Michael Thompson: It’s interesting, because increasingly we’re hearing more discussion about how this stuff doesn’t work, right? And yet if we actually examine the leading organizations in this space, it does work. And part of what we’ve been looking at, I think, is the evidence. What are those outlier organizations that have really bent the cost curve and actually changed their value proposition for their talent and how they’ve done it? Maybe, Bruce, you might offer some observations. It goes beyond just leadership, culture, and programs but a certain level of discipline and orientation to execute in this space too.
Bruce Sherman, MD: I think 1 of the evolving terms that we’re hearing in the marketplace now is this notion of psychologically safe workplaces, where we’re dealing with what is essentially a fully operationalized culture of health. And it extends beyond simply what the benefits or offerings are and whether there is equity or equitable benefit design, and extends much more to how middle managers treat their subordinates, how the C-suite views the success of the company, and a widespread recognition and acceptance, importantly, that the success of the company is dependent on the health—with a capital H—of the workforce in its entirety.
Patricia Haines: One of the shifts I’ve seen is away from trying to prove ROI [return on investment] on medical expenses but looking instead at overall productivity. That has been a very distinct shift.
Michael Thompson: Yes, and we did a survey, and what we found is the great majority of employers today still are looking only at the medical costs. And when they’re looking at the medical costs, they’re looking at the medical costs for those conditions.
One of the areas that I think everybody has alluded to is the role of mental health in this context. And of course, mental health and well-being go very much hand in hand. Why mental health, and is there a payback on mental health? I know you’ve said that’s the No 1 issue we should be focusing on. I’d be interested in your take on that.
Andrew Crighton, MD: I think it’s an unrecognized problem and probably the largest driver in what we’re seeing in medical claims costs. Issues with mental health don’t necessarily have to be a diagnosable mental health condition; they can be anything emotional. So there are stressors going on at home, things like that. But they affect one’s ability to be compliant, especially a diabetic. A diabetic who has an underlying mental health condition will not be compliant with their diabetes until you get the mental health condition taken care of. So we see this in our data all the time. We even see unrecognized mental health issues. Vague diagnosis, abdominal pain, low-back pain with frequent medical visits, their cost per employee with those conditions are more than somebody with a mental health condition and about 6 times those of an employee who has none of those.
Michael Thompson: Wow.
Bruce Sherman, MD: It really—Andy, to your point—speaks to the need of a more integrated and, not to use the cliché, patient-centric approach. We have so many new programs and so many new vendors entering a marketplace. I heard recently or read recently that there are now over 5100 apps for management of diabetes. And we have to think more mindfully about sticking with this patient-centered—truly patient-centered—holistic approach because that’s where we’re going to have the greatest value. If those diabetes programs don’t account for depression, we are not going to have the success, and those employers aren’t going to have the success that they want to have.
Andrew Crighton, MD: And many times, you already have an engaged patient who’s going to use that app. So they were going to be good anyway. It’s really the hard patients, and how do you deal with this, who really need to be measured and accounted for.
Patricia Haines: Well, I would argue that most people who suffer with some kind of chronic condition have periods, episodes—and maybe throughout—of depression. I think managing a condition—diabetes, heart, anything—if it’s a layer over your life, it is most likely to create some level of depression. And back to the role of primary care, they have the perfect opportunity to really call out that kind of behavior in a patient if they had time.
Michael Thompson: Related to that is this issue around caregivers, right? Pat, you have a population of caregivers. That’s their job. How does that manifest their role, their personal well-being, their personal health? Have you seen that? Have you studied that?
Patricia Haines: Well, in a couple of ways, I think. We have a higher rate of utilization by probably 100% than most employers with our EAP [employee assistance] program. And I think part of that is a willingness by these caregivers to call out their own need. They don’t always take care of that need, but they’re willing to call it out. And an EAP is a safer place to do that. So I think that explains some of the rate of utilization. But we worry a lot about the stress that they have in their lives of taking care of others and definitely think it has a role in the health.
Michael Thompson: And that’s in our employees too.
Andrew Crighton, MD: It is. And again, it’s the social support. So the social aspect of health of who do you have supporting you at home, at work, things like this. And caregivers have their own health problems. They have a higher mortality than a noncaregiver. So there are a lot of issues from that. When you’re dealing with a significant medical condition, we’ve seen it. I don’t know, but I saw it when I was in practice: someone who had a large network of support did a lot better than somebody who was more isolated.