Cardiovascular disease accounts for roughly $286 billion in health expenditures - including the direct costs of medical care and indirect costs associated with lost productivity - according to the latest numbers from the American Heart Association. Spending on cardiovascular medications accounted for 20% of drug plan costs, according to Medco's 2011 Drug Trend Report.
"One in three Americans has already been diagnosed with some form of heart disease, including high blood pressure, coronary artery disease, stroke, heart failure," says Dr. Ron Loeppke of U.S. Preventive Medicine. "That's a high prevalence rate."
Yet heart disease is one area where things are dramatically better than they were just a decade or two ago. "We see much less premature heart disease now than we did 20 years ago," says Jeff Levin-Scherz, M.D., and a senior consultant in Towers Watson's health management practice. "We smoke a lot less, which is very meaningful in terms of preventing heart disease, and when people have high cholesterol they take statins, which are widely available generically and are relatively cheap."
A 2010 study from Kaiser Permanente, meanwhile, found significant cost savings of up to 90% for those who were enrolled in its cardiac care program, which translates into about $60 per day in savings per patient. Teams of nurses and pharmacists work with patients who've been admitted to the hospital for acute coronary events. Because the teams each cover about 800 patients - the same number of patients a typical primary care physician might have - the cost of the program can be spread out amongst all 800 patients, explains Dr. Tom Delate of Kaiser Permanente Colorado. "It works out to about a dollar a day to run the intervention," he says.
Despite the positive news, some employers have become disenchanted with traditional disease management programs. "Employers have gotten tired of just paying and paying and not seeing any results," says Michael Jacobs, national clinical practice leader with Buck Consultants. "If you go to a pharmacy benefit manager, they all say how much you'll save and yet your bill goes up every year. If you go to a health carrier, they're just paying your claims and your expenses go up every year. We need them to manage more effectively."
He adds: "We've had disease management out there for a long time, yet America's still getting fatter, diabetics are still increasing in number, the people with high cholesterol and high blood pressure are still getting worse. So, frankly, the perception is that it hasn't been as successful on a population management level as it has been on a personal, individual level."
Traditional disease management - where employees must opt in to the program - is sometimes viewed as too Big Brother. "A lot of the carriers offer disease management and employees view that as, 'My employer is watching my claims and I'm going to lose eligibility if I talk to this individual or I participate,'" says Heather Provino, chief executive officer with Provant Health Solutions. "There's a huge trust factor."
What's been a challenge with disease management in the past, says Tom Carter, vice president with Kaiser Permanente, who leads its national workforce health engagement strategy for employer-sponsored markets, is the opt-in factor. "You're out there in a non-integrated model, you're seeing your primary care physician and you would have to call your carrier and say, 'I have hypertension and I want to take care of myself,'" he says. "You'd have to be very motivated as an individual to engage in disease management."
Presenting disease management in a non-traditional way can lead to better engagement, says Provino. "If the employer can go out to the employees and say, 'You're our greatest asset, we really want to ensure you take care of yourselves so you can ultimately have the best life possible - both at work and outside of work - so we're going to offer you access to your own personal health coach,' then people are much more receptive," she says.
In addition, because the individual components - the medical care, the emergency room visits, the hospital care - of treating heart disease and other chronic conditions have gotten so expensive, it can actually pay to hire a professional case manager to manage those patients, says Jacobs. "It's cheaper to pay this case manager whatever they make than it is to just pay the claims," he says. "And I think that's kind of the tipping point we've seen in the last few years."
Vendor summits gain ground
Jacobs also sees a move toward employers hosting vendor summits, which gather all of an employer's health-related vendors - medical, pharmacy, specialty pharmacy, Medicare, disease management, workers' compensation, employee assistance program, disability, absence management - together to discuss the health of the workforce, share data and brainstorm solutions.
"You bring in your vendors and you say, 'You guys are going to play nice. You're going to share data, you're going to work together and have liaisons that are responsible for talking to one another. And you're going to manage my patients,'" he says, noting that this type of event is the exception, rather than the norm.
To hold an effective vendor summit, employers must have a clear understanding of the effect poor health has on their business performance, says Carter. For example, "bring your vendors into the room and say, 'I have a business problem. One of my risk factors is obesity. I want to talk about how it's impacting my total costs across the board,'" he says. "People would begin to share information and get momentum."
And for those vendors unwilling to share data, Jacobs warns they could lose that employer's business. He recalls attending one vendor summit where a vendor refused to share data and the employer said, "Thank you very much and goodbye. We'll find someone else who will."
Carter agrees. "Employers are saying, 'Help me keep my workforce healthy, which is good for my business. And if you don't help me, I'll find a vendor that will,'" he says. "There's no holding back on data because employers are the ones paying the premiums. If a competitor hides the ball from you a little bit, I think employers are willing to find another vendor that won't."
When selecting disease management vendors and health care vendors in general, Carter suggests employers ask the following questions:
* How do you promote health? "Not just treating [employees], but actually engaging them in staying healthy," he says. "Not just how many doctors you have or what your rate is or what your plan design is, which is where we typically spend a lot of time."
* Are your disease management programs optional? "Part of the care gap out there - and why I think some disease management results are not good - is because it's optional," says Carter. "You get 40% of people compliant with taking their medications, for example. So you'd want to be able to sit in front of a health partner and say, 'Tell me how you keep people engaged in managing their chronic conditions?'"
* How are you anticipating the health risks of my population? For example, ask a vendor how they'd engage a 50-year-old male whose weight might start creeping up as he gets older.
* How do you manage chronic conditions?
* Do you have ways my employees can access your delivery system using technology? For example, do employees have to see their doctor to get lab results or can they see them online? "There's a whole new evolution in how technology can open access for employees," says Carter.
* How do you manage major events, such as high-risk pregnancies or palliative care?
Setting expectations
Steve Harstad, senior director of disease management with OptumHealth, emphasizes that employers must have realistic expectations when it comes to disease management.
"The first year is about identifying populations, attaching people to the right doctors, getting them on the right medications, getting them to understand and deliver against care platforms," he says. "Those activities do actually cause a spike in costs, particularly as it pertains to med spend, office visits and lab visits. And that's because the program is being successful in communicating and getting to people. On the back end, you're going to start to see inpatient and ER utilization start to trail down."
Years two through five is where employers should expect to see the most tangible return on investment. And measuring results is important. Be prepared to change your approach midway if you're not seeing measurable results.
"Even a perfectly good program that got written up in the New England Journal of Medicine two years ago, for example, might not be executed in such a way that it's really effective for your employees," says Levin-Scherz. "So you need to be willing to change programs along the way if it turns out the measurement is suggesting you're not getting real value out of them."
