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The Chronic Disease Avalanche

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Imagine that you could start a health insurance company that enrolled only healthy people. Would you ignore your members until they got sick and then pay whatever expenses they incurred? Or would it be worth the cost to help keep them healthy as long as possible?

In the real world, where health plans insure people with chronic illnesses, they offer disease management services to help hold down costs. Even though services like telephonic counseling are expensive, they can help reduce hospitalizations.

But what if a plan could help people avoid using those services in the first place by helping them stay healthier? 

The Avalanche Model

Chronic illness can be compared to an avalanche. Although both often seem to appear out of the blue, they are almost always preceded by warning signs. On a ski slope, expert skiers can often spot conditions that are likely to trigger an avalanche. Likewise, there are certain preconditions that can predispose individuals to chronic diseases.

Avalanches have three parts. The starting zone is the area that, though it may look stable, conceals dangerous conditions that can trigger a shift in the snow mass. This is analogous to the population with asymptomatic preconditions like prehypertension and prediabetes.

Section two, the avalanche track, is the path the avalanche takes down the mountainside. It can be compared to the accumulation of risk factors, such as inactivity and insulin resistance, that finally reaches a tipping point and results in chronic disease, such as diabetes. The avalanche model helps demonstrate a critical but often overlooked detail: once the accumulation of risks moves past the tipping point, health conditions become much more difficult and costly to treat.

The third section, the run-out zone, is where the avalanche comes to a stop. It is comparable to end-stage disease, the inevitable result for those who don’t succumb to acute illness or trauma. By intervening in the disease process early on, however, we may be able to delay or reduce the duration of disability from chronic disease. This is known as the compression of morbidity, a concept introduced by James Fries, MD, more than thirty years ago. Dr. Fries showed that, with the human lifespan approaching its maximum, people with healthier lifestyles will have shorter periods of disability because they will develop chronic disease closer to the time of death.

Why Pay Attention to People Who Aren’t Sick?

The statistics on diabetes are grim. Over 25 million adults in the U.S. have diabetes and in 2010, about 1.9 million adults were newly diagnosed. Diabetes is the seventh leading cause of death and is a major cause of heart disease and stroke. Estimated direct medical costs for diabetes in 2007 were $116 billion and indirect costs were $58 billion. Direct medical costs for people with diabetes were 2.3 times higher than for those without diabetes. The American Diabetes Association (ADA) states: “One in five health care dollars is spent caring for people with diabetes.”

But even people with prediabetes incur higher costs than those with normal blood sugar. The Centers for Disease Control and Prevention has estimated that in 2005-2008, 35 percent of Americans aged 20 and over—79 million – had prediabetes. ADA estimates that prediabetes accounts for $25 billion in health care costs annually. What’s a health plan to do? Providing telephonic counseling to everyone with prediabetes would be prohibitively expensive. Should health plans simply ignore the impending avalanche?

If preconditions weren’t reversible, there would be no point in identifying them. But research has shown that it is often possible prevent them from progressing to chronic diseases or even reverse them.

Ten years ago the Diabetes Prevention Program (DPP) study showed that prediabetes can be reversed successfully with intensive lifestyle management. In fact, dietary change and exercise worked better than medication in preventing the progression to diabetes (58% vs. 31% reduction compared to placebo, respectively). In a 10-year follow-up study, the cumulative incidence of diabetes remained lower in the lifestyle group compared to the other groups.

DPP has been successfully translated into an effective and affordable community-based intervention, as illustrated by a program jointly sponsored by a large health plan and the YMCA. Community program outcomes have been similar to those from the research study but at one quarter the cost per participant ($275 to $325 vs. $1,400, respectively). There are currently more than 170 similar programs in 23 states. The Urban Institute estimates that a nationwide, community-based DPP program could save $191 billion in health care costs in the U.S. over 10 years.

The Role of Health Plans

Health plan managers — and the agents, brokers and consultants helping consumers and employers choose coverage — should be thinking about the role plans can play in dealing with the coming avalanche.

Of course, you’ve read article after article about wellness programs. Read more of them. They’re important.

Health plans are in a unique position to affect preconditions since they bring together doctors, patients, employers, payers, and a wealth of data. They can do the following to help avoid the chronic disease avalanche:

  • Raise awareness of reversible preconditions among providers, patients, and employers
  • Provide lifestyle management programs to their own at-risk employees and members
  • Provide lifestyle management programs to the at-risk employees of their employer customers

But to provide these services to so many people the interventions would have to be:

  • Affordable
  • Scalable
  • Effective
  • Convenient

Digital health coaching (DHC) can fulfill all these criteria and provide a personally tailored experience that helps people change lifestyle behaviors. By using DHC, health plans can disseminate programs to their entire at-risk membership at low cost. Members like them because the programs are available around the clock and can be done privately on a home computer. Scalable programs like DHC also allow health plans to focus more expensive, labor intensive services like telephonic coaching on members who need it most. And many health plans are realizing the benefits of using combinations of digital and telephonic coaching to maximize the effectiveness of overall health management efforts.

DPP has already been adapted for a Web-based application. And community programs that used electronic media-assisted interventions have had outcomes comparable to face-to-face group interventions.

Often the people who get caught in avalanches are the ones who ignored the warning signs. Like skiers who willingly venture into avalanche zones, we have no excuses. Warning signs about the chronic disease cost avalanche are all around us. Health plans have an effective and affordable option to help them improve their members’ lifestyles, increase member satisfaction, and reduce future cost of chronic disease care.

The question is, can health plans afford not to take advantage of digital health coaching as the avalanche approaches? 

And, if a plan says it has a DHC program in place, what is it doing to measure the performance and make sure it has the best possible program in place?


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