For more than a decade, Benefit Performance Associates has been working with companies to determine what percentage of their employees are spending the most of their health care dollars. The contingent of medical benefits recipients is what BPA calls the high-risk or “tertiary care” group.
The experience BPA has gained while working with people who suffer from multiple chronic medical conditions has enabled the company to identify the secondary and tertiary groups in a workforce, as well as the financial costs those people will incur during their lives — in any health care plan. BPA has also learned there are hidden health care costs that are often not captured. These include the loss of productivity — the impact of actual workdays missed due to illness and the challenge to presentism.
The future of chronic disease management should rely on finding effective and appropriate programs for each of the various health levels if we ever hope to reverse or prevent chronic diseases.
For BPA and its Integrated Health Advocacy Program® (IHAP®), the tertiary care group needs the most attention and intervention, but no wellness program or fitness club can come close to helping these individuals to fulfill their needs. IHAP’s only focus is this group, and for very good reasons.
The primary care group
To most people, primary health care means the basic level of care that comes from your primary care provider, typically a general physician or family doctor. You go to this doctor for annual wellness checkups, when you are sick with the flu or perhaps coming down with something more complex. Primary health care is defined as “the basic level of health care that includes programs directed at the promotion of health, early diagnosis of disease or disability, and prevention of disease. Primary health care is provided in an ambulatory facility to limited numbers of people, often those living in a particular geographic area. It also includes continuing health care, as provided by a family nurse practitioner.”
You probably know a coworker, let’s call her “Jane,” who is in pretty good shape. Jane tries to eat right and exercises as regularly as she can. She is rarely out sick and is genuinely happy about her life. She is also part of the benefits population that only utilizes about 5 percent of the company’s health care benefits. Jane is sick maybe two to three days a year and is lucky enough to not have any chronic conditions. She is always at work, so there’s no loss in her productivity. She never utilizes all her health care dollars and probably never meets her deductible. She is an employer’s ideal benefit plan member.
The secondary care group
Most people have probably had some experience with secondary care at some point in their lives. Secondary care is the next level in the treatment of a condition because the primary doctor either cannot treat it or has exhausted all treatment options. Say you go to the primary care physician for an annual physical and the blood-work shows your A1C and cholesterol levels have increased, and your pre-diabetes has escalated to Type 2 Diabetes. Your primary care physician refers you to an endocrinologist, a doctor that specializes in the glands of the body. You have now moved into the secondary care group.
Secondary care can be defined as treatment provided by a specialist or facility that was referred by a primary care physician and requires more specialized knowledge, skill or equipment than the primary care physician can provide. Individuals that fall in this care group only spend 20 percent of population claims and are usually around 35 percent of the plan population, but can cost an employer almost $3,000 in lost productivity dollars because of their illnesses.
What most people and employers do not realize is the risk that this isolated condition can progress into a chronic condition if not properly addressed and treated. And if steps are not taken immediately to prevent the diabetes from escalating, there’s a high risk for developing heart disease, kidney issues, stroke and sometimes eye problems.
It’s easy to see how health care issues can escalate, but with the proper intervention and treatment, such as diet and exercise, even the risk for insulin-dependent diabetes can be eliminated. One of the easiest ways to do this is utilizing disease-management programs and wellness programs offered through most employers.
The tertiary care group
For the tertiary care group, basic treatment and intervention-like wellness programs or disease management won’t help. These people need the most attention and intervention from a care provider or team of care providers that no wellness program or fitness club can provide. Tertiary health care requires a specialized, highly technical level of health care that includes diagnosis and treatment of disease and disability. Specialized intensive care units, advanced diagnostic support services and highly specialized personnel are usually necessary for tertiary health care patients.
BPA and IHAP can identify the tertiary care group within an employer’s benefit plan and has had more than a decade of experience helping these individuals improve their chronic conditions and overall lifestyle.
An individual that falls into this care group usually requires long-term, chronic-care management that can deal with the multiple chronic conditions an individual lives with every day. An average patient has more than four chronic conditions, and usually it's between seven and 10. This population spends more than 80 percent of health care dollars in claims, but compose 20 percent or less of the benefit plan population; and is responsible for lost productivity in the amount of $6,000 annually, on average, despite only representing 23 percent of the full-time workforce.
Some of the most common chronic conditions are asthma, obstructive lung disease, stress, heart disease, arthritis, chronic kidney disease, chronic obstructive pulmonary disease, inflammation and chronic pain. This is a pretty long list and doesn’t even cover all the conditions listed by the Centers for Disease Control and Prevention.
Perhaps more surprising is the average age of these patients is 45 to 55 years old. Now, imagine living with just a few of these conditions and how they might affect your quality of life.
As an example of an average individual in this care group, consider the statistics from an actual benefit plan member with which BPA worked. In a three-year period, this individual filed 122 claims totaling more than $125,000 and was diagnosed with 15 chronic conditions affecting seven body systems. This individual suffered from COPD and diabetes, and was morbidly obese. Obesity led to hypertension, coronary artery disease and, because of some other conditions, the person had become dependent of prescription medication.
Why wouldn’t anyone want to help this individual? Most primary care physicians become overwhelmed by patients with so many health issues, and feel they cannot help in a way this individual needs. But finding the right tertiary care or center will change this individual’s life.
BPA works intensively with each individual, provides personalized one-to-one care, and learns all there is to know about them. By doing this, BPA can help people work better with their primary care doctors to hopefully reduce the number of medications they take; get them on customized exercise plans; and teach them how to change their lifestyles to better manage their health. BPA believes health care must focus on these individuals and help them better manage their health, thus improving their lives.
But what does all this mean for the employer? By treating people that fall into the tertiary care group, employers can reduce the risk of being burdened with rising health care costs, and reduce lost productivity dollars while improving employee absenteeism and the work experience as a whole. Employers will, in turn, have a better understanding of each level of care and can help provide the right benefits to their employees.
A graphic of the preventive care model is available on page 14 of the Transforming Healthcare digital magazine, located on Benefits Performance Associates community page.