The story of health care in America is paradoxical. We can rightfully be proud of our many technological and scientific contributions to the practice of medicine.
Yet for too many Americans, our health care experience is best described by Mark Fendrick, an MD at the University of Michigan, as “either too much too often or too little too late.”
It is widely acknowledged that our dysfunctional “health care system” has created a dysfunctional health care “market” in America. The end result is unsustainable costs, and a population that once died from infectious diseases which now suffers from preventable chronic illnesses like heart disease, stroke, diabetes and diet related cancers.
For the foreseeable future, employers will need to solve through their own means what our health care system has not. Every employer wants to know “How do I stop spending so much money on health care so I can invest it elsewhere?” The answer is that we will stop the rising health care cost tide when we get better health for each dollar we invest in health care, or, said a little differently, when we get better value for the money we already spend on health care.
Our health care “reimbursement model” has created perverse financial incentives for health care providers and consumers alike. Our health insurance plans reimburse for each unit of care delivered rather than for the health outcome of the patients served. This has led to a “pay for treatment rather than prevention” model for patients and providers. Employers should ask why we are paying for so many procedures (stents, angioplasties, by-pass surgeries, etc.) and for so many prescription drugs? Aren’t the drugs supposed to reduce the need for the procedures?
The easy answer is “behavior and lifestyle.” And while this is true, a deeper root-cause analysis reveals that we have way too many people in our workforce that are:
• Treated, but not “to goal”; or
• Treated, but not in compliance with “standards of care”; or worst of all
• Undiagnosed, and untreated
Each of these situations leads to poor health outcomes and complex episodes of care at great cost, many of which would have been unnecessary if we took the “ounce of prevention” message seriously.
Neither is it an aging baby boomer issue.
Consider the evidence. The common misconception is that chronic disease is a product of old age, and that as our workforces age we are doomed to higher rates of chronic disease, i.e. “the claims are the claims and there’s not much we can do about it.”
Our data clearly demonstrates that the risk factors for chronic disease have limited correlation to age. Sample results from one large employer (n = 20,000 participants) are typical and shed light on the clinical risk factors in virtually all working populations.
The following illustration shows screening participants plotted according to their age and total cholesterol. Our data for glucose, blood pressure, weight and triglycerides show a similar lack of correlation between age and the risk factors for chronic disease.
The purpose of our “health plans” should be to “improve health.” Isn’t that what we’re paying for? Better health for the money we spend on healthcare?
A growing number of employers have adopted this school of thought, and have realigned incentives to transform their health care plans from a payment-for-sickness model, into a reward-for-health model. This approach, the so called value-based approach to benefit plan design, has demonstrated that when done correctly, it can generate better health outcomes and lower direct and indirect health related costs.
Another even more concerning misconception is that a person taking prescription drugs to lower their risk factors is “treated.” The more important question is: are the drugs working to reduce the patient’s risk factors to a clinically safe level? According to the Heart Lung and Blood Institute, “Of patients who need lipid lowering drugs for treatment of high cholesterol, only 38 percent are treated to goal.” Again, the data clearly illustrates that medication alone is frequently insufficient to “get to goal.”
A value-based approach to benefit plan design shifts the focus from a reimburse-for-sickness model to a reward-for-health strategy. Experience shows that costs can be reduced when health is improved, and that the three keys to successful health improvement lie in following:
An evidence-based medical model to help individuals know that they are at risk for chronic illness;
A data-driven approach to identify gaps in compliance to standards of care for chronic patients;
Incentives and high touch interventions to educate, motivate and engage higher risk individuals in reversing the slide toward preventable disease.
Employers like Pitney Bowes, Hannaford Brothers and Safeway have accomplished extraordinary results by changing the way they think about the health of their workforce and what they expect from their healthcare benefit plans. By moving from a model in which we reimburse for sickness, toward one in which we reward for health we can begin to recognize a new tide in traditional workplace wellness programming — that of workforce health. We can recognize considerable costs savings in our businesses, motivate employees toward better health and even save lives in the process.
William Mauke is partner and workforce health practice leader at Ovation Benefits in Farmington.
