The High-Touch Arm of Integration: Disease Management

Integrated benefit plan design is about much more than traditional health and disability coverage. What was once a group insurance industry has evolved into a series of specialty sectors encompassing healthcare, disability management, disease management, and wellness and lifestyle management, and more. Moreover, where employers and plan sponsors once looked at each component individually, they are increasingly viewed as an integrated platform under the single umbrella of an employer’s total employee benefits and insurance offerings.

Healthcare-related spending is severely disproportionate: 70 percent of a company’s total healthcare expenditure is typically associated with a mere 10 percent of the population with diagnosed chronic conditions and/or catastrophic medical events. Disease management is a highly interactive, “high-touch” service paid for by employers and plan sponsors, and offered to individuals with chronic conditions to help them better manage their health and motivate them to become more informed healthcare consumers.

The delivery of disease management services typically features a system of coordinated interventions such as regular telephonic health coaching, educational literature and support tools to encourage “ownership” of one’s condition and – ultimately – healthcare self-advocacy. Disease management programs have proven to not only control health benefit costs but also improve the overall health and productivity of workplace environments.

The ability for individuals to understand – at least at a basic level – clinical matters and self-advocate in healthcare decisions is critically important to achieving positive clinical outcomes and properly utilizing health benefits and resources. This is especially true for individuals diagnosed with a chronic disease or serious illness. Unfortunately, however, when people are first diagnosed or experience an acute disease-related event, the newness of the situation and emotional stress often leave them not knowing what to do. Even well educated people can struggle to communicate their health-related needs, questions and fears, let alone understand complex clinical information. Disease management seeks to empower and motivate individuals by providing them access to expert health educators and support services.

Disease management is also “population-based” in that it seeks to understand the trends and prevalence of various conditions across the healthcare continuum.

Prevalence of chronic disease typically follows age and gender demographics. The types of chronic conditions most likely to affect a given employer population largely depends on the type of industry and workforce profile. Musculoskeletal conditions are most prevalent among companies with predominantly younger, male populations whereas employers with older workforces would, for example, face a greater likelihood of cardiac disease. Blue-collar environments typically have higher rates of lifestyle-related medical conditions such as diabetes, while white-collar environments face higher healthcare costs for behavioral health issues.

One of the roles of disease management plays in the integrated model is to inform and help guide the overall benefit plan design such that it reflects needs of individuals with chronic conditions as well as those with risk factors that may lead to a chronic condition. Beyond this, the high-touch nature of disease management counseling provides additional insights into workplace dynamics that allow for a better understanding of benefit management realities and the challenges that individuals afflicted with chronic conditions face. This knowledge helps to inform how programs should be designed for individuals across the healthcare continuum to improve the overall health of the population at large.

An integrated model that brings together health plans, disability management, disease management, and wellness and lifestyle programs creates the framework for a broad-based continuum of care management programs where employees and their covered dependents receive the most appropriate level of assistance and support depending on their health status and current life situation. It encourages wellness to reduce health risks and reinforce healthy behaviors. Early identification and prevention alerts those at high risk and also helps detect indications of chronic disease before a costly medical event happens. For those already diagnosed, disease management helps individuals adapt healthy lifestyle changes and use their medical benefits properly.

Ultimately, the goal of integration is to coordinate access and delivery of services across an employer's various health-related employee benefits programs. Because every employer organization has their own unique organizational profile and workplace environment, each therefore has their unique requirements when constructing an integrated benefit plan design. The need to mix and match services varies greatly and there is no “one-size-fits-all” solution.

The key to success for integration to work effectively is cooperation among and between vendors to achieve four primary objectives:

• Integrated Problem Identification : Data sharing (respectful of personal privacy concerns and regulations) to determine the health status of the population and identify candidates for potential programmatic services
• Integrated Benefits Information : The sharing of benefit plan information among all program vendors to ensure accurate and timely communication and encourage proper utilization of services
• Integrated Operations : Collaborative and consistent partnerships in day-to-day functional operations to provide the right level of service, delivered by the right expertise, at the right time; this may take the form of electronic transfers of information among various sectors such as disability management and disease management, and may even include telephonic "warm transfers" of program participants from one program to another
• Integrated Measurements : Merging absenteeism and productivity data with healthcare utilization, disability and clinical data within the standards of patient confidentiality

While there are significant barriers to overcome to in achieving true integration, it is a concept whose time has come given the industry shift to consumer-directed healthcare. Distinctions between competitors, partners, providers and managers must and will continue to blur as the healthcare and insurance industries come together in unique and different ways to meet each employer’s unique and different needs. As a best-of-breed component, disease management offers a high-touch approach that can provide insight into the highest cost segment of the healthcare continuum while encouraging an open-minded spirit of cooperation among vendors.

Dan Cave

About Cardium Health: Cardium Health is a leading provider of health improvement and disease management programs to self-insured employers and benefit plan sponsors. The company’s core focus is on reducing healthcare costs by providing medical support and educational interventions to those individuals with chronic conditions. The Company’s people-centered disease management programs are based on proven clinical and economic best-practice protocols. They include such conditions as heart disease, diabetes, asthma, COPD, back pain, cancer management, and tobacco cessation, and easily integrate into employers' back-to-work and wellness initiatives. For more information about Cardium Health and its programs, please visit www.cardiumhealth.com.

Appeared in Prudential Financial Group Insurance Newsletter, “Prudential Perspectives Disability Management”, Volume Two, ©2006.