Seven Keys to Greater Change

8/9/2019 Seven Keys to Greater Change

1/9

Seven Keys to

Greater Change:

Best Practices for

Employer HealthPrograms

WWW.HEALTHWAYS.COM

February 2010


2/9 1Change the Facts: Best Practices for Employer Health Programs

70% of U.S. smokers say they want toquit. 40% try each year. Yet almost 20%of American adults still smoke.1

55% of Americans say they wouldlike to lose weight. 27% are making a

serious attempt.2Yet 67% of Americanadults are overweight or obese.3

In ve years, healthcare costs forobese Americans grew 82%; foroverweight Americans, 36%; and fornormal-weight Americans, 25%.4

The cost burden is profound foremployers. More than 60% of

Americans obtain health insurancecoverage through an employer-based

plan.5 In the last decade, employerhealthcare costs have increased

approximately 150%.6

Achieving

Greater Change

with Employer

Health Programs

Changethe

Facts

Healthcare cost trends have longbeen moving in the wrong direc-

tion. Some employers have success-fully reduced the upward trajectory of

health-related expenses with healthand wellness programs, but wide vari-ations exist in program performance.

Newer approaches to health and well-being based on recent advances in

science and research signicantly im-prove outcomes.

This paper identies seven key ar-

eas in health program design with thehighest potential to achieve change.

The most eective solutions support

well-being across total populations,focus resources to prevent the high-

est-cost health developments, andmotivate change with personalized

support that drives the step-by-stepprocess, recognizing the many factorsthat inuence health behavior.



Smart approaches can reverse the trends.Many companies have implemented workplace health and wellness

programs. In the U.S., 58% of employers are oering some type of wellness

benet, ranging from web-based resources to telephonic and onsite coachingprograms. The percentage of large rms (200 or more workers) oering at leastone wellness program grew from 88% in 2008 to 93% in 2009.7

The quantity of health and well-being programs available in the marketplace

continues to grow. A meta-analysis of literature on costs and savings associatedwith workplace disease prevention and wellness programs found that for every

dollar spent on wellness programs, medical costs fall by approximately $3.27 andabsenteeism costs, by $2.73.8 Figure 1.

Quality has improved with advances in knowledge and research. Yet nationalhealth statisticsand wide variances in program approaches and resultsindi-

cate room for improvement. At Healthways, the Center for Health Research usesobjective scientic methods to:

Assess and validate the value of health solutions, methodologies, and tools

Support the development of improved solutions and approaches

Lead the healthcare industry in innovation

Beyond committing substantial internal resources to best science, Health-ways collaborates with well-known external expertsM.I.T. AgeLab, Pro-Change

Behavior Systems, Gallup, and other strong partners.

Research, partnerships, and three decades of real-world experience have putHealthways on a continuous path of improvement. Through external assessmentand internal evaluation, Healthways has identied seven key areas in health pro-

gram design with the demonstrated potential to signicantly improve the out-comes of employer health programs.

1. Serve the total population, looking beyond physical health, to

cut costs and raise productivity.Nearly half of all Americans suer from one or more chronic diseases and

each year millions of people are diagnosed. Health support programs that serveonly on a subset of the populationtraditionally dened as those with existing

chronic diseases or high health riskscan fail to prevent those new diagnosesand signicant associated costs.

As leading wellness researcher Dee Edington noted at the University of Michi-gans 28th Annual Workplace Wellness Conference9:

Risks ow toward high-risk, and costs toward high-cost, if left unchecked.

Keeping healthy people healthy is a critical health management strategy.

A comprehensive, three-pronged strategyoptimizing care for those with

health conditions, reducing and eliminating lifestyle risks, and sustaining goodhealthserves the total population and prevents both short- and long-termavoidable costs.

The cost benets of prevention extend far beyond medical expenditures.

Studies have calculated productivity costs associated with chronic disease andrelated health risks to be up to four times those of direct healthcare costs to em-

ployers.10

FiguE 1:RETURN ON INESTMENT

On average, employee

healthcare costs fell by

$3.27 for every $1.00

spent on employee

wellness programs.



New insights into the factorsthat inuence health and produc-tivity suggest that health support

programs couple a complete viewof the total population with a more

complete view of individual healthand the work environment.

In her featured presentationat the Workplace Wellness Confer-

ence, Dr. Cathy Baase, Global Di-rector of Health Services for Dow

Chemical Company, emphasizedthe importance of including cul-

ture in corporate health strategies.The National Business Group onHealths National Conference on

Health, Productivity, and HumanCapital in October 2009 was fo-

cused on a similar theme.

The Gallup-Healthways Well-Being Index, a comprehensivemeasure of national well-being, is

amassing new data each day onthe interrelationships of factors

like social support, job satisfaction,physical health, healthy behavior,

and levels of happiness, anger, andstress. Through 1,000 daily surveys,the Index collects and correlates

information in six domainsLifeEvaluation, Emotional Health,

Physical Health, Healthy Behav-iors, Work Environment, and BasicAccess. Findings since the launch

of the Index in January 2008 havesubstantiated connections be-

tween:

Work environment, physical

health, and productivity Social support and well-being

Exercise and levels of stress

BMI and emotional health,nancial stress, and recognitionat work

Most mature employer health

programs use Health Risk Assess-ments (HRAs) as a starting point

for identifying health needs and asa benchmark for health improve-

ment. HRAs focus primarily onphysical health and may includelimited aspects of mental health.

Index ndings and other researchsubstantiate the need for a more

multidimensional assessmentone that captures corporate cul-ture and the inuences of social

and emotional factors on healthand workplace performance.

Historically, health supportprograms to reduce BMI would fo-cus on healthy eating and physical

activity. To be most eective, pro-grams also need to address social

and emotional needs, such as theability to cope with stress and the

presence or absence of positive

recognition for performance atwork. Figure 2.

This example supports the rec-

ommendation that an expandedview is needed. This information

can:

Arm health professionals with

a better understanding of theindividuals they are working to

help.

Inuence program implementa-tion and communication

strategies.

Next generation programsmust address social and emotional

needs in conjunction with physicalhealth, or even in advance of it.

FiguE 2:DRIERS OF BMI RISK

Days of Best Work

# of Health sks

Enery Level

Healthy Eatn*

Fnancal Stress

econton at Work

Heht & Weht*

BMi sk

EmotonalHealth

Physcal

Health*Exercse*

Copn w/ Stress

Neatve Aect

Personal Sorcesof Presenteesm

*Historical focus on BMI Risk



2. Drive participation andsustain engagement withstrategic communications,incentives and behavioraleconomics.

Without participants, health

support programs dont have the

chance to be eective. Accordingto a 2009 survey of nearly 700 U.S.companies, typically fewer than

40 percent of eligible individualsenroll in wellness programs, andfewer than 15 percent in disease

management programs.11

To motivate participation, U.S.respondents in a 2009 global sur-

vey of workplace wellness pro-grams spent an average of $163per employee per year on wellness

incentive rewards, up from $145the previous year.12

Incentives improve participa-

tion, but dollars alone dont deliversustained program engagement.

The Center for Health Researchhas studied program incentivesevidence and best practices, and

found:

Incentives and disincentives can

be eective at improving partici-pation and behavior change, butthey are not sucient to improvelong-term outcomes.

Incentives are more eective

when provided on an ongoing,periodic basis, and when their

value reects the perceived dif-culty of the action.

Incentives must be coupled withwell-designed health and well-

ness programs and eectivecommunication to have the

greatest impact.13

High-performing employersidentied in the Towers Perrin2010 Health Care Cost Survey an-

ticipated undertaking more com-munication activity and using

new channels to support healthprogram engagement in the next

two years.14 (High performers hadlower relative healthcare costs peremployee than low performers.)

Best practices in health programcommunications include:

Tailoring messages and commu-nication vehicles to the audience

Minimizing employee privacy

concerns

Maximizing reach with multiplemethods and touches over time

Driving participation with short-term, team-based challenges

Demonstrating internal support,

beginning with top management

Tracking and addressing individ-ual changes in program use

Tailored communication mes-sages and rewards, based on indi-

vidual patterns of interaction, can

both improve engagement andlower incentive costs. To maximizethe motivational impact of incen-tives, innovative programs are ap-

plying principles from behavioraleconomics. Figure 3.

People tend to discount the val-

ue of things if they do not perceivean immediate benet a conceptknown as hyperbolic discounting.

The phenomenon helps explainwhy as many as 50% of individuals

with doctor-prescribed medica-tion fail to take their medication as

prescribed.15 Intermittent econom-ic and noneconomic methods ofreinforcement can overcome that

tendency by providing a perceivedbenet, but individuals respond

dierently to dierent types ofmessages and levels of reinforce-

ment.

A study of one such program,

using proprietary software to de-termine optimum, individual lev-

els of economic reinforcement,found that it improved medication

adherence by 34.6%to 97.9%while limiting costs.15 In trial and

commercial environments, thesame system has produced 33% to56% increases in sustained adher-

ence to targeted behaviors whiledecreasing incentive budgets.

FiguE 3:REINFORCEMENT ARIATION

The right re-inforcement

is dierent

for dierent

people:

Cash-equivalent

HSA / plan benets

Acknowledgement

Competition

Sense of Belonging

Non-economc

Economc

one size

does not

t all.



3. Use advanced predictivemodels to focus outreach onhigh-impact opportunities.

No organization has unlimited

resources to invest in wellness. In-vestments that deliver the greatestimpact will prevent the highest-

cost, avoidable health problems.The challenge is to anticipate and

prevent those health develop-ments before they occur.

Fifty years ago, weather fore-casters relied on information from

land-based observation stations,balloons, and aircraft to predict

the weather. Satellites and sophis-ticated computer modeling ca-

pabilities have since transformedthe accuracy and value of weather

forecasts. The same phenomenonhas begun to take place in the eldof health support. Advances in pre-

dictive modeling and data analysisallow increasingly accurate identi-

cation of the best opportunitiesto prevent high-cost health prob-lems.

An analysis by the Center for

Health Research identied severalrules of healthcare costs across to-

tal populations.

A consistently small percentageof individuals typically generatethe greatest costs within a

population30% of employeesaccounted for 80% of one

employers costs.

The high-cost populationchanges from year to yearonly12 to 18% of one years costliest

group remained so the next year.

Neither chronic disease norclinical risks alone best predict

healthcare needs and costs.Other important indicators

include multiple conditions,medications, prior utilizationpatterns, self-management,

health behaviors, demographics,and psychosocial factors.

A prediction of high-cost health-

care needs does not guaranteean opportunity to make animpact that improves health or

reduces costs.16 Figure 4a-b.

Predictive modeling math-

ematically determines the likeli-hood of dened outcomes. Neu-

ral net technology builds modelsby identifying hidden patternsin datacombinations of risks,

claims, and other information that

signal potential future costs.

Predictive models for healthsupport programs should consider:

Which individuals are likely toincur high costs in a given time

period (6 to 12 months or 12 to24 months)

Cost trajectoriessome

individuals are likely to returnto lower costs and stable health

status without intervention

Gaps in care, or actionable risks,that can be addressed to reduce

disease progression and medicalspending

The high-cost health conse-

quences of individual risks andsets of risks, in combination with

demographics and otheravailable information

Results can guide an appropri-ate level of intervention for each

individual within the population,making the most cost-eective use

of outreach resources. Proactiveoutreach may include care sup-port and coaching from a primary

health professional or team. Everymember of the population should

receive some level of health sup-port.

CHANGE IN HEALTHCARE COSTS AMONG 898 DIABETICMALE EMPLOYEES, YEAR 1 TO YEAR 2 Lynch and Gardner,2009

percent of the year 1 population

> $30,000

$7,500 - $30,000

$2,500 - $7,500

$1,000 - $2,500

< $1,000costin

quintilein

year1

reduced costs same costs increased costs

83%

70%

34%

23%

17%

19%

55%

44%

59%

11%

11%

33%

41%

FiguE 4b:

same costsreduced costs increased costs

percent of the year 1 population

> $30,000 80%

73%

55%

47%

20%

20%

36%

27%

80%

7%

9%

25%

20%

$7,500 - $30,000

$2,500 - $7,500

$1,000 - $2,500

< $1,000costin

quintilein

year1

CHANGE IN HEALTHCARE COSTS AMONG 13,000 MALEEMPLOYEES, YEAR 1 TO YEAR 2 Lynch and Gardner, 2009

FiguE 4a:



4. Move each person for-ward with a science-basedapproach to behaviorchange.

Preventing avoidable, adverse

health developments requiresmore than informed outreachit

requires change in health-relatedbehaviors. The most eective pro-grams:

Use a proven behavior change

approach to guide interventions

Address multiple behaviors

Draw on the benets of socialsupport

Embed the change process into

online resources for individualsand technology that supports

health professionals

The Transtheoretical Model

(TTM) of behavior changead-dressing self-ecacy, decisional

balance, and the ve stages ofchangeproduces signicant be-havior change even in populations

that include large numbers of un-motivated participants.17

Studies of the ProChange TTM,

implemented in populations in

which 70 to 80% of people werenot ready to take action, have

found:

Individualized interventions forsmoking cessation, the most

dicult behavior to change, pro-duced long- term abstinence

rates within the range of 22 to26%.

Interventions directed towardeective stress managementchanged behavior and stress lev-

els for 60% of an at-risk nationalpopulation originally identied

with levels of stress that pre-dicted a need for care within two

weeks.

Interventions to address adher-

ence to cholesterol-loweringdrugs and antihypertensive

medication moved 60% of thenon-compliant population to

compliant during a six-monthtreatment period.

Other interventions trimmedthe number of physically inactive

participants by 40% and moved25% of the population from

unhealthy to healthy eating

habits.

Full implementation of theTTM addresses behavior at every

stage of change, from pre-contem-plation (not even thinking about

change) to maintenance of a newhealthy habit. The concepts of self-

ecacy and decisional balance areessential to the change process,determining and building:

The condence to change

A favorable balance of pros and

cons inuencing the decision tochange.

Research and experience sup-

port the idea that behaviors areinterrelated and that people tendto change them in clusters. If

someone wants to stop smokingbut fears weight gain or irritability,

those fears may hamper or preventchange. Figure 5.

Addressing multiple behaviorssimultaneously, rather than se-

quentially, boosts eective changein single behaviors18 and inu-

ences more behaviors, oering

advantages in both eciency andoutcomes.

Social support is another in-

creasingly recognized tool toinuence behavior change. An

analysis of Healthways QuitNetComprehensive tobacco cessationprogram found that active or pas-

sive use of QuitNets online thera-peutic communities boosted quit-

ting success by more than 15%.19

Figure 6a-6b (next page).

5. Provide options andconsider preferencesfor interaction to elevateoutcomes.

On a daily basis, consumers

receive personalized recommen-dations for books, movies, music,and even banking products based

on past online transactions andother available data. One-size-ts-

all programs are becoming a thingof the past as the trend toward per-

sonalization spreads across everyindustry.

Receptivity varies by individualto certain information, messages,

and methods of contact. A personsresponse can relate to factors like

level of education, age, social envi-ronment, personal preference, and

personal circumstance.

Research has shown that dif-ferent modalitiesonline, tele-phone, face-to-face, and others

can achieve comparable levels ofsuccessful behavior change. The

use of multiple modalities and theopportunity to select a modalityof preference both improve out-

comes.19

Beyond the modality, or com-munication channel, aspects of

FiguE 5:

THE IN CREASED PROBABILITY OF PRO GRESSING TO ACT ION ON ASECOND BEHAIOR E.G. DIET WHEN INDIIDUALS HAE PROGRESSEDTO ACTION O N AN INITIAL BEHAIO R E.G. SMOKINGPro-Change Behavior Systems, Inc., 2009

Co-variation in: Odds Ratio

Control Group .85

TTM Intervention Group 3.44



QUIT RATES ARE HIGHER FOR MEMBERS WHO USEINTERACTIE WEBSITE FEATURES

FiguE 6b:

60

50

40

30

20

10

0

30-

DayAbstinenceResponderQu

itRate

Interactive Website Features

Active SocialNetworking

Passive SocialNetworking

Interactive Tools

58%

43%

51%

38%

46%

32%

Yes NoUse of Feature

wellness program measurementinclude:

Using clinically valid measures

that relate to emerging researchon the factors most closelyassociated with chronic illness

Developing and using consistent

measures that enable compara-

tive analysis and benchmarking Regularly re-measuring to deter-

mine the impact of steps taken

Ensuring consistent data prac-

tices and eective tracking with asystems approach to data

management21

Frequent reporting and direct,real-time access to meaningfulmetrics support program success

and ongoing eorts to improve

engagement and outcomes.

Relevant metrics for employer

health and well-being solutionsmay include:

Financial returns on short- andlong-term avoidance of health

care costs

Health improvement opportuni-ties identied through assess-

ment tools (including populationphysical, emotional, and social

health factors) with comparisonsto a benchmark population

A population health risk prole,

including percentages of high-risk, medium-risk, and low-riskparticipants; aggregate numbers

of individuals by identied health

risk (BMI, tobacco use, physi-cal inactivity, stress manage-ment need, etc.); eligibility and

enrollment; and actionable risksimproved and eliminated

Interaction details, includingtwo-way interactions and use

of online resources

7. Support a seamless ex-perience with integratedtechnology that builds on

every interaction.Many solutions appear inte-

grated from the outside but lack

the technology that supports trueintegration. Without an integrated

technology platform, the conver-sation that a clinician has with an

individual about recent heart pal-pitations is not available to the t-ness coach promoting high-ener-

gy workouts.

personalization that can improvethe eectiveness of interventions

include:

The tonality: informational,educational, motivational, or

empathetic messages can workbest for dierent personalitiesand at dierent junctures

The frequency or intensity

The depth and density of con-

tent, based on personality andliteracy level

Key to making the tailoring

process cost-eective is automa-tion. A sophisticated softwarefeedback system can assess and

respond to what members do andwhat they react to, incorporating

input from employees and healthprofessionals.

6. Track valid, consistent,comparable measures to di-rect program improvement.

Only 22 percent of employers

reported using nancial metricsto measure the success of well-ness programs in a recent global

survey.20Rates were higher amongU.S. employers, but measurement

practices are far from uniform.Faulty measurement tactics can

inate success and mask programfailure.

The World Economic Forumsrecommended best practices for

30-

dayabstinenceITTquitrate

QUITNET COMPREHENSIE OUTCOMESSURPASS THE WEBONLY OFFERING

FiguE 6a:

Quitnet program type

comprehensive web-only

27.2%

0

10

30

20

9.7%


9/9 8Ch th F t B P i f E l H l h P

REFERENCES1. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm,January 26, 2010.2. http://www.gallup.com/poll/124448/in-u.s.-more-lose-weight-than-trying-to.aspx, January 26, 2010.3. http://www.cdc.gov/nchs/fastats/overwt.htm, January 26, 2010.4. http://www.reuters.com/article/idUSTRE57I4LK20090819, January 26, 2010(cited data source: Agency for Healthcare Research and Quality).5. Blumenthal D., Employer-sponsored health insurance in the United Statesorigins and implications, New England Journal of Medicine, 2006; 355(1):82-8.6. http://www.towersperrin.com/tp/showdctmdoc.jsp?country=global&url=Master_Brand_2/USA/ Press_Releas-es/2009/20091008/2009_10_08.htm, January 26, 2010 (cited data source:Towers Perrin 2010 Health Care Cost Survey).7. http://ehbs.k.org/, January 26, 2010 (cited data source: Kaiser FamilyFoundation Employer Health Benets 2009 Annual Survey).8. Baicker, K., Cutler, D., Song, Z., Workplace Wellness Programs Can GenerateSavings, Health Aairs, Vol. 29, No. 2, February 2010.9. http://www.umich.edu/~hmrc/news/WW28.html, January 28, 2010.10.Working Towards Wellness: Measuring Results, World Economic Forum, 2008, p. 9.11. http://www.pwc.com/en_US/us/hr-saratoga/assets/review_september_2009.pdf, February 2, 2010.12. http://www.buckconsultants.com/buckconsultants/Portals/0/Documents/PUBLICATIONS/ Press_Releases/2009/PR-Global-Wellness-Survey-2009-111609.pdf, January 26, 2010.13. Rula, E., S acks, R., Incentives for Health & Wellness Programs: Strategies,Evidence and Best Practice, Outcomes & Insights in Health Management, Vol. 1,No. 3, 2009.14. www.towersperrin.com/hcg/hcc/TPHCCS2010srvycharts.pdf, Exhibit 8,February 2, 2010.15. Kalayoglu, M. V., Reppucci, M., Blaschke, T.F., Marenco, L.N., Singer, M.S., AnIntermittent Reinforcement Platform to Increase Adherence to Medications,American Journal of Pharmacy Benets, Vol. 1., No. 2, 2009.16. Rula, E., Hobgood, A., Hamlet, K., Zeng, H., Montijo, M., Maximizing CareManagement Savings through Advanced Total Population Targeting, Outcomes &Insights in Health Management, Vol. 1, No. 2, June 2009.17. Prochaska, J.O., Butterworth, S., Redding, C., Burden, V., Perrin, N., Leo, M., et. al.,Initial ecacy of MI, TTM tailoring and HRIs with multiple behaviors for employeehealth promotion, Preventive Medicine, 46, 2008, pp. 226-231.18. Hyman, D.J., Pavli, V.N., Taylor, W.C., Goodrick, G.K., Moye, L., Simultaneous vs.Sequential Counseling for Multiple Behavior Change, Archives of Internal Medicine,167, 2007, pp. 1152-1158.

19. Severtson, L., Haas, J., Neftzger, A., Purvis, J., Rula, E., Tobacco Cessation throughParticipation in a Comprehensive Multi-Media Program, Outcomes & Insights inHealth Management, Vol. 1, No. 1, April 2009.20. http://www.buckconsultants.com, op. cit., January 26, 2010.21.Working Towards Wellness: Measuring Results, World Economic Forum, 2008, p. 9.22. http://www.towersperrin.com/tp/showdctmdoc.jsp?country=global&url=Master_Brand_2/USA/ Press_Releas-es/2009/20091008/2009_10_08.htm, February 2, 2010.23. www.towersperrin.com/hcg/hcc/TPHCCS2010srvycharts.pdf, Exhibit 9,February 2, 2010.

Coordinating services through manual re-ports or periodic calls can minimize health con-icts but alienate participants by requiring them

to share the same information multiple times.Truly integrated services build on every interac-

tion.

An integrated system with a clinician dash-

board that identies the most important itemsto address in each interaction supports health

professionals in guiding the change process.Online tools that respond to individual input can

help set goals and identify steps to action, work-ing in tandem with other interactions.

Integrated technology connects multiplevendors, programs, health care providers, and

pharmacies. It enables timely, informed healthoutreach and supports the concept of the per-

sonal health record.

In the Towers Perrin 2010 Health Care CostSurvey, 51% of high-performing companies saidthey build connectivity across all health-related

programs and vendors, compared to 21% of lowperformers.22 More than 60% of high-performing

employers expect to support personal health re-cords for their populations by 2012.23

ConclusionEmployer health programs can achieve mea-

surable health change and signicant healthcare

cost savings. The programs with the highest im-

pact will:

Serve the total population, looking beyond

physical health.

Use tailored communication and incentive

strategies that attract and sustainengagement.

Focus outreach resources on the greatest

opportunities to contain costs and improvehealth.

Embed a science-based behavior changeprocess into all interactions.

Oer individuals a highly personalized

experience.

Use valid measurements of program impact.

Integrate all program elements to build onevery interaction.

Seven Keys to Greater Change

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