Abstract
The current US health care system is focused on treating the medical determinants of health. However, research shows that approximately 80% of the variance in a population’s health is determined by the nonmedical determinants of health. The care, health outcomes, and cost of an individual or population may be improved if the focus of the health care system were modified to place a greater emphasis on the non-determinants of health. Employee health has been identified as an area that may be able to improve individual health and the health of the community. Reviewed in this article are the outcomes of a pharmacist-run employee health program that focuses on the nondeterminants of health to improve the care, health outcomes, and costs of health care for one employer.
‘The employee worksite has been identified as a prime setting to improve community well-being.’
Health care that extends beyond the clinical care delivery system may be able to improve overall health care outcomes. 1 For most pharmacists, this means practice settings outside the retail pharmacy setting. In 2008, the Institute for Healthcare Improvement introduced a concept called “Triple Aim” as an example of a health care system that may be able to produce better outcomes compared with our current system. 1 The Triple Aim approach simultaneously improves population health and a patient’s health care experience, and at the same time reduces health care costs. 1 The Triple Aim approach extends beyond the traditional health care approach that only addresses an individual’s health status, to include other nonmedical determinants of health such as health behaviors, socioeconomic factors, and environmental elements.
It is estimated that the nonmedical determinants of health account for about 80% of the variance in the health of a given population. 2 Offering programs that address multiple health determinants via multiple types of health care providers may be able to produce a health care system that offers better care, with better outcomes, and at lower costs. The employee worksite has been identified as a prime setting to improve community well-being. The practice site for pharmacists is traditionally thought to be in a retail pharmacy or a local drug store. There may, however, be opportunities for pharmacist to improve community health in a worksite setting.
In 2008, Creighton University, a self-insured organization in the Midwestern section of the United States, agreed to work with their own Pharmacy Practice Department on a program to lower employee health care costs and to improve health outcomes and quality of life. After an initial pilot phase, the Creighton Cardiovascular and Diabetes Risk Reduction Program (CVRRP) was instituted, not as a research project, but as a sustainable employee health program run by pharmacists. 3 The program works with employees who have an existing diagnosis of hypertension, dyslipidemia, diabetes, and/or prediabetes. The fundamental tenets are to care for the whole individual on an ongoing basis, with no end date. In other words, it is not a 6- or 12-month program. Employees can continue to participate in the program for as long as they remain a Creighton employee. The pharmacist, working collaboratively with the employee and their health care providers, focuses on transforming current chronic conditions while preventing future complications with medication therapy management, lifestyle medicine, and care coordination. 3
After completing just 1 year of participation in the CVRRP, employees (n = 63) have demonstrated improvements in all 5 program objectives compared with baseline measurements. Briefly listed, the 1-year results of the program were as follows:
Health-related quality of life improved 20.6% (P < .001) and the number of self-reported unhealthy days (physical + mental) decreased by 42.5% (P < .01). 4
Cardiovascular risk (general 10-year) decreased by 2.02% (P = .017) and a correlated heart/vascular age estimation decreased by 2.7 years (P = .004). 5
Lifestyle medicine participation in exercise, fruit and vegetable intake, and stress reduction each significantly improved (P < .01). Additionally, at 1 year, 34.5% of employees were simultaneously and consistently achieving the recommended amounts of exercise, plus fruit/vegetable intake, plus abstaining from tobacco use compared with 5.5% at baseline and 5.1% of the reported general US population. 6
Medication adherence improved 15% (P < .001). 7
Work productivity significantly improved (P = .021; unpublished data).
A cost analysis of the CVRRP showed that work productivity improvements alone are saving the university more than $7000/employee/year (unpublished data). The overall financial impact of the program was calculated by an outside consulting firm and concluded that the CVRRP’s return on investment (health care + productivity savings) was 4.02:1 (unpublished data). This means that for every $1.00 that Creighton spends on the CVRRP, they are saving $4.02. It should be noted that in 2011, Creighton hired a full-time pharmacist to work with the CVRRP and the return on investment calculation takes into consideration that individuals salary and benefits.
The medical determinants of health addressed in the program center on appropriate medication management. However, several nonmedical determinants of health are also addressed. These include the implementation of an individualized behavior change program to optimize lifestyle medicine activities, environmental improvements such as support group meetings and release time from work, and socioeconomic factors such as free gym membership and access to multiple health care providers at no cost.
Another employee health opportunity for pharmacists is in the area of self-care (usually referred to by employers as medical self-care). The American Institute of Preventive Medicine reports that nearly 30% of hospital days used by employees are unnecessary, 30% of physician visits made by employees and their families are unnecessary, 25% of all medications prescribed are unnecessary, and as much as 55% of emergency department visits are unnecessary. 8 Because of these alarming numbers, approximately 35% of companies have tried to implement a medical self-care program in an attempt to control health care costs. 9 Unfortunately, only 10% of companies have an active and ongoing program in place. 9 Most medical self-care programs that are implemented are directed by the health promotion/wellness professionals with the strategy of distributing a $4 to $8 self-care book to employees and little other guidance. To no fault of their own, most of the individuals charged with implementing a medical self-care program have little to no training in self-care. Even still, medical self-care programs are reporting a return on investment of 3:1 to 12:1. 9
Pharmacists, on the other hand, receive a great deal of training in self-care. A pharmacist working in an employee health setting with a medical self-care program may be an ideal fit. Using actual 2011 medical claims data from Creighton University employees, it is estimated that if the university were to have a medical self-care program, it could save $157 661.80 each year and demonstrate a program return on investment of 21:1 (unpublished data). These numbers are estimated based on a formula developed by a nationally renowned expert in medical self-care. 10 They include setting the program goals at (a) 25% of covered households avoiding one primary care physician visit per year and (b) 5% of covered households avoiding one emergency department visit per year. 10 Creighton plans to implement a new pharmacists-run medical self-care program in the very near future.
Several nonmedical determinants of health are implemented in a self-care program. They include improvements in health behaviors through conscious decisions to more wisely use health care resources (ie, emergency room visits), environmental improvements through enhanced education about self-care, and socioeconomic improvements through lower health care premiums that would result from lower direct medical costs.
Much of the current health care system in the United States focuses on the medical determinants of health. A shift of focus and resources to the nonmedical determinants of health may be able to improve population health outcomes, an individual’s health care experience and decrease health care costs. Pharmacists working in the employee health setting may be a prime opportunity to improve the health of a worksite community and provide a novel and effective way to practice pharmacy.