The Continuing Evolution of Employer-Based Intervention in Diabetes Disease Management

Employers have long had an interest in keeping employees healthy and productive. They have attempted many strategies toward this goal, with varying levels of success. High attrition rates, low employee engagement, and poor consensus on effectiveness hinder efforts by both employers and managed care to rein in diabetes and obesity.

For some employers, the difficulty starts with their own limitations. Large multisite firms with on-site clinics may be better positioned to implement health and wellness programs than smaller companies, which may have to rely on outsourced experts and vendors. Some companies have full-time corporate medical directors with expertise at designing and managing wellness programs. Others may hire nursing staff to run their programs.

Either way, these programs need to coordinate (and perhaps integrate) with a health plan partner to create seamless intervention in patient care. Yet a more basic problem remains: attracting employees to the program and keeping them engaged. There is also a lack of consensus about the effectiveness of financial incentives to help spur workers’ participation and success in these programs.

Large Target Based on Costs

Corporate health programs have long targeted diabetes mellitus. The reasons are clear: In 2002, a landmark economic study established that the worker with diabetes costs an employer 5 times more than a worker without diabetes (Figure 1), and that half of the costs related to diabetes were indirect costs: disability payments, time away from work, and premature death.¹ Consider just absences for workers with diabetes: men accumulate 11 more days away from work each year than men without diabetes. Women with diabetes register nearly 9 more days absent from work than women without the disorder.¹

The tools used by employers to address obesity and type 2 diabetes (T2DM) include disease management programs, counseling, call centers, gym memberships, and combinations of each. Many have used financial incentives. Valuebased insurance designs (VBID) offer low or waived copays for medications used to treat T2DM, for example, because the drugs have been shown to reduce morbidity and mortality.² Others may offer lower health insurance premiums to those who actively participate in a disease management program. Some workers get discounts on gym memberships. In isolation, these programs may not provide the anticipated results—and savings—for the employer.

Beyond Health Fairs: What Comes Next?

Most midsize and large corporations actively promote on-site health fairs, offering an excellent opportunity to help identify patients with diabetes, prediabetes, or weight problems. The question then arises: what next? The employer and the managed care organization try to ensure individuals connect with their physicians. However, many corporations fail to take a comprehensive, public health approach. This may include offering only healthy snacks in the vending machines, not allowing sugared soda to be sold on premises, little toleration for smoking breaks, and promoting activity programs at lunch and after work. In other words, screening is only the start.

A Broad Attack Better Than a Precision Approach?

Perhaps the most effective, and the most logical, programs are wide ranging, and seek to influence patients not only while they are at work. Through a combination of health benefit design, health promotion on the job, worksite primary care clinics, disease management, and patient education, they seek to influence workers’ decisions around the clock, on the job and at home. These programs may rely less on financial incentives (other than lower or waived copays) but more on better practices.

Programs offering financial incentives to workers or patients have demonstrated mixed results. Some believe that financial incentives are not the way to go, that patients should not have to pay extra to do what’s in their best interest.³A study by Cornell University investigators reaffirmed these results. The study found offering financial incentives in the form of fixed payments and forfeitable bonds did not produce desirable weight loss results in 2635 workers at 24 US worksites. Attrition rates were high and the improvements in body weight resulting from the financial incentives were described as “modest.”⁴

It is probably not the best idea to focus on any one area, such as financial incentives. “What works best for companies is to have a coordinated strategy that ties in all the elements,” said Margaret Rehayem, senior director of strategic initiatives and communications, Midwest Business Group on Health, Chicago. “This includes everything from promoting the program to engage their population to targeted follow-up and evaluation.” She advised tying financial incentives, such as waived copays and paying for diabetes supplies and comorbidity drugs (ie, cardiovascular and hyperlipidemia drugs), into the entire approach.

She cautioned, however, that some problems involving financial incentives can be avoided when designing the employer-based program: “Some employers make the incentive too hard to achieve by putting too many requirements in place or make people wait an extended period of time (such as once a year) to earn the incentive, and these can reduce a person’s motivation to attain success,” Rehayem said.

Another common, avoidable problem involves inaccurate alignment of the incentive. She commented, “We had one employer reduce copays for all drugs they covered whether you participated in the (diabetes management) program or not—this removed the need to participate in the program all together.”

Further evidence that a singularly focused approach does meet expectations was published in 2012. In this study, employees who were overweight or obese were sent communications customized to each person, to try to influence behavior change.⁵ The results of communication through this web-based program were analyzed in terms of their effect on employee weight, body mass index, blood pressure, cholesterol, and blood glucose levels. The researchers, from Johnson & Johnson’s North American Global Health Services Division, studied the baseline and 2-year data from 101 employee-participants with 137 overweight or obese workers who did not receive the tailored communications. The researchers found significant mean differences in systolic blood pressure, high-density lipoprotein cholesterol, and glycemic levels, but “each in a clinically undesirable direction.”⁵

Another approach that employers have adopted, in keeping with the broad targeting concept, is to try to address prediabetes or insulin resistance to delay or prevent the development of T2DM. As people with insulin resistance tend to be overweight,⁶ this implies including obesity management and weight-loss programs in the mix.

Rehayem explained, “I’ve seen employer engagement become more focused regarding diabetes prevention/ management. Many years ago, programs that targeted any chronic condition usually tried to only reach out to the sickest percentage of the population. Now employers have put together programs that target people across all levels of risk.”

“There are new programs coming into the market that address those with prediabetes with the focus on preventing their condition from getting worse. Employers are also better at reaching out to their populations. For example, before they just relied on the health plan to reach out to people who are identified as at-risk; however, employers are now looking at follow-up from onsite health screenings to support their efforts to get people engaged,” Rehayem said.

“To be fair, in the last few years,health plans have improved the quality of their outreach programs so that folks are identified quicker and can engage with either a program or even a qualified health coach.”

A More Holistic Concept

Over the past 15 years, as health costs climbed, “Many employers have shifted their focus away from managing costs for separate and distinct episodic health care encounters, and migrated to a broad holistic approach of managing an overall health profile, concentrating on underlying drivers and behaviors, as well as the price of specific health services,” according to Ray Brusca, group vice president, human resources, Techtronic Industries Inc., Huntsville, Maryland. He told Evidence-Based Diabetes Management that this includes an emphasis on underlying lifestyle factors, such as smoking, excess weight gain, and sedentary activity levels, that are the drivers of high cost and long-term chronic disease states.

“This is particularly true with diabetes, where lifestyle factors are a major contributor to the onset of the disease,” Brusca said. “By focusing on education, value-based benefit designs and incentive- driven programs, employers can slow down the advancement of disease. In some cases, we see health profiles reversed to levels previously thought unattainable.”

David Groves, an independent industry consultant on health, wellness, and productivity management, shares this view. “Employers have moved away from the perspective of diabetes as a single disease,” he said. “Over the years, companies (and, more importantly, health care providers) have begun to understand that managing this condition requires a complex, multifactored approach.”

That means addressing not only the physical symptoms but “the behavioral aspects as well.” Groves continued, “The high obesity and depression comorbid issues are only two of the many elements of managing diabetes. The engagement of the person with this condition and the ownership they take in managing their own choices is essential.”

An Emphasis on Farming Needed

Over the years, the question of return on investment for diabetes disease management programs still remains unanswered.⁷ The Midwestern Business Group on Health’s diabetes management program, Taking Control of Your Health (TCOYH), is showing average annual cost savings of about $1000 to $1500 per year per participant. Rehayem cautioned that this is but one measurement: “We are looking at additional measures (ie, lowering level of risk over time) we can use to measure the success of this program, however, we don’t have these figures yet.”

Aggressively seeking return on investment is not really the point, according to Brusca. “From an employer’s perspective, return on investment, while important, must be viewed in the same long-term window that resulted in the onset of diabetes and other chronic disease states,” he pointed out. “These conditions did not develop in the short term. Having a positive impact will take patience and time, requiring a deep understanding that payback will come, but not right away.”

The Better Target: Managing Patient Motivation

Groves still worries that corporate thinking in diabetes and obesity disease management has not yet moved past the mindset of “fix the problem” when it comes to employees with chronic disease. He told Evidence-Based Disease Management, “Disease/condition management programs have been a step in the right direction, but have not met expectations,” he said. “They are still too ‘medically’ oriented and discuss too many things the patient is doing wrong and has to correct. That is not engagement.” This does not get to the essential aspect of “internal ownership/ intrinsic motivation” in daily decision making. Groves argues that using “strengthbased” interventions rather than “deficits-based” interventions would enhance employees’ engagement, ownership, and motivation to manage their daily decisions more positively.”

EBDM

References

1. Ramsey S, Summers KH, Leong SA, et al. Productivity and medical costs of diabetes in a large employer population. Diabetes Care. 2002;25(1):23-29.

2. Fendrick AM. Value-based insurance design for diabetes mellitus: approaches to optimal pharmacoeconomic implementation. Am J Manag Care. 2010;16(11 suppl):S314-S322.

3. Harlow D. Dexter Shurney MD promotes a 360-degree approach to lifestyle change to manage chronic disease. Idiabetesblog. http://www.idiabetesblog.org/2013/08/dexter-shurney mdpromotes-a-360-degree-approach-to-lifestylechange-to-manage-chronic-disease/#.Uq9eIvRDvGI. Published August 31, 2013. Accessed December 10, 2013.

4. Cawley J, Price JA. A case study of a workplace wellness program that offers financial incentives for weight loss. J Health Econ. 2013;32(5):794- 803.

5. McHugh J, Suggs LS. Online tailored weight management in the worksite: does it make a difference in biennial health risk assessment data? J Health Commun. 2012;17(3):278-293.

6. Kahn SE, Hull RL, Utzschneider KM. Mechanisms linking obesity to insulin resistance and type 2 diabetes. Nature. 2006;444(7121):840- 846.

7. Mehr SR. Is there a business case for diabetes management? Am J Manag Care. 2013;19(SP2):SP58-SP59.

He pointed out that “If one digs down with a client, very often the issue of low self-esteem, based on a negative selfconcept and expectations of oneself are the root causes of not managing this complex diabetes condition.”