Employers in the U.S. are being buried under an avalanche of health care costs. Solutions that promise to help companies dig out are everywhere, but as any skier will tell you, the secret to surviving an avalanche is to avoid it. Easier said than done? Not if employers start realizing that they can help change their employees’ health behaviors and therefore help delay or prevent chronic illness.
To the untrained eye, a snow-covered slope that is unstable and prone to an avalanche looks no different than a stable slope. Similarly, an individual with a precondition such as prehypertension has no symptoms and might have health care costs that are no higher than someone with normal blood pressure. On a snow-covered slope, an experienced skier knows how to check for instability of the snow pack and can avoid a potentially dangerous situation. But the U.S. health care system focuses on people with serious and costly conditions. Few resources are devoted to individuals with preconditions.
This leaves people with preconditions (prehypertension, prediabetes, subclinical depression, borderline high cholesterol and overweight) in an unstable situation, making them susceptible to triggers that propel their preconditions into full-blown diseases (hypertension, diabetes, depression, dyslipidemia and obesity). Employers are in a unique position to help keep their employees, and themselves, from being buried under the avalanche of chronic illnesses and the costs they bring.
Most common chronic diseases develop slowly. For example: Most people spend a good part of their lives with normal blood pressure. As they age, gain weight and become less active, their blood pressure rises gradually, going from normal to elevated but not hypertensive (prehypertension) to distinctly hypertensive.
Preventing the Avalanche
The progression takes years and, in a large number of cases before hypertension is established, is reversible. But many people with prehypertension are overlooked by the health care system, leaving them on a trajectory toward hypertension and chronic disease. But what if the process could be interrupted or reversed with effective, low-cost, scalable interventions?
To illustrate, let's return to the avalanche model, which has three phases:
• The starting zone is the area of greatest instability, where factors such as slope incline and orientation to the wind and sun contribute to the likelihood of an avalanche. These factors can be compared to health risk factors such as age, diet, physical activity and beliefs that can contribute to the likelihood of developing a chronic condition.
• The avalanche track is the slide path that the avalanche follows down the slope. Physical forces such as critical mass, mean slope and frictional force play a large role in determining the avalanche track. Likewise, each person’s health journey is unique, and physical forces such as the number of preconditions, severity of conditions and genetic attributes influence the progression to chronic disease.
• The run-out zone is where the massive forces that caused the avalanche finally come to rest. It corresponds to end-stage disease or irreversible physical decline that leads to death.
Of course, most people who have a normal lifespan will eventually succumb to one or more chronic diseases. The intent is not to prolong this end stage but to help people increase their chronic-condition-free years. James Fries, M.D., who introduced the concept of the compression of morbidity, and his colleagues expressed the goal well: “to compress disability into a shorter period toward the end of life, to decrease overall lifetime disability, and consequently, to reduce the associated health care burden.”
The Case for Avalanche Prevention
Once the avalanche starts barreling down the mountain, it cannot be stopped. Likewise, once a person develops a chronic disease, usually the process is not reversible. The damage caused by a heart attack, for example, cannot be undone. Early intervention in the precondition phase can delay or prevent progression to a chronic condition and can contribute to more disability-free years.
Preconditions are rampant in U.S. adults. Prehypertension affects more than a third; nearly 60 million meet criteria for prediabetes; and one-third are overweight but not obese. Reversing one person’s prediabetes will have a very small effect on health care costs, but multiplied by the large number of people with this precondition, significant savings are likely as chronic conditions are delayed or avoided. The energy and resources needed to reverse preconditions, even in a large number of people, are small compared to the energy and resources needed to treat full-blown chronic conditions. The question then is: Who will help people avoid their personal avalanche?
The Role of the Employer
Employers are positioned well to implement novel solutions to this problem. The Institute of Medicine (IOM) states that the workplace holds great potential to minimize health care costs and to promote health and well-being. IOM’s 2001 report, Health and Behavior: The Interplay of Biological, Behavioral and Societal Influences, concludes, “[Organizations] exert considerable influence over the choices people make, the resources they have to aid them in those choices and the factors in the workplace that could influence healthy lifestyles.” Employers have a vested interest in providing workplace wellness initiatives because medical claims, absence from work attributable to health problems, and reduced job performance take a toll on the success and value of a business.
In addition, most employees are on the job 40 hours a week. Compare this to a half hour a year at the doctor’s office for those who get an annual physical. Who, then, has the most potential influence on a person’s lifestyle behaviors—the employer or the doctor? The good news is that work site health promotion programs can help identify individuals with preconditions before they come to the attention of the health care system.
Novel, Scalable and Cost-Effective Solutions
Traditionally, employers have implemented disease management programs to address their population health needs and manage costs. Some programs have demonstrated positive outcomes with face-to-face and telephone counseling. However, these delivery models are expensive and cannot be scaled to meet the avalanche of employees with preconditions. On the other hand, studies have shown the potential of web-based interventions, such as digital health coaching, to be cost-effective, scalable and effective in changing behaviors. In addition, they can be deployed alongside traditional disease management interventions.
The term “digital health coaching” is used to identify technology-based, automated, highly tailored interventions that are distinct from multimedia psycho-educational programs and generic health information delivered electronically. Such technology-based programs can be disseminated to unlimited numbers of participants at low cost and tailored to each individual’s health needs and preferences using well-established behavioral science theories and techniques.
Increasingly, health plans and employers are offering digital health coaching programs to promote health and prevent disease. Because of the private nature of the programs and their accessibility on the Internet, digital health coaching might reach individuals who might not otherwise seek or have access to help.
The likelihood of reversing the effects of a chronic disease once it develops seems about as small as the likelihood of moving the mass of snow back up the mountain after an avalanche. Avoiding the avalanche or the progression from precondition to chronic condition is the most sensible course—for an individual or a population.
Employers are in a unique position to promote their employees’ well-being as they help their bottom line by focusing health promotion efforts on individuals who are at risk for developing chronic conditions but are not symptomatic. One promising means of accomplishing this involves using effective, low-cost digital health coaching programs that can be scaled for large numbers of workers but are tailored to each individual’s needs.
Janet Greenhut, M.D., MPH, is senior medical consultant at HealthMedia Inc., in the behavior science and data analytics group. She trained at Johns Hopkins University and is a board-certified specialist in preventive medicine. She has been in practice since 1980 and has been with HealthMedia since 1999.
Danielle Giuseffi, MPH, graduated from the University of Michigan School of Public Health with an MPH in health behavior and health education, and received a BS in biology from the University of South Dakota. As a member of the behavior science and data analytics team for HealthMedia Inc., Giuseffi assists with the dissemination of behavior science research on lifestyle behaviors, chronic conditions self-management, medication adherence and behavioral health.
Treat Depression Along with Chronic Illness for Costs Benefits, SHRM Online Benefits Discipline, November 2011
Lessons from First-Generation Disease Management Programs, SHRM Online Benefits Discipline, September 2011
Digital Health Coaching: Reaching Out to Older Workers, SHRM Online Benefits Discipline, November 2010
Heart Disease Prevention Program Saved Lives, Reduced Cost, SHRM Online Benefits Discipline, November 2010
Managing Diabetes: Incentives and 'Coaches' Improved Health, Lowered Costs, SHRM Online Benefits Discipline, May 2009
Health Coaching: A Helping Hand for Getting Better, Staying Well, SHRM Online Benefits Discipline, May 2007
SHRM Online Benefits DisciplineSHRM Online Health Care Reform Resource Page