Research shows that more than 125 million Americans suffer from at least one chronic illness, while 75 million have two or more. Additionally, those with three or more chronic diseases represent virtually all growth in health care spending since 1987, according to Heath Management Associates.

In the face of both rising costs and number of workers suffering from diseases, employers have adopted wellness and disease management strategies to better target workers with chronic conditions, such as online health coaching, 24/7 nurse lines and combinations of these and other high-touch and high-tech interventions.

Recently, HMA examined which types of interventions were most successful in reducing costs for specific diseases, to benefit employers as they make decisions on how and where to target valuable wellness and disease management dollars (see below). Their findings regarding three conditions - asthma, diabetes and mental illness - are outlined here.

Asthma

Many asthma interventions in the HMA study consisted of hands-on techniques like home environment assessments and amelioration for sufferers with frequent ER use or hospital admissions, and resulted in a 49% decrease in combined urgent care (ER, hospital and unscheduled clinic visits).

In the search for the most cost-effective intervention, a study employed daily monitoring by nurses and interactive software algorithms triggered to notify providers of a lack of knowledge or lack of compliance by the patient. There was no significant change in ER admissions, with only a 0.11% decrease in hospital admissions.

A combination approach of high-touch, high-tech interventions drew the best results: a 60% reduction in readmission, a 69% reduction in total hospital days and a 76% drop in lost school or work days.

The study analyzed the psychosocial approach, which used both personal contact (individualized guidance, education and self-management, hospital discharge planning and home visits) and technology (telephonic follow-ups for outpatients).

Despite a cost of $186 per patient, the intervention more than made up the difference by saving $6,462 for each patient.

Diabetes

With diabetics, HMA finds, limited wellness intervention - one telephone call or automated response per month - showed no effect on outcomes. However, significant improvement - a 71% drop in ER and hospital admissions - was achieved by implementing multidisciplinary teams for coaching, applying treatment algorithms, meal planning, exercise reinforcement and extensive individualized and group follow-up education. Such intensive interventions would cost employers $685 to $950 per patient each year, researchers conclude, but could save them 21% fewer total claims filed.

Mental illness

While HMA finds most interventions are relatively low-cost, considering the high outcomes they produce, depression calls for individualized and prolonged attention, although increasing overall costs for employers and hospitals simultaneously yields savings that over time could produce a significant ROI. Specifically, an intensive individualized chronic care model with direct patient engagement proved especially effective. Such techniques were applied to a New York City cross section of the mentally ill and found that the most successful interventions cost somewhere between $100 and $1400 per patient, yielding a 20% reduction in hospitalizations when the plan was executed effectively and progress was monitored accurately. When the city made a $3,000 investment in mental illness interventions per patient, the savings yielded $24.6 million per year.

Best of both worlds

HMA's research seems to conclude that combining high-touch and high-tech strategies achieves the most significant savings. Ideally, employers will want to implement hybrid intervention models when it comes to wellness interventions for chronic conditions.

One such option may be American Well Systems, a health management software vendor based in Boston, which presented its most recent offering at the Consumer World Health conference in Arlington, Va. The software combines technology with human contact, allowing patients to log in and directly communicate with a primary care or a specialized physician of their choice at any time.

Patients can talk with the doctor via webcam, but also can pick up the phone. While online, the patient can share aspects of their medical history with a doctor in a sidebar. They can also reference the conversation by transcript, which can be automatically sent to the primary care physician.

Today, "the challenge is to speak health care and understand how it is delivered," explains Dr. Roy Schoenberg, CEO of American Well Systems. By examining how technology can be linked with personal contact between patient and physician, the patient will "have...[the ability] to execute health transactions" more efficiently and more satisfactorily.

Case study: Caterpillar

Caterpillar, a Peoria, Ill.-based machinery manufacturer, launched an aggressive intervention plan to slow the number of at-risk and current diabetics, which had increased from 5% in 1998 to 30% in 2006.

First, the company joined forces with local hospitals for telephonic monitoring and coaching.

However, the efficiency and convenience of onsite health coaches, available for employees only, ultimately showed the most promising results. Six months after the project's implementation in March 2008, these face-to-face interactions were much more effective than ones by telephone, eliminating 34% of employees' risk factors. Currently, the company has 33 coaches in all of their facilities, each specifically tailored to the individual's and facility's needs and history, taken from extensive data collection.

Summary of HMA findings

Within the study reported and condensed by HMA, education-only interventions tended to be less effective, especially in older patients. In addition, when low-intensity telephone contact was used as the primary form of intervention, outcomes were less successful than a follow-up from higher- intensity interventions that were slowly lessened to a level of patient self-management.

The study, "Chronic Disease Management: Evidence of Predictable Savings," released in November 2008, chronicled 27 studies covering multiple chronic conditions including chronic obstructed pulmonary disease, asthma, diabetes, high-risk pregnancies and mental illness. The full study is available here.