Top-Tier Health Plans and Wellness Programs for People with Diabetes – An Employers’ Handbook
By Karena Yan
More than half of those with diabetes or at risk of diabetes are covered by an employer-based healthcare plan. It is important for employers to think about the best health plans and wellness programs for their employees that will maximize productivity and allow them to live happy and healthy lives.
People with diabetes make up a significant portion of the workforce in the US. Over 34 million Americans have type 1 or type 2 diabetes – roughly 10% of the adult population – and an additional 88 million have prediabetes. Further, over 157 million people in America get health insurance through their employer, so roughly half of the population of people with or at high risk of diabetes is covered by an employer-based health plan. This is exciting from our view; the COVID-19 pandemic has exposed so many inequities in our system and we believe that at this critical juncture, employers will be looking for how to invest in both the health and healthcare of their employees and contractors, and those in their communities whose health they can positively influence. We hope you will take this article to your employer and have a conversation with them about how you or your peers may be able to work even more productively in the years ahead.
While we know that undermanaged diabetes can lead to challenging and expensive health complications, including conditions like severe hypoglycemia, DKA, heart attacks, strokes, heart failure, kidney failure, amputations and blindness. For the sake of employee health and productivity, it is an exciting opportunity for employers, and crucial, to choose health plans and wellness programs that provide not only proper coverage and care for people with diabetes but truly smart care that helps avoid preventable complications like all the ones listed above. Without sufficient and affordable access to medications, technology, healthcare visits, optimal and understandable data that drives health success, and health-conscious work environments, people with diabetes are at an increased risk of developing both short-term and long-term complications. With access to plans that provide easy paths to the best care, people with diabetes and employers can forge wonderful partnerships together.
There is a lot of discussion about long-term complications that often include terms like “direct costs” and “indirect costs.” What does that mean? The ADA in “The Costs of Diabetes” explains that diabetes accounts for $327 billion of spending in the US each year, of which $237 billion are direct costs, the rest is indirect costs. And notably, inadequate diabetes care can be changed, with the help of employers, so that people with diabetes do better, experience better health, and the entire system spends less! This includes especially the short-term costs like the complications from severe hypoglycemia and hyperglycemia that result in lost productivity and absenteeism, that has a very meaningful direct impact on a company’s bottom line.
In 2017, this key research found that diabetes cost US companies $90 billion in lost productivity. Employers, in other words, have a significant financial incentive to keep their employees healthy.
What are the components of top-tier employer health plans and wellness programs for people with diabetes? In this article, we will examine:
You can use this information to discuss health plans with your employer. Share this article with employers to help them become aware of what people with diabetes need in an insurance plan, and how these health and wellness programs can benefit companies through cost savings.
To provide the best healthcare coverage for people with type 1 or type 2 diabetes, employers should include the following components in their health plans.
1. Add insulin to the preventive drug list.
Insulin is a life-sustaining medicine for all people with type 1 diabetes and many with type 2. While one in five people with diabetes use insulin every day, recent surveys show that as many as one in four people on insulin has rationed their use due to cost. This is one major problem with insulin use – another is that many people who could benefit from it who are not at their time in range goal do not take it at all.
In July 2019, the IRS ruled that chronic disease management can be covered pre-deductible in high deductible health plans. This paved the way for insulin to be added to what is called a plan’s preventive drug list because it helps prevent or slow the progression of diabetes-related complications and death. By labeling it as a preventive medicine, employers exempt insulin from the annual deductible. This means that when an employee submits a prescription for insulin, it will be covered as if they have already met the deductible, so they will only be responsible for paying either a copayment or coinsurance. In the best-case scenario, employers can completely eliminate employee cost-sharing for insulin, making it free for the employee.
2. Set cost sharing as a low, fixed dollar copayment instead of coinsurance percentages.
If a drug, such as insulin, is exempt from the deductible, employers can either share the cost of the drug with the employee – through a copay or coinsurance – or pay the full cost themselves. On the other hand, if a drug is not exempt from the deductible, employees must pay for the full price of their medication until the deductible is met, after which they will transition to sharing the costs.
Regardless of whether a medication is exempt from the deductible, copays are a better option for the person because they are more predictable. Whereas copays are a flat fee that an individual pays per prescription, coinsurance is a percentage of the drug’s price, which is subject to large fluctuations, especially if rebates and discounts aren’t passed through.
3. Directly pass rebates and discounts to individuals – or better yet, move away from rebates entirely.
The list price of a drug is the drug price set by the manufacturer. The net price, on the other hand, is the price after rebates and discounts are subtracted from the list price. These rebates and discounts are negotiated with the manufacturer by the Pharmacy Benefit Manager (PBM) on behalf of an insurance plan or employer.
Sometimes, employers or PBMs will pocket the rebates and discounts themselves. However, better health plans pass on the rebates and discounts directly to the individual at the pharmacy counter, meaning that the person’s out-of-pocket costs reflect the lower net price rather than the inflated list price.
If the health plan’s cost-sharing mechanism is coinsurance, passing on rebates will save people money because the percentage they pay will be calculated based on the net price rather than the list price.
If the health plan uses copays instead of coinsurance, the out-of-pocket cost will always be a fixed amount, regardless of whether rebates are passed through and whether the net price or list price is used. In other words, plans that use copays make the rebate model irrelevant.
People who use insulin make dosing decisions throughout the day based on their carbohydrate intake, physical activity, and stress levels, among other variables. It is essential that they have access to the full range of tools to support their blood sugar management efforts. Insulin pumps and CGMs can make monitoring blood glucose and injecting insulin significantly easier, but these devices are not “one size fits all.” By covering the full range of these devices, employees will be able to use the device that best meets their needs, thus improving diabetes management.
While insulin pumps are used by people who take mealtime insulin for some or all of their insulin needs, CGM can benefit all people with diabetes. CGM provides users with real-time glucose levels and trends, and alerts when glucose levels drop or rise below a preset threshold – all of which is very helpful to staying healthy and in range. We believe everyone with diabetes should use CGM either “real time” each day or “professional CGM” at least once a year. This is true whether or not the person with diabetes is on insulin. If they experience hypoglycemia or severe hypoglycemia (which usually happens if they are on insulin or drugs called sulfonylureas), they should have access to CGM to help determine if there are ways to reduce or end the hypoglycemia.
5. Cover FDA-approved blood glucose meters (BGM) and unlimited glucose test strips, as well as other diabetes supplies such as alcohol swabs, lancets, syringes, needles, and gauze.
Especially if CGM is not covered for people with type 1 and type 2 diabetes, health plans should cover blood glucose meters, unlimited test strips, and other diabetes supplies used alongside insulin. Providing unlimited test strips removes any potential burden of rationing strips and gives people the freedom to frequently check their blood sugar levels to better avoid hyperglycemia and hypoglycemia.
These glucose-lowering medications are approved for type 2 diabetes. Because each has different side effects and different efficacies depending on the user, it is important for employers to cover the full range of therapies so employees can work with their healthcare team to find the most effective treatment.
Moreover, SGLT-2s and GLP-1s are cardio-protective and renal-protective, meaning they decrease the risk of developing heart and kidney disease. Thus, health plans that encourage their use will save both the employer and the employee healthcare costs in the long run.
Additionally, SGLT-2 inhibitors have been approved for people with type 1 diabetes in Europe; if they are approved in the US, employers should cover them for all people with diabetes.
7. Cover emergency glucagon for people with type 1 diabetes or people with type 2 diabetes on insulin.
Glucagon, which helps convert stored energy in the body to blood glucose, can be lifesaving during severe hypoglycemia. It is essential for people who use insulin to have glucagon on hand in case of an emergency.
Recent advances in glucagon have made it significantly easier to administer in emergency situations, including glucagon in the form of autoinjector pens and nasal sprays. Health plans should cover all forms of glucagon to reduce the risks of untreated severe hypoglycemia.
8. Provide people with diabetes access to nutrition counseling.
While eating a healthy diet and staying active is important for everyone, food and exercise play an even greater role in managing day-to-day health for people with diabetes. Nutrition counseling with a dietician at least once a year can help people with diabetes figure out culturally-relevant meals and diets that help them manage their blood sugar, blood pressure, and cholesterol, while also working within their preferences, budget, and schedule.
9. Give people with diabetes access to mental health counseling.
People with diabetes have an increased risk of developing depression. In turn, depression and diabetes distress can also make it more difficult for people to successfully manage their condition and prevent diabetes complications. Thus, health plans that cover mental health visits can improve both the emotional and physical well-being of employees.
10. Offer the Diabetes Prevention Program (DPP) as a covered benefit to people with and at risk for prediabetes and type 2 diabetes.
Prevention is key to keeping all employees healthy and reducing healthcare costs. The DPP is a CDC-recognized lifestyle change program that can help prevent or delay the onset of type 2 diabetes. In people with prediabetes, the DPP has been shown to reduce their risk of developing type 2 diabetes by 58% (71% for people over 60 years old).
Moreover, one study found that DPP participants who received coverage for the program through their health plan achieved better outcomes in attendance and average weight loss than did those who paid out of pocket or through a grant. DPP programs can be offered at in-person community gatherings, online, and even at the workplace, where coaches can deliver sessions.
11. Offer mobile diabetes coaching services.
Mobile coaching services, which can be found online or as apps, help connect people with diabetes to healthcare professionals virtually, in real time. Mobile coaching can provide health, nutrition, exercise, weight management, and mental health support through remote, 24/7 care.
Many coaching services help improve health outcomes. In a study of more than 2,000 adults at risk for type 2 diabetes, Livongo’s digital Diabetes Prevention Program led to an average weight loss of 5.1% (about ten pounds) after one year using the program. In a study of 262 participants with type 2 diabetes using Virta Health’s program, 54% achieved “diabetes reversal” (defined by Virta as an A1C below 6.5% and no diabetes medications other than metformin).
There are many more companies that provide these services, some of which are offered directly to the patient (no insurance necessary) and others that are offered through a health plan. Many programs are offered in multiple languages, and some include unlimited test strips with their service.
12. Cover A1C checks, blood pressure and cholesterol checks, eye screenings, kidney screenings, and foot checks.
While almost all health plans cover these screenings and checks today, they are still important to note. High blood sugar can damage the body’s blood vessels and nerves, so people with diabetes are at increased risk of eye disease (diabetes-related retinopathy), kidney disease (nephropathy), foot damage, and heart disease. To avoid these life-changing and costly complications, health plans should cover these annual – if not more frequent – screenings for people with diabetes:
Blood pressure checks
Cholesterol and triglyceride screenings
Dilated eye exams
Blood and urine kidney screenings (to measure their urine albumin-to-creatinine ratio, UACR, and estimated glomerular filtration rate, eGFR)
Workplace wellness programs are designed to promote healthy behaviors and improved health outcomes. While these programs benefit all employees, initiatives that support exercise, healthy eating, and stress management are particularly important for people with diabetes.
In addition to improving health, well-designed wellness programs can lead to cost savings and improved business performance by lowering healthcare costs, reducing absenteeism, and improving productivity. For example, Harvard researchers found that for every dollar spent on employee wellness, medical costs fell $3.27, and absenteeism dropped $2.73 – a 6-to-1 return on investment.
While these savings are significant, the success of a wellness program – which depends on employee participation and improvement in overall health – relies on its design. A 2015 survey found that while four out of five employers (80.6%) provided wellness programs to their employees, fewer than half of the employees surveyed (45.0%) reported having access to these programs. This may suggest that the program offerings were not adequately robust or that communications about the programs were not effective. In either case, low levels of awareness and engagement weaken the programs’ ability to improve workforce health.
Employers must carefully craft their wellness programs to promote widespread participation within the company and produce a significant impact on employee well-being and healthcare cost savings. Below are the best practices for employers when creating their workplace wellness programs.
1. Offer voluntary biometric screenings and health risk assessments (HRAs).
Biometric screenings and HRAs evaluate a person’s health and risk factors by taking measurements such as height, weight, blood pressure, cholesterol, and blood glucose. The outcomes of these assessments can inform the design and focus of workplace wellness programs, and they can help employees detect health problems early on and identify their personal opportunities for improvement and intervention. Moreover, by following the screening results with education, program resources, and action items to improve health, employers can generate immediate buy-in into their wellness programs.
It is important to couple screenings and assessments with healthcare professional follow-up and health literacy education to ensure individuals understand their results. Without ample follow-up and education, employees may not know the next steps after the assessments.
2. Establish methods to assess employee needs and gather feedback.
In addition to having biometric assessments and HRAs inform the wellness programming, employers should conduct a needs assessment through surveys or focus groups and establish pathways to gather program feedback. Taking these measures will help assess progress within the program and determine strategic changes that need to be made, understand the changing needs and profile of your workforce, and identify organizational barriers that may be counterproductive to the success of the program.
3. Offer enticing incentives for program participation and health screenings.
Offering incentives, or disincentives, is a proven method of encouraging enrollment, participation, and completion of workplace wellness programs and biometric screenings and HRAs. Whether employees respond more to programs that reward healthy behaviors or penalize unhealthy behaviors depends on each organization’s culture.
The American Heart Association found that the most effective incentive programs are generally monetary ones that reward healthy habits or improvements in health metrics in the form of cash or lower health insurance premiums. However, incentives can come in many forms, including:
Reimbursement for all or part of the cost of a membership in a fitness center
Reward for participating in a diagnostic testing program
Waiving an otherwise applicable deductible or copayment to encourage preventive care
Reimbursing the costs of smoking cessation programs
Reward for attending a monthly health education class
Recognition in company-wide communications or on a wellness “wall of fame”
Competitions among individuals or company departments or business units
Allowing company time for participation in wellness activities
Token giveaways recognizing wellness achievements
Regulations require workplace wellness programs to offer reasonable alternatives to employees who cannot meet standards for participation due to health conditions or disabilities. Employers may defer to the individual’s healthcare professional when determining reasonable alternative standards, which could be lowering the threshold of the existing standard or substituting or waiving the standard.
4. Create supportive physical and social environments.
While incentives can activate employees to learn about health and engage in wellness offerings, incentives alone cannot sustain improvements in workforce health. Successful wellness programs must integrate wellness into the company and worksite culture to promote long-term behavioral change.
Organizational policies can be implemented to make healthy behaviors the easy, convenient, and encouraged choice. Common strategies to create a supportive environment include providing healthy food options in kitchens and at company meetings, considering ergonomics in workstation design, improving workplace structures to promote activity (such as providing treadmill desks or better lighting in stairwells), and offering gym and fitness facilities. Some workplaces also provide stress management and sleep promotion tools, such as “nap rooms” and on-site mental health counseling.
5. Improve program reach by using effective communications strategies.
Effective communication strategies can increase the awareness, appeal, and engagement of workplace wellness programs. To personalize communications to target audiences, employers can survey employees to better understand their interests, needs, and goals before tailoring messages accordingly. In addition, effective messaging employs multiple delivery channels – ranging from work emails and social media posts to building signage – and varied and sustained communications over time. Messaging should not only be simple, meaningful, and fun for your audience, but it should also provide actionable information and clear instructions for accessing program resources.
6. Make programs culturally relevant, and customize them to different health and fitness levels.
Wellness programs can only be sustainable if they accommodate each person’s health needs, backgrounds, and goals. For example, whereas some people are already in the process of making healthy lifestyle changes and are comfortable performing high-intensity workouts, others may be beginning to adopt healthy behaviors and prefer more manageable goals, such as reaching a certain number of daily steps through walking. Similarly, while some individuals may find nutritional advice straightforward and easy to incorporate into their daily meals, others may be more comfortable with foods from their own cultures that aren’t highlighted in a program’s educational efforts.
7. Garner managerial support and buy-in.
Company leadership heavily influences the culture and priorities of a company. To set the tone for a supportive culture of health, senior and midlevel managers should be vocal program advocates, actively engage in program initiatives, and personally encourage their direct reports to participate. If this is not happening in your environment, ask your manager if you can take time to discuss this with them.
To ensure that managers are knowledgeable enough to speak about wellness, companies should ideally provide them with training on healthy behaviors and encourage managers to pilot wellness programs to better understand the services offered.
8. Provide comprehensive health education, including the Diabetes Prevention Program (DPP).
The best wellness programs address multiple health risks and health conditions. Programs should be designed to focus on developing healthy habits and implementing lifestyle behavior change tailored to employees’ personal needs.
To help delay or prevent the development of type 2 diabetes specifically, companies can hire digital (or when possible, on-site) DPP coaches to teach people lifestyle changes that promote healthy eating and physical activity. Other examples for education include maintaining a health bulletin board, offering cooking classes, and hiring a registered dietician to work with employees.
9. Partner with nonprofits and community health organizations.
Many health and wellness programs exist through local organizations and nonprofits. Community programs through health departments, local fitness facilities, YMCAs, and health clinics can help inform and complement your worksite offerings – see more here for some examples. Employers can also take advantage of the free resources provided by many national nonprofit organizations. For example, the American Diabetes Association offers a free, 60-second Type 2 Diabetes Risk Test online; Aunt Bertha connects people with verified free or reduced cost services (such as medical care, food delivery, job training) in their communities; The diaTribe Foundation provides many free educational resources that teach people about diabetes drugs, devices, and lifestyle tips.
KEHP provides health insurance to nearly 300,000 public employees, retirees and their families – 6.6% of the state’s population. Recognizing that diabetes was one of the state’s most costly medical conditions, KEHP implemented DVB in 2016 to improve diabetes management, drug adherence, and regular healthcare visits.
The DVB program provides diabetes drugs and supplies (such as test strips) for free or at a reduced copay or coinsurance, with no deductible. In addition, KHEP provides 100% coverage of the national Diabetes Prevention Program (DPP) and coverage for the Diabetes Self-Management Education and Support (DSMES) program. Moreover, KEHP recognizes that full health requires well-being outside of diabetes management, so the health plan also includes several initiatives that focus on the physical, mental, social, and financial health of its members.
The health plan has already improved diabetes outcomes for its members. Medical costs, emergency room visits, clinical visits, acute admissions, and length of hospital stay have all decreased since DVB’s implementation. In addition KEHP saw adherence to diabetes medications increase by 8% between 2015 and 2019. This not only means that daily management of diabetes improved, but also that members were more likely to ward off complications and the need for additional medications. In fact, increased adherence is estimated to save KEHP $5-5.5 million each year.
Macy’s is a national retailer with over 120,000 employees, and its Live Healthy Program provides a terrific example of a comprehensive wellness program.
The program provides a $50 incentive to all employees and if they have a partner, their enrolled partners who complete at least one of five preventive screenings, all of which are completely covered under the health plan: routine physical examination;
annual well-woman preventive exam;
cervical cancer screening; and
colon cancer screening.
Similarly, employees can earn a $300 incentive by completing Macy’s on-site biometric screening and health risk assessment that examines height, weight, blood pressure, cholesterol, body mass index, waist circumference, and blood sugar levels. If any result identifies a health risk, Macy’s connects the employee to a nurse who can help with chronic disease management.
Macy’s also partners with Omada Health to host a program designed to help individuals lose weight through nutrition, activity, and behavioral changes. Completion of the program is rewarded with a $300 incentive. The Live Healthy Program also provides participants the opportunity to work one-on-one with virtual health coaches 24/7 to address their specific needs, whether it be diabetes management, weight loss, tobacco cessation, or otherwise.
The Starr Group is an insurance and risk-management agency that offers a comprehensive approach to supporting a healthy workplace.
In addition to offering biometric screenings, HRAs, and ongoing health coaching, the Starr Group places a heavy emphasis on education through their “Lunch and Learn” program. The program provides tools, classes, and nutrition and activity challenges to engage employees around topics like diabetes prevention and healthy eating.
The Starr Group generates managerial buy-in through their Wellness Committee, which includes the Executive Vice President of Starr Group, a Certified Wellness Coach, and the organization’s Wellness Coordinator. The Wellness Committee designs, tests, and implements the Group’s wellness programming to ensure that all levels of management are engaged in the health of employees.
Moreover, the Starr Group is committed to continuously improving its programs. It administers annual Culture Audits, Presenteeism Studies, Q12 Engagement Surveys, and Employee Satisfaction and Interest Surveys to track the feedback and progress of wellness programs. The results inform programming and strategy changes to best suit the employee population.
Deloitte is a multinational professional services network, and its wellness program takes a holistic, personalized approach for each of its employees.
Similar to other wellness programs, Deloitte offers a $500 annual well-being subsidy that can be used toward a number of health activities, including gym memberships and meditation classes.
However, Deloitte also uses an innovative system called Vitals, which tracks paid time off (PTO), hours worked, and business travel time. This system yields a more complete picture of an individual’s overall well-being, beyond physical health, because it allows managers to identify people at risk of burnout and intervene to help with work and stress management. Vitals allows employees to have biweekly well-being check-ins with their managers and connects individuals to counselors if they need more support.
By using systems that emphasize constructive communication and holistic well-being, Deloitte signals to employees that their health is of utmost importance.