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
SAGE Program
Tobacco Quitline-Warm
Transfer
We Can Prevent Diabetes
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) Mail
2) Mail + Incentive
3) 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
Treatment
Group
N
Calls
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
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
We Can Prevent Diabetes
• 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 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 Diabetes
Incentive 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
Target Population
• 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
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