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Chronic Disease in the Workplace: Are We Fighting the Wrong Battle?

Al Lewis wears multiple hats, both professionally and also to cover his bald spot. As founder of Quizzify, he has married his extensive background in trivia with his 30 years experience in healthcare to create an engaging, educational, fully guaranteed and validated, question-and-answer game to teach employees how to spend their money and your money wisely. As an author, his critically acclaimed category-bestselling Why Nobody Believes the Numbers, exposing the innumeracy of the wellness field, was named healthcare book of the year in Forbes. As a consultant, he is widely acclaimed for his expertise in population health outcomes, and is credited by search engines with inventing disease management. As a validator of outcomes, he consults to the Validation Institute, part of an Intel-GE joint venture.
As a strategy to improve Americans’ health status and reduce healthcare costs, the Affordable Care Act (ACA) allows employers to place up to 30% of total health insurance spending “at risk” for employees. Employees can keep/earn that share by participating in programs to reduce chronic disease risk factors and/or by controlling their cholesterol, blood pressure, and body mass indexes (BMI). Partly as a result of this provision, chronic disease risk factors have become a primary focus of many if not most major employers in America.
Whether these wellness programs have worked is beyond the scope of this posting, but is unresolved. In 2010 Health Affairs published an oft-cited (albeit challenged and undefended) meta-analysis finding savings with these programs. This conclusion was directionally confirmed (except for randomized control trials, which showed a negative return on investment) by a 2014 meta-analysis in a wellness trade journal. Conversely, the Incidental Economist published several pieces on the questionable finances and other concerns raised by these programs. The Bloomberg BNA Healthcare Policy Report published a concise summary of the “con” argument. A 2014 RAND study of PepsiCo found no savings.
Instead, the question to be addressed in this article is not who is right or wrong in this battle but rather whether we are fighting the right battle in the first place. Is there so much chronic disease—and is it so out of control—that self-insured employers should be spending up to $500 per employee per year plus incentives to try to avoid costly cardiometabolic events?
Most importantly, to quote a statistic that appears 200,000 times on the internet—sourced to the CDC website and traceable to a 2004 Johns Hopkins report—is it true or meaningful for employers that, to quote one example: “chronic diseases, most of which are preventable, account for 75%” of healthcare spending?1 (That statistic is a common misreading of the CDC’s original statement, which is: “75% of our healthcare spending is on people with chronic conditions.” And it includes Medicare-age patients, who are far more likely to have one. Nonetheless, it is the mantra for wellness.)
Recently—the impetus for the author checking the figure and writing this article—the CDC hiked the 75% figure to 86% of our nation’s healthcare budget being spent on people with chronic disease.
This question is easily answered using the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP) database: No. There may be some narrow semantic sense in which this 75% or 86% statistic is true, in that people with one or more chronic diseases are more likely to be hospitalized for anything than people without them, but that doesn’t make their chronic disease the cause of their hospitalization.
The leading chronic diseases in the Johns Hopkins report are:
Now contrast that list to the list of the top 25 diagnosis-related groups (DRGs) in aggregate costs for the privately insured (meaning not Medicare or Medicaid) population, for the most recent year available, 2013:
Nothing on the chronic disease list appears in the top 25 DRG discharge list except mental health. While most employers have employee assistance programs to assist with mental health issues, those offerings are notable for being underutilized. (Bypasses and stents make the list, but it’s doubtful that employers are denting those rates with wellness screenings. Those are more about management of existing disease.)

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