There seem to be five categories of things that employers, insurers, and government payors for healthcare are trying to manage:

•  Case – pretty much restricted to hospital admissions or expensive episodes of sickness care, and intended to improve its coordination, efficiency, and quality
•  Care – similar to case, but including pre-admission and post-discharge services, with the same intent
•  Health – aimed at protecting and promoting general health and wellness, chiefly by promoting healthy behaviors, but also healthy environments
•  Risk – preventing and modifying unhealthy behaviors, plus detecting and controlling or reversing risk conditions, in order to reduce the incidence, prevalence and costs of sickness
•  Disease – minimizing the crises, complications, worsening, and costs of chronic conditions

The five differ in terms of whose behavior they hope to change, with care and case management focused mainly on sickness care providers, while health, risk and disease management focus mainly on patients’, employees’, plan members’ or beneficiaries’ behavior.  Disease management is the more likely of the patient behavior change modes to include the patients’ physicians as well, so is a cross or “boundary area” between the care/case and health/risk modes, though many DM providers deal solely and directly with patients, while others limit themselves to motivating and coaching providers, who are then expected and usually paid to deal with patients.

For payors to deal with patients’ own physicians is a complicated and difficult process, since payor’s populations at risk rarely are the same as physicians’ populations.  Exceptions arise in the case of worksite clinics, staffed by nurse practitioners, physicians, or both, which can serve precisely the population that employers wish better managed, for as many of the five management challenges that employees will permit.  The same applies to staff model HMOs, where the population at risk is cared for by the same group of physicians.

Otherwise, independent physicians would have to cope with a wide range of different payors, each with its own idea of how the various management challenges should be handled.  This complexity would add to the cost of physicians’ participation, and make it more onerous and difficult for them.  Moreover, if payors are already paying for their own internal management programs, or have hired a specialized provider to do so, bringing in patients’ physicians will add significantly to costs.

All five are focused primarily on managing costs, at least when they are sponsored, paid for, and controlled by payors.  Some degree of case and care management can be supplied by patient advocate services, however, where patients, or sometimes their employers, may pay for such services.  Health, risk and disease management services are often paid for out-of-pocket by patients, when they prefer having control over the goals, processes and outcomes of such services, rather than relying on the generosity of payor sponsors.

The degree to which costs can be controlled varies widely across the different applications, with case management having the narrowest and most reactive focus, while health and risk behavior management have the most proactive.  Risk condition management is proactive in that it first detects the condition, then reacts by attempting to keep it from getting worse, or perhaps reducing, even reversing it for added protection.  Disease management is equally reactive in that it applies to people already afflicted by chronic disease, though it is proactive in terms of aiming to minimize its consequences and worsening in future.

The biggest difference across the five applications is often the scope of the costs to be reduced.  For case and care management, the costs always include, and mainly comprise sickness care costs.  Occasionally, when employee disability “cases” or “care” are involved, disability costs and early return to work are also included, to reduce short- or long-term disability insurance or direct expenses (STD/LTD).  When workers compensation cases are involved, both reducing its direct costs and speeding employee return are likely to be involved.

For disease management, initial focus was invariably on reducing sickness care costs, since “health care” costs often increased, due to the provider services and management drugs required to control chronic conditions.  The trade-off is often reflected in “value-based” health benefits, where treatments that control chronic conditions are handled as investments, rather than costs, as long as they reduce sickness costs.  Since most chronic diseases cause worker absences, productivity and performance impairment, DM increasingly focuses on these costs as well.

Both health and risk management will often focus on similarly wider cost dimensions, when they are applied to employee populations, and occasionally on retirees and dependents as well.  These two applications have the potential of preventing the most sickness care costs by reducing the incidence and prevalence of disease and injury.  And they can promote “positive wellness”, and “positive presenteeism”, where workers are not only neither absent nor impaired, but surpass the norm in terms of productivity and performance.

To maximize “positive presenteeism” and workforce performance, however, more than health and risks must be managed.  Employee motivation, capabilities, and leadership must all improve in order to complement health improvements and optimized employee contributions to their employers.  Moreover, when productivity and performance are involved, the definition of “health” and “risk” become altered, to include all dimensions of both that tend to impair employee contributions, not merely cause sickness care costs.

For example, among the biggest “impairment factors” for employers to be concerned about are allergies, mental/emotional problems, chronic pain (including neck, back, joint and head pain), sleeping problems, obesity, smoking (separate from its health risks, it causes lost productivity due to “smoke breaks”),etc.  Poor nutrition and poor fitness impair employee performance directly, in addition to risking disease and injury.  Poor “hydration” at work, i.e. not drinking enough fluids, can have similar effects.  These problems may be managed through medical interventions (e.g. nicotine replacement therapy for smoking, drugs for insomnia, bariatric surgery for extreme obesity), but require behavior modification primarily.

The costs to be managed by all five applications include the costs of the application, itself, though this is somehow often overlooked in published reports of success.  And the costs to be managed should also include the costs to participants, not merely any out-of-pocket expenses, but the time, loss of enjoyable activities, and other personal burdens imposed on those who participate.  It is the benefits and costs to participants that are most often overlooked, yet usually make the greatest difference to the cost savings that payors are able to achieve.