Understanding and Managing the Complexity of Healthcare

5 Prevention and Wellness

Chapters 3 and 4 focused on the costs of healthcare delivery, particularly in terms of the cost per use of the system. Chapter 3 addressed the means to reducing cost per use, and chapter 4 considered the implications of simply capping cost per use. These possibilities focus on one element of the overall equation of total cost, which equals cost per use times the number of uses. Chapters 5 and 6 focus on reducing the number of uses. Chapter 5 considers prevention and wellness to, hopefully, eliminate uses of the healthcare system, albeit via use of the “wellness system.” Chapter 6 addresses chronic disease management where the goal is an increased number of very-low-cost uses to avoid a large percentage of very-high-cost uses. These are very timely topics in the United States. Anderko et al. (2012) argue for the importance of prevention and wellness and how such programs can be promoted through the Affordable Care Act (ACA). Their argument is, Workforce conditions are changing. The decrease in acute traumatic injuries from work and the increase in chronic conditions such as depression and anxiety reinforce the need to improve the availability of wellness programs. Depression and stress are major sources of lost productivity in the workplace. The inclusion of workplace wellness program funding in the ACA increases the potential for these programs to improve the declining health of an aging demographic . Through the social and organizational support structures of the workplace, wellness programs can be integrated effectively into the lives of a demographically shifting workforce that is steadily growing less healthy. Beyond the health outcomes achievable by prevention and wellness programs , there are two overarching issues. First, is the cost of prevention and wellness worth it in terms of downstream savings of healthcare costs and productivity losses? Contrary to the perspectives of the Congressional Budget Office, discussed in earlier chapters, the general answer is often “yes” 5 Prevention and Wellness 72 Chapter 5 (Berry, Mirabito & Baun, 2010), as is illustrated in this chapter. The reason for this difference in perspectives is that employers are able to take advantage of productivity gains in terms of greater output per worker and, hence, fewer workers needed to achieve output objectives. Employers are interested in a specific answer for their population of employees and covered lives, not a general answer for all people. Obviously , depending on the nature of their businesses, these populations can be substantially different. Thus, the second issue concerns the extent to which prevention and wellness is worth it for a specific demographic, working in a particular enterprise. A variety of factors affect the answer to this question. For example, consider highly trained, difficult to replace workers in an enterprise where long tenures are common, versus minimally trained, easy to replace workers in an enterprise that experiences more than 100% turnover per year. It seems reasonable to argue that the former investment may be worth it while the latter may not. This chapter proceeds as follows. We review what is generally known about prevention and wellness. The basic phenomena being addressed are first elaborated. Then, alternative interventions and their efficacy are considered . This leads to discussion of the economic valuation of these interventions . Finally, the chapter concludes with an extensive case study of employer-based prevention and wellness using the four-level model introduce in chapter 1. Background First, consider the phenomena that prevention and wellness programs are intended to address. Thorpe, Howard, and Galactionova (2007) discuss differences in disease prevalence as a source of the U.S.-European healthcare spending gap. They conclude that, rather than system capacity, access to technologies, gross domestic product, and prices, “Disease prevalence and rates of medication treatment are higher in the United States than in Europe. Efforts to reduce the U.S. prevalence of chronic disease should remain a key policy goal.” In other words, number of uses of the healthcare system is at least as strong a determinant of overall costs as is the cost per use. Consequences of an increasingly overweight and obese population are important examples of phenomena that lead to a range of chronic diseases. Devine et al. (2010) provide a literature review of studies of this phenomenon . Their findings include: • Prevalence of being overweight and obese is strongly affected by mental health disorders. Prevention and Wellness 73 • “Even the slightest chemical imbalance in the brain can disrupt healthy signaling and result in significant weight gain...