A 'marshall plan' for employers: marshaling resources to bridge the needs of individual patients and that of a group of employees encourages companies to focus on the consumption of health care instead of the production of benefits

Risk & Insurance, Jan, 2005 by Diane L. Huber, Mindy Owen

Faced with rapidly escalating health care costs, employers are focusing on ways to save money by eliminating preventable expenditures. Often, this involves strategies such as educating employees about prevention and self-care. But it also involves better coordination of care when employees become ill or injured, and making sure that employees are following their treatment to reduce the likelihood of even more expensive treatments in hospital emergency rooms.

In other words, they are turning to disease management and case management.

Distinct yet complementary, disease management and case management strategies enable employers to focus on the consumption side of health care costs.

This doesn't mean eliminating or reducing health care benefits. On the contrary, it means making better use of health-related services so that employees and their dependents get the care they need when they need it, as well as receiving education and support to promote wellness.

Disease management and case management belong to a multitiered approach to care and wellness in the workplace.

The first level is population health, which takes a "big picture approach" by looking at the needs of the entire employee group (e.g. blood pressure screening for employees). The next level is disease management, which targets groups of employees who have been diagnosed with or who run a high risk of having specific diseases or health issues, such as diabetes or heart disease.

Another level is case management, which advocates on behalf of an individual employee who needs coordination of care, usually as a result of a specific event, such as the onset of illness, an accident, or a flare-up in an existing medical condition that is compounded by other health issues.

Disease management and ease management cannot be rolled out in the same way at every employer. Rather, it takes a customized strategy based on the specific employee population in order to get the most out of these two approaches.

For employers looking at health care from "the CFO perspective, they are trying to manage the increase in health care spending year-over-year," said Rufus Howe, vice president of product development for Nashville, Tenn.-based American Healthways Inc., a provider of specialized, comprehensive disease management, care enhancement and high-risk health management services. "Now, they recognize that money is the end point. The process of getting there is care management."

Increasingly, employers have come to expect that their health plans and other vendors provide a care management solution that encompasses both disease management and case management. To get the most out of both, these programs must be coordinated and precisely timed, with communication and cooperation among all the players involved. They may include the company's liaison with the health plans (whether internal or an outside consultant), the insurers, disease managers and case managers, physicians and other care providers.

Most importantly perhaps, just as medicine is most effective for a patient in the correct amount, so too the health care strategies implemented in the workplace must be just the right "dosage." Not every employee will require disease management, nor will every health care intervention require case management. The key is the right amount of intervention and service at the right time and with the right frequency.

"Employers need to tailor their health care programs to their specific company and their specific population," said Kathleen Ward Douglas, president of K.A. Shannon Consulting LLC, in Phoenix, Ariz., which provides medical management solutions for large employers through strategic program design. "Employers need to understand that they are in the driver's seat; they are the ones paying the health care coverage bill. They need to demand and expect the programs that work best for their population."

Health plans, too, recognize the value of ease management and disease management as part of their strategies to offer comprehensive and integrated services to employers.

"If I am a health plan selling to an employer, I'm telling them how the health plan pays claims and manages costs by doing this and that," Howe said. "But that is all 'mind stuff.' There is also an important 'heart' component. Yes, we do a lot of transactions, but employers are also paying for care for the members, and to ensure that the care is of the highest quality possible. Part of this, we believe, is something called disease management and part of it is something called ease management."

For the employees, who are the ultimate consumers, the distinctions between disease management and ease management should not matter at all. In fact, the better integrated the programs are the more the employee will experience them as part of one, seamless service.

"Employers are saying, we want one point of contact with 24-hour-a-day, 7-day-a-week service. Call that person the advocate or the navigator or the care manager; it doesn't matter. Just don't fragment the services for my employee population any more," said Douglas.