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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.
One would expect—if $6 of every $7 were truly going to chronic disease in anything like a literal sense—far more representation of chronic disease on this list of top DRGs.
By contrast, consider the incidence rates of wellness-sensitive cardiometabolic events. Using a list of cardiometabolic, hypertension, and stroke International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM), codes proposed in a 2013 Health Affairs case study of wellness, they amount to about 6% of all hospital admissions for privately insured patients or roughly 620,000 out of 10,851,000:
These events are rare enough that it costs about $1 million for an employer to predict and prevent a heart attack.
Despite the mismatch between the chronic disease list, the DRG ranking, and cardiometabolic admissions, the 75%/86% statistic has led thousands of companies to embrace wellness to avoid hospital events. They are spending $8 billion to do so, which may be more than they are spending on the admissions themselves. It is possible that there is some cost to be avoided other than hospitalizations, but the industry’s own measurement guidelines say (page 22):

The concerns of this mismatch are not solely financial: screening vendors either ignore or willfully disregard accepted clinical guidelines, thus causing potential harms to employees. (Causing harm due to overscreening and overdiagnosis does not violate the law. There are no regulations requiring wellness vendors to adhere to or even understand clinical guidelines, and malpractice laws don’t cover wellness vendors because there is no licensing requirement to be a wellness vendor.)
Time to Refocus Corporate Strategy?
Along with potential direct harms to employees, perhaps the biggest unappreciated harm of the wellness emphasis is diverting employers from list of most costly DRGs—and hence from the opportunities it reveals. (Every employer will have a somewhat different list, but most should resemble this one.) The remainder of this posting makes observations about what employers—and the government—could do based on this data.
First, orthopedics makes multiple entries. In general, the musculoskeletal category has many prevention and mitigation opportunities in the workplace. Ergonomics is one. Exercise classes, for sure. Benefits design and education to include encouraging access to lower-cost care is another.
Drilling down in orthopedics, total joint replacements have more than doubled since 2000 in the commercially insured population. Perhaps employees don’t realize that the earlier a joint is replaced, the sooner it will wear out, or that altering a gait following replacement of one joint may stress other joints. Or they may not be aware of conservative therapies. It’s also possible they would prefer conservative or alternative therapies but that their employer’s benefits design discourages their use.
Employers may find the most surprising item on the list to be spinal fusions (numbers 3 and 16). These procedures are highly controversial. Benefits design, employee education, provider profiling, and regional centers of excellence are tools that can be used to avoid inappropriate ones.
Many other items on the list of most costly DRGs are often also found on lists of overused procedures, such as stents and cesarean sections. In both cases, education about alternatives could be worthwhile.

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