Moderate-risk individuals deserve more than moderate attention

Health plans and the providers within their networks now treat a growing number of individuals with multiple chronic diseases that deeply influence healthcare utilization and costs. Individuals in the early stages of most chronic diseases have modifiable risk factors that, if left unchecked, worsen their health and increase costs.    

This particular population, termed by many as the “moderate risk,” represents a significant portion of the U.S. consumer population (25 to 35%) that contributes to a large and increasing portion of healthcare spending. If member programs do not successfully engage this population, healthcare costs for health plans and employers will increase markedly.

Examples of conditions within the moderate risk cohort, which are frequent in any adult population and especially prevalent among those over age 55 years, include:

• Pre-diabetes / metabolic syndrome;

• Obesity;

• Hyperlipidemia;

• Hypertension;

• Type 2 diabetes, cardiovascular disease and kidney disease without complications;

• Non-alcoholic fatty liver;

• Depression;

• Sleep apnea;

• Joint or back pain;

• Problems with bladder control; and

• Gout.

One of the key reasons individuals become part of this moderate risk cohort is the impact of obesity on a variety of metabolic processes. Obesity directly causes or exacerbates nearly all of the conditions listed above, and the extraordinary increase in obesity over the past several decades has contributed to the marked increase in the number of people with multiple chronic diseases.

However, if moderate weight loss can be achieved (e.g., a decrease of 5 to 7% of the person’s body weight), the person’s risk (and his/her associated costs) can be considerably lowered. 

Short- and long-term benefits 

Common population health approaches, like wellness and disease management, tend not to focus on moderate risk-individuals. If moderate risk programs exist, they often zero in on treatment and medication adherence rather than specific lifestyle, self-management and behavior modifications needed to influence the long-term effects of evolving chronic conditions.

Multiple trends have created the need for fresh approaches to address the moderate risk cohort’s growing clinical and economic burden. In the past, high turnover rates have made it difficult for plans and providers to achieve high return on investment (ROI) with moderate risk cohorts.

This situation is likely to change with the proliferation of marketplace insurance exchanges and other organizational structures such as accountable care organizations (ACOs). As government and commercial payers pay providers based increasingly on risk adjustment, tackling the moderate risk cohort will emerge as a high priority. In addition, the use of technology-enabled approaches to help individuals adopt healthier habits and successfully manage their own conditions has significantly lowered the treatment cost and can lead to a robust ROI in one to two years.

Moderate risk-individuals can remain moderate risk for years and sometimes for decades. They do not become very sick or very high cost until their diseases have led to significant organ damage, causing frequent hospitalizations and emergency department visits. Because moderate-risk individuals represent a significant portion of any population, they contribute to a large and increasing proportion of healthcare spending. 

Focusing attention on these individuals can bring both short-term and long-term clinical and economic benefits.

Neal Kaufman, M.D., M.P.H., is chief medical officer of DPS Health.