1. The Use of Incentives in Low-Income and Medicaid Populations to Encourage Health Promoting Behaviors Mary S. Manning, RD, MBA Minnesota Department of Health January 24, 2014

2. We Can Prevent Diabetes SAGE Program Tobacco Quitline-Warm Transfer

3. SAGE Program MN version of the National Breast and Cervical Cancer Screening Program Serving approximately 18,000 low-income women in MN annually.

4. Phone Component MDHs 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

5. Direct Mail Study: Women 40 – 64 Target population: Sage-eligible women ages 40–64 Sampling frame: Experians Inforum database Study groups: 1)Mail 2)Mail + Incentive 3)Control (no intervention) Main outcome: mammogram within 13 months

6. Mail Intervention Two versions of folded cards – Attention-grabbing message – Free mammogram – Prompt to call Sages phone centers toll-free number – Extension code MDH envelope Bulk rate (standard presort) postage Personally addressed

7. The Robinsons Mailer

8. The Beads Mailer

9. 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

10. Main Outcome Results Treatment Group NCalls Received Eligible Callers 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 662 (0.7%)

11. 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

12. Sages Use of Direct Mail Today State of MN agency and program lists Consumer lists Clinic medical record lists Sages internal lists: – Annual Reminders – Relapsers – Refer-A-Friend

13. Newer Direct Mail Pieces

14. 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 8 th grade literacy level White space

15. 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

16. Tobacco Quitline-Warm Transfer

19. 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

20. 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

21. 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

22. We Can Prevent Diabetes Incentive Structure

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Study Support to Clinics Funds for study coordinator and patient navigator Clinic stipend for set up Training and technical support from study staff

30. 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

31. 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

32. 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