Integrated Health Management Enhances Care and Saves Costs for One Employer

Programs to improve the health and welfare of people are not limited to health plans. In 2003, a self-insured school district took on the challenge of diabetes for its 12,000 employees and 4,000 retirees. While the school district has a third-party administrator who handles the administration of its health insurance benefits, it wanted to do more to prevent illness and promote health improvement.

In 2002, the school district examined claims data and discovered a large number of services related to obesity, heart disease, and diabetes. In one year alone, there were 78 employees with renal failure from diabetes, hypertension, or both. There were seven amputations costing on average $69,000 each, for a total of $483,000. In a single year, the school district spent $16.7 million on diabetes-related care, 18.2% of its total health care expenditures. The district spent another $10 million on cardiac care during this same period.

An initial biometric screening program implemented by the school district indicated that 15% of its employees already had diabetes and that another 27% were at high risk for developing diabetes based on blood glucose levels and insulin resistance. The school district recognized the link between obesity and diabetes. A screening program identified that 70% of its employees were obese based on body fat percentage (>25% for males and >32% for females). Given the high cost and prevalence of diabetes, along with the obesity risk factor, the school district decided to address the issue head on.

This employer believed an opportunity existed to work more closely with its employees to promote accountability in managing their own health. The goal was for workers to adopt a health-conscious lifestyle and to seek appropriate preventive services to maximize their health. The school district recognized the inherent challenges in reaching this goal, including the fact that teachers and staff are spread out among 160 schools located over a broad geographic area. Reaching all of these employees with a single set of activities would be difficult. In addition, the time restrictions based on employee work hours meant that convenient, easy-to-access services were needed. The district felt that access and incentives for its employees should be key components of the program.

A two-pronged approach was developed to address diabetes care, one focused on health promotion and the second focused on disease management.

Health Promotion

The goal of the health promotion program was to create a culture that fostered healthy decision-making skills and identified potential health risks before they reached a significant disease state. The health promotion program utilized screening through health risk appraisals, one-on-one counseling, and education for behavior modification. The program components included:

• Health risk appraisal (required)
• Annual biometric screening (required)
• Educational seminars (minimum of two per year required): diabetes insulin resistance, self-care management skills, and exercise
• Nutritional counseling (required)
• Physical fitness testing (required)
• Stress management seminar
• Wellness “bucks” to be redeemed for pedometers, workout packages at fitness centers, yoga/Pilates packages, workout bags, or massage therapy

The wellness “bucks” were given to employees who annually completed the five required components of the program.

In addition, the employees could earn “wellness days off” by making lifestyle changes, providing personal testimonies on the impact of the wellness program, or by demonstrating wellness leadership at the school/worksite.

To participate in the health promotion program, schools submitted a proposal and were awarded funding through a grant. Employees at each school developed a worksite wellness team to determine how the grant money would be spent, coordinate implementation of services, and promote the initiative among the teachers. In this manner, each location tailored the wellness program to the specific needs of employees and health care services available in the area. The program was unique to the particular school and local and convenient for the workers. The wellness “bucks” and opportunity for time off provided incentives for employees to participate.

Disease Management

Disease management services were designed for employees with diabetes to promote adherence to the ADA guidelines and to build self-management skills. Discussions with employees identified that many had difficulty affording prescription medications and, without proper drug therapy, the workers’ health was at risk. The school district believed a financial incentive would be a useful motivator to improve utilization and compliance. Program content included:

• Semiannual biometric screenings for LDL-C and A1c levels, retinal eye examinations, and foot care
• One-on-one counseling for members identified as at risk based on screening results; an additional health risk appraisal was also completed for this group
• Follow-up telephone contacts from health care professionals for further education and counseling for those with low health risk appraisal scores; educational materials were mailed following the telephone call
• Eight hours of education on nutrition, diabetes management skills, fitness, and other lifestyle issues

If the employee completed all of the above services, he or she received a 50% reduction in pharmacy co-payments. Annually, the employee submitted a checklist completed by the health care providers as services were rendered. The completion of this checklist ensured an ongoing reduction of co-payments.

Outcomes

Based on completed biometric health risk appraisals, over 5,000 employees participated in the health promotion program. In addition, 21% of employees with diabetes participated in the disease management program. Considering that participation involved eight hours of education, biannual screenings, individual counseling sessions (twice per year), and other ongoing communication, this was a significant achievement. The first full year of the health promotion program yielded multiple improvements in care as evidenced through laboratory results and self-reported findings.

Of those employees enrolled in both the wellness and disease management programs, medication adherence improved 24% in one year.

The total cost for both programs in one year was approximately $700,000 for staff and materials. The savings yielded in medical expenses during this period was achieved for the employees who participated in the wellness program. At the end of the first year of implementation, claims for this group were $456 less per person compared with those employees not enrolled in the program. With approximately 5,000 workers participating, this translates into a savings of $2.2 million.

The results from the disease management program were not yet available, but even without these data, the savings from the wellness program covered the cost of the entire effort. Using a dual approach of prevention and disease management, this employer demonstrated that it is possible to achieve healthy outcomes for its workers and appropriately manage its resources.

An Employer Uses Its Existing Occupational Health Clinic to Improve A1c Screening and Control

A self-insured manufacturing company with 12,000 employees found that 14.4% of its employees had diabetes, which cost $21 million over a 24-month period. The employer decided to take action and began by looking at its occupational health clinic. The clinic had successfully managed to reduce workplace injuries, while worker safety continued to be a concern. The employer saw an opportunity to shift the focus from acute care to chronic care management. As a result, it began managing health care issues for its employees with diabetes in 2003.

The approach relies on several means of identification:

• It offers a Web-based health risk assessment (HRA) (also available in hard copy), which has been used by more than 60% of its employees for screening
• All new hires are referred to the occupational health clinic for a full assessment and are required to complete the HRA.
• Workers who come to the clinic for injuries are also screened for diabetes.

The goal of the program is to identify people who have diabetes or are at risk for developing diabetes (based on a blood sugar level >100 mg/dL) and to help employees with diabetes maintain glycemic control. The clinic physicians and nurses provide laboratory testing, counseling, and referral to primary care physicians (PCP) for follow-up. The occupational health clinic is open 24 hours a day/seven days per week for the convenience of employees on all shifts.

Following the initial assessment, employees are encouraged to return to the clinic monthly for A1c and medication evaluation, a check for complications, and for dietary and exercise counseling. Once an employee’s diabetes is well controlled, visits become quarterly. The employer also offers diabetes classes to employees and family members who wish to learn more.

The occupational health clinic recently developed a database to track employees’ lab values and progress in meeting health care goals. All information is shared with the PCP quarterly, or more frequently if the employee’s condition warrants. The number of regular visits to the clinic indicate that the program is having a positive impact on employees’ self-management skills.

The occupational health clinic has other programs that are beneficial to the employee with diabetes, including an onsite fitness facility and programs to address smoking, cholesterol management, and hypertension. This company believes helping employees improve their own health is a worthwhile undertaking for all concerned considering the large amount of time and money invested in training and professional development of its skilled workers.