Employee Benefits and Chronic Conditions: Right Care, Right Time, Right Level

Chronic disease among employees is a complex and costly challenge. Conditions like arthritis, diabetes, and heart disease can impact health care costs, productivity losses, and quality of life. An evidence-based approach can help employers provide benefits for the right care, at the right time and level of care.

What is chronic disease?

Chronic disease refers to a condition that lasts one year or more, requires ongoing medical attention, and/or limits daily activities.¹ People with chronic conditions can experience daily pain, limited mobility, and/or low energy.

These physical impacts make it harder for an employee to remain fully engaged. In turn, this translates to increased absenteeism and lower productivity, as well as higher employee health insurance claims.

Chronic disease management can require frequent office visits, long-term medication, specialist referrals, or even surgery. The cost burden rises sharply when health conditions get overlooked or ignored without the right care at the right time.

Chronic conditions and total cost of care

Centers for Disease Control and Prevention (CDC) estimates chronic disease accounts for 90% of $4.5 trillion in U.S. health care spending.² High-cost conditions include:

• Arthritis — Arthritis affects 60 million American adults, over half of whom have jobs. There are more than 100 arthritis-related conditions.³ Osteoarthritis (OA) is the most common, costing $304 billion in 2023.⁴
• Cardiovascular disease — Heart and vascular care accounts for $254 billion in health care dollars per year. It also costs another $168 billion in lost productivity. The annual cost may rise to $2 trillion by 2050.²
• Diabetes — More than 38 million Americans have diagnosed diabetes with total annual costs of $413 billion. The CDC estimates that another 98 million U.S. adults have prediabetes, with elevated blood sugar levels.²

Health plan benefits and chronic disease

Insurance providers regularly review chronic conditions. They assess the prevalence of disease among their policy holders, along with supporting economic, social, and clinical data. Diseases with the highest treatment costs get reviewed at least annually to assess covered medications,   surgeries, and/or therapies.

Chronic conditions that affect larger populations are also prioritized, as are conditions with the greatest quality of life impacts. These insurance company reviews help employers make informed decisions about their health care benefits plans. 

“It is every branch of the health care system that must remain responsible for the total cost of care,” says Timothy D. Law, DO, MBA.Dr. Law is the Chief Medical Officer for Highmark Delaware. “The trick is to do this while making sure our members are getting the right care at the right time and level.⁵

Dr. Law recommends that insurers and employers work together to make data-driven decisions about coverage, treatment options, and health care services. “From both payer and society’s perspectives, the effect of chronic disease is profound,” he says.

Evidence-based employee health insurance decisions

Insurance companies rely on clinical trial results, cost-benefit analyses, patient-reported outcomes, and real-world evidence to determine coverage guidelines. They employ researchers, physicians, pharmacists, and research nurses to analyze all available data.

New medications and devices receive additional scrutiny to validate manufacturer data beyond industry publicity and marketing. For example, an overlooked footnote in a drug study may point to a potential danger or inconsistent results. The insurance company might decide not to cover the medication because of this fact.  

“Insurance companies are interested to know which interventions provide the best outcomes for patients,” explains Dr. Law. “If a new treatment has similar effects as an existing treatment, it may not be covered or only partially covered.”

Patient-reported outcomes (PRO) also present important data on treatment use, symptom reductions, quality of life, and overall well-being. “PROs provide insights into how treatments affect patients’ daily lives and functionality,” Dr. Law continues.

Understanding health plan coverage and limitations is crucial when choosing insurance plans for employees with chronic conditions. “Long-term benefits, including improved patient outcomes and reduced health care expenses, must be considered,” stresses Dr. Law. “We must all be good stewards of the health care dollar so that access  and quality are available to all.”

_{All references to “Highmark” in this communication are references to Highmark Inc., an independent licensee of the Blue Cross Blue Shield Association, and/or to one or more of its affiliated Blue companies.}