Can Population Health Help Employers Control Expenses?
What if employers viewed employees and their families as populations? What if they applied population health management principles to understand their unique characteristics? In all large populations, some people are healthy and need very little care; others need a moderate amount of care, while a small number have complex care needs. The same is true for an employer’s population. Population health is a new way of thinking for many employers. But early adopters with this holistic view can better understand the needs of their employees and give them better, more personalized options to help improve care and reduce costs.
Providing the Right Care Across the Continuum
An employee population with more than 1,000 members is likely to have diverse care needs, and a one-size-fits-all approach to health coverage may not take differences into consideration. Population health tools and analytics help providers and health systems understand where patients are on the care continuum and deliver the appropriate level of care. These same methods can be applied to employer populations with potentially comparable results over time.
- Is the employee and his or her family enrolled in an accountable care organization?
- Is an employee’s physician part of a value-based arrangement?
- Is the employee using health care services but has no established relationship with a physician?
- Is the employee not using any health care services?
Kathe P. Fox, Ph.D., is Head of Informatics at Aetna. In this role she supports the design and assessment of provider and network services, the assessment and monitoring of Aetna's accountable care partners, reporting and analysis for customers, and manages the business use of the data warehouse. Informatics also manages Aetna’s partnership with the Harvard Medical School Center for Biomedical Informatics. In 2014 Kathe won Aetna's Innovator of the Year Award for her Health/Wealth product idea.
Prior to joining Aetna, Kathe was Vice President and Practice Leader for Health Plan customers at Medstat (now Truven Health). Earlier in her career, Kathe held positions at Blue Cross and Blue Shield of Michigan, and was a faculty member at the University of Michigan Schools of Public Health and Nursing, Yale School of Public Health and Lehman College, at the City University of New York. She was also a Robert Johnson Faculty Fellow in Health Care Finance at The Johns Hopkins School of Public Health. Kathe holds a Ph.D. in Epidemiology and Public Health from Yale University and a B.A. in History from Skidmore College.
This is a good idea, but Population Health and Employee Wellness Programs are not addressing the root cause of illnesses--they're still focused on symptom management and early detection. I've spent the better part of the past six years reading cross-disciplinary research on the basis of human thriving. In every case (physical, mental, behavioral and emotional health, relationships and career success) the research points to one single root cause for most problems: stress. Stress was widely recognized as early as the 1970's as a root cause of physical illnesses, but efforts to address it stayed on the surface. At first, people were told to cut down on activities but the only things they could cut from their lives were those that they enjoyed and created important social connections. That was a fail. The "Think Positive" slogan gained popularity, but thinking is the result of habits of thought and telling someone whose habits of thought are not positive to think positively is a waste of words and time unless the advice is accompanied by skills that actually empower them to change their habits of thought. Also, most people are defensive of their thoughts because filters in the brain ensure we perceive reality as if our underlying beliefs are true. If people don't understand how those filters work, they won't be open to changing their habits of thought. They'll view it as delusional, Pollyannish, or rose-colored glasses instead of what it is -- an equally accurate interpretation of reality from a different (less stressful) perspective. I've developed a program that teaches large groups of individuals in classroom settings how to think more positively that begins by opening a back door to willingness (instead of the resistance the direct approach encounters). I call it The Smart Way because it is a form of Primary Prevention instead of reactive, episodic care. The Smart Way has been compared to Cognitive Behavioral Therapy in the following way: Cognitive Behavioral Therapy (CBT) is done one-on-one and resembles having an expert marksman stand next to an amateur who is blindfolded while attempting to hit a target by obtaining instructions from the expert, who is the only one who knows the location of the target. The Smart Way can be delivered in large group settings where hundreds can be taught at the same time because it removes the blindfold and makes the target fully visible to the individual, who is given skills that empower them to identify the right target and continually improve their aim. Intrinsic motivation occurs naturally because each step results in positive emotional feedback. Even when the overall emotional state is still negative, the student feels the relief of feeling better and the hope that comes from knowing one has the skills to shift to increasingly better feeling emotional states. The Smart Way also avoids hindrances CBT encounters including: 1) Stigma associated with mental illness 2) High cost of one-on-one therapy 3) Recurrent need because CBT resolves current issues without necessarily developing skills to address future issues “Cognitive behavioral therapies can be defined as those interventions with the core assumptions that what individuals think directly impacts how they feel and what they do.” Despite the fact that Cognitive Behavioral Therapy is used as a curative rather than a preventative method of improving mental (and in some cases, physical), health, “it is clear that the evidence-base of CBT is enormous.” Hoffman, et al. conducted a review of meta-analyses of the use of CBT to address a wide variety of issues and concluded by recommended that countries adopt it as a first-line defense against mental disorders. I go a step further in my hypothesis. My Hypothesis is that anything Cognitive Behavioral Therapy is effective at treating, The Smart Way can prevent from happening in the first place. The Smart Way is not synonymous with Cognitive Behavioral Therapy provided before an individual develops a mental or physical health problem. It is CBT Plus delivered primarily to groups or provided as self-help using videos and books. It is significantly more cost effective because it does not require one-on-one therapy and because it prevents the problems before they happen, thus avoiding the costs associated with the problem. Also, it is more difficult to permanently cure a condition than to prevent its occurrence in the first place and there is no relapse because the illness did not manifest in the first place. One major difference is that Cognitive Behavioral Therapy does not include Emotional Guidance, which overturns a prevalent but inaccurate interpretation of the purpose of emotions. The Smart Way also disabuses negative beliefs about the subconscious portions of personality that often include beliefs that the subconscious is secret, dark, and frightening as well as unreliable and dangerous to explore. The basic premise behind my hypothesis is supported by research that shows Cognitive Behavioral Therapy works by helping patients change the way they think to healthier thought patterns which significantly reduce the likelihood a person will relapse after treatment. Instead of waiting for someone to develop a mental health disorder, which may or may not receive treatment at some point, The Smart Way provides information and skills that empower individuals to develop healthy habits of thought before a mental health problem develops. While there is a strong emphasis on prevention, I have case studies demonstrating that The Smart Way is effective in restoring mental health to individuals who were suffering from severe long-term PTSD, severe chronic depression, and that is has been effective in preventing imminent suicides. Butler and his colleagues concluded, “The meta-analyses reviewed strongly suggest that across many disorders the effects of CBT are maintained for substantial periods beyond the cessation of treatment. More specifically, significant evidence for long-term effectiveness was found for depression, generalized anxiety, panic, social phobia, OCD, sexual offending, schizophrenia, and childhood internalizing disorders. In the cases of depression and panic, there appears to be robust and convergent meta-analytic evidence that CBT produces vastly superior long-term persistence of effects, with relapse rates half those of pharmacotherapy.” The robust support for persistence of Cognitive Behavioral Therapy suggests that learning metacognitive processes protects against the occurrence of many chronic problems our society would like to eliminate. The persistence of the results suggests (strongly, in my opinion) that prevention is possible. There is evidence-based support that Cognitive Behavioral Therapy (CBT) is effective in reducing and/or healing the following issues. I believe that providing knowledge and skills that prevent the maladaptive cognitions Cognitive Behavioral Therapy is designed to correct will prevent the problems from manifesting in the first place, thus preventing a significant portion of the suffering that currently affects people around the world. Anxiety 18% of adults suffer from some form of anxiety, which costs the US $148 billion (1/3 of the country’s mental health expenditures). Cognitive Behavioral Therapy is effective in treating anxiety , and was the preferred method for “children and adolescents, with effect sizes in the large range” Depression Depression affects more than 16% of the population at some point during their lifetime and about 10% of the population is affected each year. For individuals living in poverty, 31% have been diagnosed as depressed. Because of stigma and the cost of care, it is likely that this number significantly understates the prevalence of depression in our nation’s poor. The economic burden of depression in the United States in 2010 was $98.9 billion. Cognitive Behavioral Therapy is effective in treatment of depression, including severely depressed unipolar patients. Panic Disorders Cognitive Behavioral Therapy was found to: 1. Be effective in reducing symptoms to levels “near or below those found in the general population by the end of treatment,” 2. Have lower attrition rates than pharmacological treatments (fewer people stopped treatment before completion), 3. The effect was stable with “virtually no slippage in effect” after one year. Bi-polar disorders Cognitive Behavioral Therapy is a useful adjunct therapy for bi-polar disorders and appears to reduce relapses regardless of how many episodes of bi-polar disorder occurred prior to treatment. Crime Reduction Chicago youths who were given Cognitive Behavioral Therapy committed 44% less crime than a control group. Hoffman et al.’s review of meta-analyses indicated that “. . . behavioral therapy and CBT appeared to be the superior interventions in reducing recidivism rates, both with medium mean effect sizes.” Even the National Institute of Justice recognizes the value of Cognitive Behavioral Therapy. Patrick Clark commented, “One form of psychotherapy stands out in the criminal justice system. Cognitive behavioral therapy reduces recidivism in both juveniles and adults.” Improved High School Graduation Rates “Using cognitive-behavioral interventions can substantively lessen the kinds of problem behaviors that frequently result in school suspensions and/or expulsions that subsequently lead to school dropout.” The same study in Chicago that showed a 44% reduction in crime increased graduation rates from 13% to 23%. Treatment of and Reduction in Physical Pain Cognitive Behavioral Therapy is an effective therapy for chronic pain in adults , and improves the ability to cope with pain. Educational Success Cognitive Behavioral Therapy combined with intensive tutoring profoundly improved academic achievements for children who were previously considered lost causes. Bullying (Recovery from) “One of the most effective therapies in addressing the emotional distress caused by bullying is Cognitive Behavioral Therapy.” Bullying Prevention “In 2007, 15.2 percent of U.S. children were identified as bullies by a parent or guardian. Overall, children with mental health disorders were three times more likely to bully other children . . . children with a diagnosis of depression were three times more likely to bully, while a diagnosis of Oppositional Defiant Disorder (ODD) was associated with a six fold increase in the odds of being identified as a bully.” As noted earlier, Cognitive Behavioral Therapy is an effective treatment for depression. It is also used alone and in conjunction with other methodologies to treat ODD. Violence Reduction Cognitive Behavioral Therapy has a small positive impact on domestic violence and . . . a medium to large positive effect on sexual offenders (although surgical and hormonal treatments were more effective for the later. Butler et al found that Cognitive Behavioral Therapy was as effective as hormonal therapy and less likely to be refused and more likely to be completed. Prevent relapse of Mood Disorders. “CBT does appear to have an enduring effect that protects against subsequent relapse and recurrence following the end of active treatment, something that cannot be said for medications.” Substance Use Disorders “These disorders are highly common, with lifetime rates of substance abuse or dependence estimated at over 30% for alcohol and over 10% for other drugs, and past year point prevalence rates of 8.5% for alcohol and 2% for other drugs. . . Cognitive behavioral therapy (CBT) for substance use disorders has demonstrated efficacy as both a monotherapy and as part of combination treatment strategies.” Smoking Cessation “Treatments for smoking cessation found that coping skills, which were partially based on CBT techniques, were highly effective in reducing relapse in a community sample of nicotine quitters, and another meta-analysis noted superiority of CBT (either alone or in combination with nicotine replacement therapy) over nicotine replacement therapy alone.” Problematic Gambling Pathological gambling affects 1 – 3% of the adult population and is a greater problem for adolescents . . . and the less severe problematic gambling affects an additional 1.3% to 3.6% of the population. The societal cost of pathological gambling is estimated at 5 billion dollars annually. Cognitive Behavioral Therapy is effective in the treatment of gambling problems. , Schizophrenia and Other Psychotic Disorders Although Cognitive Behavioral Therapy does not cure Schizophrenia or other Psychotic disorders, it is effective in reducing symptoms. When other research is considered, the pathway to psychosis appears to be paved with chronic stress. For example, “The current literature provides some evidence that the onset of psychotic disorders may be associated with a higher rate of stress and changes to the hippocampus.” Phobias Cognitive Behavioral Therapy is effective in treating phobias and demonstrates the ability to provide long-term maintenance of improvements. Obsessive Compulsive Disorder (OCD) A meta-analysis for OCD found Cognitive Behavioral Therapy provided substantial relief and that the improvements persisted over time. Posttraumatic Stress Disorder (PTSD) Cognitive Behavioral Therapy is superior to supportive counseling and reprocessing for PTSD. I also have a case history where long-term (Vietnam era) PTSD was successfully alleviated for a veteran using The Smart Way. The veteran had received a variety of treatments over the years and was being treated using Mindfulness, counseling, and pharmacology at the time we met, but his level of functioning remained very limited. After learning The Smart Way he was able to participate in many activities of life he had previously been unable to enjoy and (under doctor supervision) stop taking medication for PTSD. The improvements included being able to attend an event where loud fireworks went off unexpectedly without triggering an anxiety attack and beginning to enjoy frequent travel, including international travel, with confidence. His improvements have been sustained for over six years at this writing. Body dysmorphic disorder (BDD) Cognitive Behavioral Therapy is more effective in treating this disorder than “psychoeducation, explanatory therapy, cognitive therapy, exposure and response prevention, and behavioral stress management.” Hypochondria Cognitive Behavioral Therapy is more effective in treating hypochondria than “psychoeducation, explanatory therapy, cognitive therapy, exposure and response prevention, and behavioral stress management.” Eating Disorders Cognitive Behavioral Therapy has a significant positive effect on eating disorders. The National Institute for Health and Clinical Excellence review “and two other recent systematic reviews is that cognitive behavioral therapy Cognitive Behavioral Therapy is the clear leading treatment for bulimia nervosa in adults.” Insomnia “Problems with falling asleep or daytime sleepiness affect approximately 35 to 40% of the U.S. adult population annually and are a significant cause of morbidity and mortality. . . sleep medicine education (among general population and health care professionals) and the availability of diagnostic and therapeutic facilities to treat sleep disorders will reduce the profound socioeconomic implications of untreated sleep disorders.” Cognitive Behavioral Therapy is well-established as an effective treatment for sleep disorders. Personality Disorders Cognitive Behavioral Therapy was not the best therapy for personality disorders, but it did have a significant positive effect in a meta-analysis. Anger and Aggression Beck and Fernandez found that, “the average CBT recipient was better off than 76% of untreated subjects in terms of anger reduction.” Cognitive Behavioral Therapy “is moderately effective at reducing anger problems.” General Stress My hypothesis is partially based on the pathway from chronic stress to physical, mental, and behavioral problems, highlighted in the charts on pages (review). Cognitive Behavioral Therapy has a large positive effect on occupational stress and is also effective (albeit with a smaller positive impact on the stress of parenting a child with developmental disabilities. “As a stress management intervention, CBT was more effective that other treatments, such as organization-focused therapies.” Teacher (Trainee) Stress Levels Teacher trainees experiencing high levels of occupational stress who received Cognitive Behavioral Therapy “had significant reductions in their levels of stress, depression, state and trait anxiety” compared to the control group following treatment. Distress Due to General Medical Conditions Cognitive Behavioral Therapy had a small to medium beneficial effect on distress and also on secondary issues stemming from the primary medical condition. Irritable Bowel Syndrome “Self-management programs that include cognitive behavioral strategies have been shown to improve gastrointestinal (GI) symptoms, psychological distress, and quality of life (QoL) in persons with irritable bowel syndrome (IBS).” Chronic Fatigue Syndrome Cognitive Behavioral Therapy is moderately effective as a treatment for Chronic Fatigue Syndrome according to Malouff and his team of researchers. Rheumatoid Arthritis Cognitive Behavioral Therapy of more than six weeks duration was consistently effective as an adjunct therapy for Rheumatoid Arthritis in the short-term but of long-term efficacy was mixed. Premenstrual Syndrome Premenstrual Syndrome depression and anxiety responded favorably in one study but further research is needed for the findings to be considered robust. Type II Diabetes The pathway from chronic diabetes to diabetes is well established in the literature Pre-term births Mounting evidence points to chronic stress changing an internal clock that makes the body think it is time to deliver a baby before it is ready. It is time to prevent illnesses where we can and clearly we can prevent many in a cost efficient manner. This will become the standard at some point. Will our generation be like the one alive when Semmelweis walked the Earth or will we act sooner and prevent unnecessary suffering? Jeanine Joy Author, Scholar, Speaker,