Nico Pronk, Ph.D., FACSM, FAWHP, is vice president of the Center for Health Promotion at HealthPartners health plan in Minneapolis, MN. He is responsible for member, patient, and community-wide health education and improvement programs. Dr. Pronk is an investigator and co-director of the Population Health Unit in the HealthPartners Research Foundation. He has a broad background in exercise science and behavioral medicine. He has published extensively in the areas of exercise and physical activity, behavior change, and the integration of health risk management strategies in population health initiatives. Dr. Pronk received Fellow status for ACSM and the former Association for Worksite Health Promotion (AWHP).
From the perspective of the worksite health promotion practitioner, disease management (DM) can be a most promising tool for improving the quality of care for employees with chronic diseases. As employers are looking for ways to reduce their total health-care bills, DM has emerged as one method that may aid in the control of rapidly rising health-care costs. Despite high expectations in this area, rigorous scientifically sound studies that evaluate the effectiveness of DM and case management program successes in controlling costs remain limited. Proof of clinical benefits appears to be stronger and more pervasive. In spite of the apparent lack of convincing data on cost-effectiveness and health outcomes, the tension that exists for employers to address the health-care costs dilemma has persuaded many employers and health plans to invest in DM, and rapid growth in this industry has been noted. This trend has great potential to complement and support worksite health promotion efforts, as long as the positioning of such services is strategically aligned across the population.
Figure No caption av...Image Tools
What is Disease Management?
Whereas multiple definitions of DM exist, the Disease Management Association of America (DMAA) defines DM as "a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management supports the physician or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health" (1).
In addition, according to the DMAA, DM programs include several components that are needed to ensure a comprehensive approach. In cases where not all components are applied, the definition of DM is not applicable, and such programs should be referred to as DM support services. Critical DM program components include the following:
1. population identification processes
2. evidence-based practice guidelines
3. collaborative practice models to include physician and support-service providers
4. disease self-management education and counseling
5. behavior modification programs
6. process and outcomes measurement, evaluation, and management
7. routine reporting and feedback (may include communication with patient, physician, health plan and ancillary providers, and practice profiling)
Targeting Areas of High Health-Care Costs
Currently, chronic and complex medical conditions are associated with the major reasons for the rising costs of health care. Approximately 10% of the population incurs 70% of overall health-care expenditures. In the context of the workplace, the major conditions that apply here include the following:
* heart disease
DM programs tend to select these conditions because they are associated with available evidence-based treatment guidelines, yet research has documented significant gaps between the care those guidelines describe and the care that many patients with these conditions actually receive.
What about the Rest?
It stands to reason that if 10% of the population incurs 70% of the costs, then the remaining 90% is associated with only 30% of the costs. It also means that the 10% of employees associated with high costs may in fact have health-care bills that exceed their contribution to the company's per capita net revenue. Hence, the remaining 90% of the population would represent the group of employees who contribute most positively to the bottom line, which is a group of high value. Obviously, the company would benefit greatly if this group maintained its lower-cost profile, a result that may be obtained if the risk factors for the major medical conditions noted above are kept in check. The major risk factors that create new cases of diagnosed diseases include obesity, physical inactivity, major stress, and poor self care, among others-all factors that are highly prevalent among today's workforce.
Enter Worksite Health Promotion
As noted above, DM includes disease self-management principles and behavior change. These lifestyle-related programs are core to worksite health promotion services. In addition, worksite health promotion professionals tend to work closely with others in the company around the creation of supportive environments for health. In this context, DM can be strategically aligned with worksite health promotion efforts, and duplication of efforts may be avoided. Furthermore, this approach strongly supports the need for both services, as opposed to forcing decisions that will limit the implementation of one area over the other with reduced effectiveness as an unintended consequence.
Strategic Alignment by Design
If trends for increases in incidence of disease (i.e., newly diagnosed cases) were not as disturbing as they are today, a single approach to DM implementation may make sense. However, most companies across the United States suffer from high prevalence in the areas of obesity, physical inactivity, and high stress, to name a few. Even more disturbing is the observation that these trends occur among younger and younger employees.
Therefore, a strategic design that by nature is complementary of health promotion and DM at the worksite makes good sense. As an example, such a design may look like the one presented in the Figure. Specific subgroups of employees are identified through, for example, a combination of claims-related information and health-risk assessments. Subsequently, individual employees may be stratified into risk-specific categories that include a low-risk, apparently healthy group; a high-risk predisease group; a group of employees with mild, moderate, or severe cases of disease; and a group of employees who have complex disease-related issues. Program focus is complementary to the specifics of the subgroup as well as the subsequent projected outcomes.
Figure. Alignment of...Image Tools
Tips, Hints, and Other Prep Information
If DM is coming to your company, you may find the following questions, tips, hints, suggestions, and considerations helpful in preparing for an optimal plan (Table).
Table. Preparing for...Image Tools
The combination of health promotion, disease prevention, and disease management into an integrated and strategically aligned worksite-based program can provide high value and return to the organization. Because multiple players exist in these areas, it is of importance to assure that DM vendors, health plans, care systems, Health Management vendors, and the employer functions (including human resources, finance, the worksite health promotion staff, and the corporate medical director division) all align and are presented with clear roles and responsibilities. Once a clear vision is designed and all parties are on board with the concept, the details of implementation need to be linked to accountabilities and performance guarantees. In such a scenario, the impact of the program will reflect the complementary nature of its design and the ability of the multiple parties to work together toward meaningful outcomes.