Disease management (DM) is moving from a limited focus on insurance plan members and employees whose chronic conditions already cause outlier levels of healthcare costs – to identifying and reducing the risks of future diseases and costs.  When applied to employees, it is also moving from a limited focus on healthcare costs to the total economic performance impact that employee diseases and risks have now on employers.

Healthways, Inc. was one of the first to move beyond existing diseases to what it called “impact conditions”, that can include existing conditions such as chronic pain or high blood pressure that create risks of future disease or present reductions in productivity and performance, or both.  HealthMedia, Inc. includes emotional problems and risk conditions, but also risk behaviors such as smoking, inadequate sleep, inadequate stress management, lack of physical activity and poor diet among the “diseases” it manages.

This means that the proportion of plan members and employees participating in DM initiatives is rising from former levels below 10% to levels as high as 95%, as incentives and marketing efforts entice more participants.  This increase is also helped by making enrollment as simple as possible, including “opt-out” approaches, where all members of the target population are automatically enrolled in a basic “total health management” effort, but have the option of dis-enrolling if they wish.

DM is also moving from a provider-determined “one-size-fits-all” approach of relatively high intensity in most cases to customizing the type and intensity levels of intervention to risk/reward segments, and even to individuals.  As the majority of members in the target population are included, their widely varying risk/reward potential makes such customization essential to controlling the costs of DM interventions so that positive returns on investment (ROI) can be achieved.

When existing disease was the only problem being addressed, intensive and expensive “solutions” seemed to make more sense.  Of course, this made the costs of such solutions fairly high.  In one of the Medicare DM demonstration projects, for example, the costs among the fifteen participating DM providers ranged from $80 to $444 per participant per month.  With average charges of roughly $220 per month, this meant that savings achieved would have to exceed $2600 per participant per year just to break even, and $5200 to achieve a 2:1 ROI ratio.

When entire populations are involved, risk/reward potential can be as little as a few dollars per year, though when employees are the population targeted, the potential is usually at least in the hundreds of dollars per year range, counting absences, productivity, quality, customer satisfaction, turnover and the full range of effects being achieved.  But only a small percentage of the population would be worth thousands of dollars a year in costs, at least in terms of the potential financial gains involved.

Customization by risk/reward potential is perhaps the most important kind of “tailor-made” solutions involved.  By itself, this means that DM providers must have at their command online and computer-customized communications capabilities, in addition to the services of individual professional coaches and phone or face visit communications.  And DM providers have responded to this necessity, by developing, or more often acquiring such added capabilities through acquiring other providers.

Healthways, Inc. has added other organizations to its almost comprehensive set of solutions almost as fast as it has added customers to its client list and problems to its solutions list. HealthMedia, Inc. lists a full dozen “partners” it can bring to bear on solutions offered to insurers, employers, pharmaceutical firms, and behavioral health organizations.

Tailoring interventions to the perceived problems and preferences of individual participants is the other half of the customization challenge.  Some programs, such as the Duke Prospective Health Program, tailor each “problem” by empowering individual employee and dependent participants to create their own health mission/vision statements and set their own goals.  It can then vary its “solution” based on the risk/reward potential of each participant, with some eligible for customized care management or personal coaching. (www.dukeprospectivehealth.org)

Healthways, Inc. employs computer-automated customization based on the health risk assessment (HRA) each participant in any its many programs completes.  For employees, the HRA includes assessment of productivity impairment and absences to enable the inclusion of productivity improvement, along with healthcare costs in evaluation of employer gains.  With as many as fifty or more questions in the HRA, and many different answers possible, there are literally billions of combinations, making it likely that every participant receives individually tailored attention.

Customization based on risk/reward is essential when DM moves toward including all risk population members and future risks as well as existing diseases.  Otherwise, any standardized intervention would either tend to be too expensive or too ineffective to yield a positive ROI.  But it is customization based on individuals’ problems, values, and preferences that may deliver the greatest value to insurers and employers, by ensuring that DM also delivers significant value to the individuals whose enthusiastic cooperation and continuous participation ultimately determines how much their behavior, health status, and costs plus performance end up changing for the better.