-for both patients and staff-is more likely when the effort is initiated and guided by professional educators.
The Health Educator All educators have, to varying degrees, been educated in selected biological and social sciences, and in psychological and sociological foundations of education. Working in the field of health, whether in school systems or other agencies in the community, the health educator adds an understanding of health functions, organization, and practices related to health services and goals. With extended training, the health educator learns to analyze educational needs, to design programs, mobilize resources, and evaluate efforts. He learns to participate in program planning with other disciplines.' 9 The successful educator will employ far more than his skills in the use of learning theory and teaching methods, techniques, and tools. The art which largely determines the degree of his influence in planning and program development is an expression of his understanding of the "culture" of the HMO he may work with. He must respond to its administrative character and atmosphere, use the skills of interpersonal relationships, and be sensitive to role identification, value hierarchies, and the process of change.20 There is need to consider ways of utilizing the existing pool of health educators, both graduate and undergraduate, efficiently and effectively. Obviously, the HMO which employs and appropriately supports a staff of better qualified educators is most likely to achieve more of its educational objectives. This is particularly so where such objectives include behavioral responses among the greatest possible number of staff and enrolled members.
preventive medicine procedures,2 1 has no answer yet. At the same time, the essential need to motivate and educate patients receiving primary medical care is readily acknowledged. More broadly, and despite the lack of a dollars and cents cost accounting, the logic remains that people must be helped to utilize any system properly. "To overlook this is to ask for a lowering return on an expanding investment."2 1 Whether because it is believed that it can save money or time, or that many treatment and health goals are meaningless without it, or that it is a human need or ethical right, or simply that we need more exact knowledge of its usefulness and costs, health education belongs in HMOs. The Health Insurance Plan of Greater New York and the Group Health Cooperative of Puget Sound pay out of premium income considerable and expanding sums of money to support staffs of health educators and the programs they stimulate and guide. The health education research at Kaiser-Permanente program at Oakland has been supported by the Kaiser Foundation Research Institute and Public Health Service funds. Despite the validity and success of these pioneering efforts, the costs of desired improvements within these programs are not easily met. As discussed here, health education is seen as a necessary component of high quality medical care. The justification exists now for its inclusion in programs of health services organized to provide such care. During recent years, national government advisory committees and task forces have strongly recommended federal involvement in research, demonstration, and standard setting for health education in various programs.22 For 2 years prior to the enactment of the Health Maintenance Organization Act of 1973 (P. L. 93-222) there was an HMO Services unit within the Department of Health, Education, and Welfare which included an Office of Consumer Education and Information. Through contract arrangements, it offered the technical assistance of professional health educators on a consultant basis to HMO grantees receiving planning and development monies. With the passage of the law, a task force of health educators was convened to recommend rules, regulations, and guidelines to assist in the implementation of the health education section of the law. A major obstacle remains. How will health education be paid for? Funding mechanisms to encourage the integration and expansion of health education activities in HMOs and to support these efforts with sufficient and stable funds should be explored. These mechanisms include the use of general funds, a percentage of prepaid premiums, a fixed sum per individual or family covered, and third party contributions by government and private organizations.
Funding
Summary
Any analysis of the rationale for-and the place of-health education in a health care organization faces certain dilemmas. If its major justification must be economic payoff, health education, as is true for many
HMOs, by their stated purpose and nature, have a necessary and central involvement with health education. The specific characteristics of any HMO determine the extent and quality of health education.
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An HMO has the responsibility to identify its educational objectives, as well as the educational components of any of its other objectives. The more professional the educational guidance, the better it is integrated into the organization, and the greater its financial and administrative support, the more likely will be the success in achieving objectives. In brief, every HMO has the need and potential for a health education effort. The extent and quality of that effort will reflect the mix of administrative philosophy, organizational characteristics, the degree to which professional educators are involved, and the amount and stability of financial support.
10.
11. 12.
13.
14.
References 1. Health Maintenance Organizations. A Policy Paper (No. VII of Resolutions Adopted by the Governing Council of the American Public Health Association). Am. J. Public Health 61:2528-2536, 1971. 2. Green, L. W., and Figa-Talamanica, I. Suggested Designs for Evaluation of Patient Education Programs. Health Education Monographs. SOPHE 2:54-71, 1974. 3. Avery, C. H., Green, L. W., and Krieder, S. Reducing Emergency Visits to Asthmatics: An Experiment in Patient Education. Johns Hopkins University School of Hygiene and Public Health, Baltimore. 4. Ridenour, N. Criteria of Effectiveness in Mental Health Education. In Mental Health Education, Ch. 3, pp. 37-52. Mental Health Materials Center, New York, 1969. 5. Ellwood, P. M., Jr. Implications of Recent Health Legislation. Am. J. Public Health 62:20, 1972. 6. Professional Standards for Medical Groups, pp. 11-12. Health Insurance Plan of Greater New York, New York, 1968. 7. Information for Physicians. Health Insurance Plan of Greater New York, New York, 1972. 8. Rosen, G. Health Education and Preventive MedicineNew Horizons in Medical Care. Am. J. Public Health
42:687-693,1952. 9. Shapiro, I. S. The Patient and Control of Quality in
15. 16.
17. 18.
19.
20. 21.
22.
Medical Care, pp. 99-107. In Proceedings of Tenth Annual Group Health Institute of the Group Health Association of America, Washington, DC, 1960. Shapiro, I. S. The Health Educator and the Practice of Medicine, Relating Theory to Practice, 1963. Reprinted in Consumerism in the HMO Movement, DHEW Pub. no. HSM 73-13012. U.S. Government Printing Office, Washington, DC, 1973. Shapiro, I. S., and Levine, H. H. Integrating Glaucoma Detection into Group Medical Practice. Am. J. Public Health 55:1638-1642, 1965. Weed, L. Medical Records, Medical Education, and Patient Care, pp. 50-53. Case-Western Reserve University Press, Cleveland, 1969. Switzer, J. M. Health Education Aspects of the Group Health Cooperative of Puget Sound, Health Education in Medical Care, pp. 45-52. School of Public Health, University of California, Berkeley, 1962. Birnbaum, H. M. Statement on the Function of Health Educators in a Health Maintenance Organization. Appendices I and II. Presented to the President's Committee on Health Education, San Francisco, Jan. 19, 1972. Collen, F. B., Madero, B., Soghikian, K., and Garfield, S. R. Kaiser-Permanente Experiment in Ambulatory Care. Am. J. Nursing 71:1371-1374, 1971. Garfield, S. R. Prevention of Dissipation of Health Services Resources. Am. J. Public Health 61:1499-1506, 1971. Garfield, S. R. Delivery of Medical Care. Sci. Am. 222:15-23, 1970. Collen, F. B., and Soghikian, K. The Educational Component in the Delivery of Medical Care Services at Kaiser/Permanente in Oakland, California. Presented at Group Health Institute of Group Health Association of America, Boston, 1973. Criteria and Guidelines for Accrediting Graduate Programs in Community Health Education. Committee on Professional Education. Am. J. Public Health 59:534-542, 1969. Shapiro, I. S. The Teaching Role of Health Professionals in a Formal Organization. Health Education Monographs. SOPHE, No. 36, 1973. McNerney, W. J. Health Care Reforms-The Myths and Realities. The Tenth Bronfman Lecture. Am. J. Public Health 61:225-227, 1971. Shapiro, I. S. Health Education Horizons and Patient Satisfactions. Am. J. Public Health 62:229-234, 1972.
CONTRIBUTIONS SOUGHT FOR WOMEN'S HEALTH BOOKSHELF Contributions and suggestions for content for a "Women's Health Bookshelf," which is being developed for publication in a forthcoming issue of this Journal, are being sought by APHA's Standing Committee on Women's Rights and the Women's Caucus. Dealing with all aspects of women and health-including women as health professionals and as consumers of health services, and women's health problems-the bookshelf will feature bibliographies of books and journal articles of merit, and lists of organizations to contact for inforrnation. Interested contributors are invited to submit materials or information appropriate for the bookshelf to any of these persons: Jane B. Sprague, PhD, Assistant Professor, Department of Community Medicine, School of Medicine, University of California at San Diego, LaJolla, CA 92037; Jayn Graves, 444½/2 North Curson Avenue, Los Angeles, CA 90036; or Mary Plaska, APHA, 1015 Eighteenth Street, NW, Washington, DC 20036. HMO AND HEALTH EDUCATION
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The role of health education in the structure and functioning of health maintenance organizations is examined.
Introduction Health maintenance organizations (HMOs), by name, by organization and operation, by social philosophy, and by economic logic must integrate health education into their structures. The label itself, health maintenance, proclaims a focus on behaviors which one is educated toward, rather than which are assured by medication or surgery. The organization and operation of an HMO is today variously defined. If its general purpose is "to assure responsibility for the total health care of defined populations on the basis of fixed annual contracts," there remains the variation possible in financial support, services, population coverage, patterns of delivery, sponsorship, safeguards, and implementation.' The specific characteristics of a particular HMO will, of course, determine its health education potentials and affect the realization of health education goals within it. Health education is also variously defined. In essence, it is generally seen as being concerned with the knowledge, feelings, and behavior of people in relation to health. Within the context of a health services delivery system, or the HMO concept, health education can be viewed as an active process aimed at providing and strengthening influences and experiences for both staff and covered population which will encourage health maintenance and recovery from illness. The rationale for health education effort can be expressed in both philosophical and pragmatic terms. Philosophically, hominid evolution-the culture which Dr. Shapiro is Director, Health Education Program, School of Public Health, Columbia University; Adjunct Professor, Institute of Health Sciences, Hunter College, New York, New York; and an educational consultant. He was formerly Director, Health Education Division, Health Insurance Plan of Greater New York. This article is based on a position paper prepared for the President's Committee on Health Education, of which Dr. Shapiro was a member.
makes man human-has in all societies revealed traditions which express man's concern for health, whether labeled magico-religious-supernatural or secular-scientific. Thus, each has a "need" to know, to be educated in health, which is fulfilled in various ways. One's "right" to know is an ethical expression of our own particular culture. There is also our stated preference for education over manipulation, free choice over force, respect for individual dignity and integrity over contempt and exploitation of others. Pragmatically, particular activities and goals also mandate health education. Thus, the practicing physician writes a prescription he hopes the patient will take. A health department offers immunization it hopes mothers will bring their children for. Schools hope students will learn to handle drugs appropriately as well as to read. And other agencies hope people will eat less or stop smoking. All health-related activities have educational or teaching-learning components. Some are major or crucial, requiring large, conscious effort. Others are minor or incidental, occurring with no interest or awareness. A significant number of health-related goals are simply not attainable without appropriate behaviors-all of which are learned. The justification for health education may also be expressed in economic terms. Do its benefits match its costs? Does it reduce costs beyond its own expense and thus actually save money? Attempts to answer these questions in a rigorous fashion have been few, although a growing interest in the area is evidenced by recent publication of summaries of such studies and of evaluative designs for patient education programs.2 ,3 * However, some data generated in health education programs are of a special nature. They do not lend themselves as readily as others to traditional methods of counting up and costing out.4 Within the context of an HMO, it is obvious that appropriate and efficient use of its facilities and personnel, * Avery et al. comment, "A cost-benefit analysis of these data will likely yield a compelling argument in favor of patient education in many medical care settings"3
HMO AND HEALTH EDUCATION
469
cooperatively determined individual and joint efforts by patients, doctors, nurses, and others during treatment, a shift to demands for services earlier in illness, and a lessening in demand due to better health maintenance all mean cost savings.
Within an HMO To examine in greater detail how health education may be integrated into the structure and functioning of HMOs, it is necessary to examine specific organizational characteristics. While the label, HMO, may indeed cover many different kinds of organizations, the fact is that relatively few already exist with a history of "providing a full-range of medical care services to a defined or enrolled population in return for a fixed annual fee paid in advance."5 These few include the prepaid group practice plans, which have been referred to by governmental officials as one model for HMO development. The Health Insurance Plan of Greater New York (HIP), the Group Health Cooperative of Puget Sound, and the Kaiser Foundation are often named. These particular prepaid group practice plans have also developed health education programs which have unique as well as common characteristics. Obviously, among HMOs of a similar type there is room for variation, flexibility, and growth. It is also true that the differing internal characteristics of other types of HMOs will be reflected in the kinds and qualities of the health education activities they may initiate. HIP
Of the three organizations named, HIP has had a health education unit the longest, dating back to 1945 when it was in its planning and organizing stage. Characteristics of the plan which are relevant to its health education potential and developments include its stated purposes, which find expression in its medical and administrative standards,6 and its specific financing method and organizational structure.7 Included in its range of comprehensive services are periodic health examinations, immunizations, and other measures for the prevention and detection of disease. There are minimal extra charges which only a few enrollees are occasionally apt to face. Thus, for their prepaid premiums, subscribers can turn to full and continuous care, free of cost inhibitions. The 27 HIP medical groups, with a total of about 1,000 physicians, provide services to 750,000 people. The groups are legal medical partnerships, comprising family physicians and specialists representing at least 12 of the recognized medical specialists. Each medical group contracts with HIP to provide comprehensive services to every member it serves in return for a yearly capitation fee. The medical group partnership utilizes this income, which is based on the number of its enrollees and not on the numbers or kinds of services rendered, for staff remuneration and other operating expenses. Other features relevant to health education potentials 470
AJPH MAY, 1975, Vol. 65, No. 5
include close working relationships among physicians and allied health personnel, the provision of unit medical records, the principle that necessary care is rendered only by physicians qualified by training to do so, and a broad orientation toward illness and health expressed in staffing by nutritionists, social workers, and mental health workers, as well as health educators. The administrative separation of finance management from the practice of medicine makes it easier to allocate funds for educational activities. The fundamental of true team service for an identifiable and stable group of individuals and families makes possible a joint effort and the sharing of educational responsibilities. It encourages growth of mutual understanding. It taps a pool of human resources for a variety of educational objectives. In any health care system, the physician is central. Consequently an operational guide for all health education activities in the HIP medical groups has been that the physicians in a particular medical group agree to endorse, sponsor, or participate in educational efforts for their patients. Through the years, a wide variety of health educational activities has been developed. These include large and small meetings, classes, and continuing group discussions; regular mailed bulletins, internal newsletters, leaflets, welcome letters, interpretive booklets, the screening and distribution of materials produced elsewhere; subscriber committees; special immunization and check-up cards, exhibits, bulletin boards; in-service training courses; liaison with community organizations; field and residency programs for students; orientation for visitors; consultation and guidance; evaluation. These activities have embraced a far-ranging content, focusing on: health maintenance (human biology, nutrition, health hazards, mental health, preventive medicine, etc.); the use of available services (how to recognize need, the value of prompt action, specific steps to take, the reasons for medical and administrative procedures, etc.); medical care (national and historical trends, the nature of medical practice, why group practice is organized and works the way it does, etc.); special planwide campaigns (polio and measles immunizations, tonometry screening for glaucoma, expectant parent group education, etc.); face-to-face contacts between staff and patients (in-service training sessions in interpersonal relations, study of how well the patient understands the doctor, study of how Spanish-speaking members may view health, illness, and medical treatment, etc.); particular subjects (health needs and problems for different ages and sex groups, addictions, food fads, radiation, menopause, child care, diabetes, allergy, chronic illness, mental health, headaches, the doctor's instruments and procedures, etc.); and the development of special clinics and services (adolescent clinics, family planning, counseling, cooperation with nutritionists and social workers, consultation with students and outreach workers, etc.).8'1 l This listing of educational activities in HIP may be extended considerably. Recent developments calling for health education activities have been HIP's new Multiphasic Health Testing Center and its first hospital. There is interest in the problem-oriented medical record, whose main
proponent has himself stressed the necessity for health education. * While many of these activities continue today, some are intermittent, some have been transferred to other units, and some have ceased. What is noteworthy is the extent and range of activities realized. They have involved hundreds of physicians and dozens of key administration personnel. They reach all subscribers through the regular mailing of individualized medical group bulletins and thousands of members through the other activities. Evaluation of achievements in the program has included measurements and observations such as special studies, attendance at meetings, reader response to bulletin articles, written questionnaires, personal interviews with subscribers and physicians, evaluative comments at meetings, subscriber committee activity, the nature and quantity of questions asked at meetings, the number of physicians and administrators participating, the response by individual physicians and group administrators to subscriber comments and suggestions, subscriber reaction to medical group information, suggestions, advice, or directive, and community response.
Group Health-Puget Sound The Group Health Cooperative of Puget Sound in Seattle, Washington, is an outstanding model of a prepaid group practice plan developed and owned by a consumercooperative. It shares many organizational characteristics with HIP. For at least 15 years, its health education unit has guided activities involving the membership, the medical staff, the employees, and the community.' 3 As in HIP, there have been large meetings of members and small group discussions; newsletters, reports, leaflets; consultation and guidance for staff; the development and use of questionnaires and audiovisual material; special in-service training conferences and workshops. These efforts have focused on orientation of members to the Plan, health maintenance, preventive procedures, improved understanding between patient and staff and between staff units, and cooperation with community organizations. For a time, member complaints were received and processed by a health educator. More recently, in response to the enrollment of poverty groups, the health education unit has trained outreach workers recruited from this population to function as auxiliary health educators, nurses, and social workers. In another direction, a health educator has organized and guides a task force of staff nurses, social workers, physicians, and administrators to study and install family planning services for members.' 4 *
"Plans for education of the patient have been seriously neglected by the medical profession.... They should not expect the patient to grasp, after one exposure all the implications and details of the management of his disorder.... Advantage can be taken of that resource (patients and potential patients) through education of the 11 2 patient. .
Kaiser-Permanente In 1967, at the Kaiser-Permanente Medical Group in Oakland, California, the use of nurse-instructors in an ambulatory care unit was started. The objective was to "(1) improve care by positively influencing patient motivation and compliance, and (2) conserve physician time and increase the efficiency of medical care delivery."'' With educational staff members as resource people, the nurseeducators use many teaching methods and audiovisual tools to reduce patient confusion and anxieties and to guide patients in self-care and the use of services. The concept of conserving physician time within the Plan was elaborated into a suggested system which would regulate the flow of patients who might be identified as well, worried well, early sick, and sick.' 6 These members would follow different routes as they received necessary services. Thus, "With health testing as the heart of the system, the entry mix is sorted into its components which fan out to each of three distinct divisions of service: a health education service, a preventive maintenance service, and a sick care service."1 7 A Health Education Research Center has been established in Oakland which contains a popular Exhibit Theatre, with displays on a variety of subjects. Open house programs are planned. A health education library for patients has been established, where different teaching aids may be used. Topics covered include baby care, back pain, diabetes, family planning, nutrition, sex education, and adult immunization, among others. Patients are referred to the Health Education Center for advice and counseling in many areas.' 8
Potentials The programs in these three organizations demonstrate that a health education program in an HMO can serve as an efficient mechanism for providing patients with scientifically accurate information and reassurance about illness, for improving cooperation during treatment and recovery, and for encouraging the maintenance of health. It can reduce friction, misunderstanding, annoyance, and delay by explaining medical group practice and administrative functions and by describing specific procedures to be followed for medical care. It can contribute to the creation and improvement of certain health services. It can establish, maintain, extend, and encourage the use of channels of communication between patient and doctor, and between all members and the HMO. It can also help build a larger reservoir of good will between patients and staff, and between the community and the HMO. There are many other types of HMOs, only some of which are being patterned after the prepaid group practice structure exemplified by the three plans mentioned here. Interested in HMO programs have been physician groups, community hospitals, neighborhood health centers, medical schools, private corporations, medical societies, and state HMO AND HEALTH EDUCATION
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and local health departments. Blue Cross and Blue Shield plans and major commercial health insurance carriers are considering or actively developing and supporting HMOs. The new HMO law, despite specific criteria for certification, permits a wide range of HMOs. It also includes the injunction, "Each health maintenance organization shall encourage and actively provide for its members health education services, education in the appropriate use of health services, and education in the contribution each member can make to the maintenance of his own health" (Sec. 1301-C-9). The potential and need for health education exists in every HMO. But however it may be assayed, and whatever the results of particular efforts, best success is not achieved mechanically, nor does it flow automatically from the distribution of information to a covered population. The fullest realization of teaching-learning potentials-for both patients and staff-is more likely when the effort is initiated and guided by professional educators.
The Health Educator All educators have, to varying degrees, been educated in selected biological and social sciences, and in psychological and sociological foundations of education. Working in the field of health, whether in school systems or other agencies in the community, the health educator adds an understanding of health functions, organization, and practices related to health services and goals. With extended training, the health educator learns to analyze educational needs, to design programs, mobilize resources, and evaluate efforts. He learns to participate in program planning with other disciplines.' 9 The successful educator will employ far more than his skills in the use of learning theory and teaching methods, techniques, and tools. The art which largely determines the degree of his influence in planning and program development is an expression of his understanding of the "culture" of the HMO he may work with. He must respond to its administrative character and atmosphere, use the skills of interpersonal relationships, and be sensitive to role identification, value hierarchies, and the process of change.20 There is need to consider ways of utilizing the existing pool of health educators, both graduate and undergraduate, efficiently and effectively. Obviously, the HMO which employs and appropriately supports a staff of better qualified educators is most likely to achieve more of its educational objectives. This is particularly so where such objectives include behavioral responses among the greatest possible number of staff and enrolled members.
preventive medicine procedures,2 1 has no answer yet. At the same time, the essential need to motivate and educate patients receiving primary medical care is readily acknowledged. More broadly, and despite the lack of a dollars and cents cost accounting, the logic remains that people must be helped to utilize any system properly. "To overlook this is to ask for a lowering return on an expanding investment."2 1 Whether because it is believed that it can save money or time, or that many treatment and health goals are meaningless without it, or that it is a human need or ethical right, or simply that we need more exact knowledge of its usefulness and costs, health education belongs in HMOs. The Health Insurance Plan of Greater New York and the Group Health Cooperative of Puget Sound pay out of premium income considerable and expanding sums of money to support staffs of health educators and the programs they stimulate and guide. The health education research at Kaiser-Permanente program at Oakland has been supported by the Kaiser Foundation Research Institute and Public Health Service funds. Despite the validity and success of these pioneering efforts, the costs of desired improvements within these programs are not easily met. As discussed here, health education is seen as a necessary component of high quality medical care. The justification exists now for its inclusion in programs of health services organized to provide such care. During recent years, national government advisory committees and task forces have strongly recommended federal involvement in research, demonstration, and standard setting for health education in various programs.22 For 2 years prior to the enactment of the Health Maintenance Organization Act of 1973 (P. L. 93-222) there was an HMO Services unit within the Department of Health, Education, and Welfare which included an Office of Consumer Education and Information. Through contract arrangements, it offered the technical assistance of professional health educators on a consultant basis to HMO grantees receiving planning and development monies. With the passage of the law, a task force of health educators was convened to recommend rules, regulations, and guidelines to assist in the implementation of the health education section of the law. A major obstacle remains. How will health education be paid for? Funding mechanisms to encourage the integration and expansion of health education activities in HMOs and to support these efforts with sufficient and stable funds should be explored. These mechanisms include the use of general funds, a percentage of prepaid premiums, a fixed sum per individual or family covered, and third party contributions by government and private organizations.
Funding
Summary
Any analysis of the rationale for-and the place of-health education in a health care organization faces certain dilemmas. If its major justification must be economic payoff, health education, as is true for many
HMOs, by their stated purpose and nature, have a necessary and central involvement with health education. The specific characteristics of any HMO determine the extent and quality of health education.
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An HMO has the responsibility to identify its educational objectives, as well as the educational components of any of its other objectives. The more professional the educational guidance, the better it is integrated into the organization, and the greater its financial and administrative support, the more likely will be the success in achieving objectives. In brief, every HMO has the need and potential for a health education effort. The extent and quality of that effort will reflect the mix of administrative philosophy, organizational characteristics, the degree to which professional educators are involved, and the amount and stability of financial support.
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References 1. Health Maintenance Organizations. A Policy Paper (No. VII of Resolutions Adopted by the Governing Council of the American Public Health Association). Am. J. Public Health 61:2528-2536, 1971. 2. Green, L. W., and Figa-Talamanica, I. Suggested Designs for Evaluation of Patient Education Programs. Health Education Monographs. SOPHE 2:54-71, 1974. 3. Avery, C. H., Green, L. W., and Krieder, S. Reducing Emergency Visits to Asthmatics: An Experiment in Patient Education. Johns Hopkins University School of Hygiene and Public Health, Baltimore. 4. Ridenour, N. Criteria of Effectiveness in Mental Health Education. In Mental Health Education, Ch. 3, pp. 37-52. Mental Health Materials Center, New York, 1969. 5. Ellwood, P. M., Jr. Implications of Recent Health Legislation. Am. J. Public Health 62:20, 1972. 6. Professional Standards for Medical Groups, pp. 11-12. Health Insurance Plan of Greater New York, New York, 1968. 7. Information for Physicians. Health Insurance Plan of Greater New York, New York, 1972. 8. Rosen, G. Health Education and Preventive MedicineNew Horizons in Medical Care. Am. J. Public Health
42:687-693,1952. 9. Shapiro, I. S. The Patient and Control of Quality in
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Medical Care, pp. 99-107. In Proceedings of Tenth Annual Group Health Institute of the Group Health Association of America, Washington, DC, 1960. Shapiro, I. S. The Health Educator and the Practice of Medicine, Relating Theory to Practice, 1963. Reprinted in Consumerism in the HMO Movement, DHEW Pub. no. HSM 73-13012. U.S. Government Printing Office, Washington, DC, 1973. Shapiro, I. S., and Levine, H. H. Integrating Glaucoma Detection into Group Medical Practice. Am. J. Public Health 55:1638-1642, 1965. Weed, L. Medical Records, Medical Education, and Patient Care, pp. 50-53. Case-Western Reserve University Press, Cleveland, 1969. Switzer, J. M. Health Education Aspects of the Group Health Cooperative of Puget Sound, Health Education in Medical Care, pp. 45-52. School of Public Health, University of California, Berkeley, 1962. Birnbaum, H. M. Statement on the Function of Health Educators in a Health Maintenance Organization. Appendices I and II. Presented to the President's Committee on Health Education, San Francisco, Jan. 19, 1972. Collen, F. B., Madero, B., Soghikian, K., and Garfield, S. R. Kaiser-Permanente Experiment in Ambulatory Care. Am. J. Nursing 71:1371-1374, 1971. Garfield, S. R. Prevention of Dissipation of Health Services Resources. Am. J. Public Health 61:1499-1506, 1971. Garfield, S. R. Delivery of Medical Care. Sci. Am. 222:15-23, 1970. Collen, F. B., and Soghikian, K. The Educational Component in the Delivery of Medical Care Services at Kaiser/Permanente in Oakland, California. Presented at Group Health Institute of Group Health Association of America, Boston, 1973. Criteria and Guidelines for Accrediting Graduate Programs in Community Health Education. Committee on Professional Education. Am. J. Public Health 59:534-542, 1969. Shapiro, I. S. The Teaching Role of Health Professionals in a Formal Organization. Health Education Monographs. SOPHE, No. 36, 1973. McNerney, W. J. Health Care Reforms-The Myths and Realities. The Tenth Bronfman Lecture. Am. J. Public Health 61:225-227, 1971. Shapiro, I. S. Health Education Horizons and Patient Satisfactions. Am. J. Public Health 62:229-234, 1972.
CONTRIBUTIONS SOUGHT FOR WOMEN'S HEALTH BOOKSHELF Contributions and suggestions for content for a "Women's Health Bookshelf," which is being developed for publication in a forthcoming issue of this Journal, are being sought by APHA's Standing Committee on Women's Rights and the Women's Caucus. Dealing with all aspects of women and health-including women as health professionals and as consumers of health services, and women's health problems-the bookshelf will feature bibliographies of books and journal articles of merit, and lists of organizations to contact for inforrnation. Interested contributors are invited to submit materials or information appropriate for the bookshelf to any of these persons: Jane B. Sprague, PhD, Assistant Professor, Department of Community Medicine, School of Medicine, University of California at San Diego, LaJolla, CA 92037; Jayn Graves, 444½/2 North Curson Avenue, Los Angeles, CA 90036; or Mary Plaska, APHA, 1015 Eighteenth Street, NW, Washington, DC 20036. HMO AND HEALTH EDUCATION
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