SummaryOften in collaboration with a vendor, employers offer comprehensive wellness programs for all benefit-eligible individuals, including employees, spouses, domestic partners, and/or retirees. The typical program identifies individuals' risks through an annual health risk assessment and biometric screening and then addresses these risks through various initiatives, including lifestyle management programs and health coaches. The benefit design creates financial incentives to participate, while communication campaigns and incentives encourage both initial enrollment and ongoing engagement in the program. While results vary across employers, one representative, large employer implementing a comprehensive program attracted broad participation and achieved meaningful improvements in health-related behaviors and risk factors, which in turn led to a leveling off of overall health care costs.Moderate: The evidence comes from one large employer with 14,000 covered lives that implemented a comprehensive wellness program with meaningful financial incentives for participation; data include post-implementation participation rates; pre- and post-implementation comparisons of the prevalence of health-related behaviors and associated risk factors (e.g., smoking, alcohol intake, cholesterol and triglyceride levels, symptoms of depression); and pre- and post-implementation trends in overall health care costs.
Developing OrganizationsPro-Change Behavior Systems, Inc.; Quality Health Solutions, Inc.
Quality Health Solutions is located in Portland, OR.
Pro-Change Behavior Systems, Inc. is located in South Kingston, RI.
Date First Implemented2005
Problem AddressedPoor diet, physical inactivity, smoking, and other lifestyle-related behaviors increase the health risks of employees and their dependents, leading to high costs, absenteeism, "presenteeism" (when employees show up to work but perform at less-than-optimal effectiveness), and low productivity. Comprehensive worksite health and wellness programs can reduce such risks, but relatively few companies offer them and those that do typically attract few participants.
- Link between health-related behaviors and costs, absenteeism, and presenteeism: Employees with many health risk factors tend to use more health care resources, miss more days of work, and perform at less-than-optimal levels of efficiency and productivity. For example, a study of Novartis Corporation employees found a significant, consistent link between common risk factors—including high biometric laboratory values (e.g., cholesterol, blood glucose, blood pressure), cigarette and alcohol use, and poor emotional health—and increases in presenteeism, absenteeism, and health care costs, with medical expenditures being 13 to 22 percent higher for at-risk men and women.1 Obesity alone costs employers $12 billion annually due to higher health care utilization and medical claims, lower productivity, increased absenteeism, and higher disability insurance premiums.2
- Unrealized potential of worksite wellness and health promotion: Well-constructed worksite health and wellness programs can be effective in reducing risk factors among employees and dependents. For example, a recent systematic review found that worksite nutrition and physical activity programs yield a modest reduction in weight status and body mass index (BMI).2,3 Other studies have shown that employee participation in worksite wellness programs reduces absenteeism4,5 and has modest effects on short-term health care costs and a greater impact on long-term costs.6 Yet, relatively few companies offer such programs, and those that do typically attract relatively few participants. Although financial incentives can boost participation,7,8 many companies do not offer them.
Description of the Innovative ActivityOften in collaboration with a vendor, employers offer comprehensive wellness programs for all benefit-eligible individuals, including employees, spouses, domestic partners, and/or retirees. The program generally includes an annual health risk assessment and biometric screening to identify individuals' risks and then addresses those risks through various initiatives, including lifestyle management programs and health coaches. The benefit design creates financial incentives to participate, while communication campaigns and incentives encourage initial enrollment and ongoing engagement in the program. Key program elements include the following:
- Annual health risk assessment and biometric screening: Each year, enrolled individuals log into the online system and complete a survey that assesses health status and various risk factors, along with an individual's readiness to change at-risk behaviors (based on the Transtheoretical Model of Behavior Change; see Context section for more details). Enrollees undergo annual biometric screenings that include a full lipid panel and measurement of blood pressure, height, weight, and BMI. While such screenings can occur at the employer site, the employer and partner vendor generally encourage individuals to have them done by their primary care provider, who can also deliver age- and gender-specific screening tests that cannot be done at the employer site, such as colonoscopies.
- Personalized report: After completion of the health risk assessment, program participants automatically receive a personalized report based on the assessment and biometric screening. The report details various behavior-related health risks and the individual's readiness to change these behaviors. If the participant desires, an onsite health coach can review the key findings from the report and point out various lifestyle management programs that can help based on the individual's readiness to change.
- Online and paper-based lifestyle management programs: Online and paper-based wellness programs cover the following areas: weight management, exercise, stress management, depression prevention, medication adherence for lipid-lowering drugs and blood pressure medications, healthy eating for those with normal BMI, smoking cessation, and being a proactive health consumer. For individuals who complete the risk assessment and use the online versions of these programs, the home page is prepopulated with recommended programs when the individual logs into the system. The online programs generate individualized feedback designed to resemble that given by a health coach. Employees and other eligible individuals can go through any of these programs at a convenient time and at their own pace. The online program Health in Motion was added in 2012 for adolescents. This internet-delivered program includes voice-overs read by adolescents, ten full-motion videos of adolescents encouraging and motivating each other to exercise and eat healthy.
- Ongoing support from health coach: As a complement or an alternative to the lifestyle management programs, enrolled individuals can work with a trained health coach who uses motivational interviewing techniques during telephone conversations to encourage clients to change behaviors and reduce identified risk factors. Coaches initially let the individual set the agenda, tackling whatever issue they would like to deal with at the time, including those not directly related to physical health (e.g., a runaway teenage daughter, loss of a home due to foreclosure, having a child off at war). The goal is to build a supportive relationship and prove the coach's value in addressing key stressors and challenges. Over time, as the individual gains trust in the coach, they begin working on issues more directly related to health, such as quitting smoking, making dietary changes, increasing levels of physical activity, and/or taking medications as prescribed. The frequency and intensity of interactions vary according to the individual's needs. Typically, coaches and participants talk at least four to six times a year, although some participants want to speak more frequently, and no limits exist on the number or intensity of interactions. The first few conversations typically take 30 to 40 minutes each, after which calls usually last 15 to 25 minutes.
- Financial incentives and communications to encourage participation: The benefit design, a communications campaign, and ongoing incentives, campaigns, and contests encourage eligible individuals to enroll and actively participate in the wellness program, as outlined below:
- Benefit design: The benefit design includes at least one option that gives benefit-eligible employees lower out-of-pocket costs if they participate in the wellness program. For example, one large employer with 14,000 covered lives in 26 states gave employees and their dependents the following plan options:
- Lower-cost option tied to wellness program: Under this option, employees have a $1,000 annual deductible, but receive a $1,050 annual contribution from the employer, which goes into a health reimbursement account. The employer covers 75 percent of the employee's health care costs after retirement. Those choosing this option must agree to undergo the aforementioned annual health risk assessment and biometric screening and to participate in appropriate lifestyle management programs, as defined by a designated number of interactions with them.
- Higher-cost option with no wellness program requirement: Under this option, employees have a lower deductible ($300) but do not have a health reimbursement account. Those choosing this plan do not have to participate in the wellness program, but every year they must pay any difference in the premium increase for this plan and the lower-cost option described above. In other words, if the premium for the lower-cost option rises by $10 a month while the higher-cost option increases by $20 a month, the employee pays the full $10 difference along with other required cost-sharing under the plan. With this option, the employer covers only half of health care costs for employees after they retire.
- Communications campaign and followup contact: As detailed below, an aggressive communications campaign around open enrollment each year encourages employees to sign up for the lower-cost option and engage in ongoing tracking and follow up to encourage continued participation after enrollment.
- Initial and follow up mailings: Each year around open enrollment, all benefit-eligible employees receive a welcome kit (mailed to the home) with a letter from the chief executive officer or another respected individual within the employer organization, a program brochure describing the benefit design and the associated wellness programs, a list of frequently asked questions, a guide to the potential rewards of participation (including what needs to be done to achieve those rewards), and information on how to log into the system to set up a personal profile and access the various online programs. As appropriate during open enrollment, the employer sends out "e-mail blasts" reminding employees of when they must sign up for a plan option and of the need to begin participating actively in the wellness programs.
- Ongoing tracking and followup: The employer tracks on a weekly basis those who have signed up for the program and completed the initial health risk assessment and those who have and have not participated in various components of the wellness program. As appropriate, staff call those who have not yet accessed recommended programs, providing them with support as needed in logging into the system and participating. (Employers without an online system can do this through paper-based forms.)
- Ongoing incentives and rewards: Various onsite challenges, incentives, and campaigns help keep individuals motivated and engaged in behavior change over time. For example, employers with a significant number of overweight/obese employees and dependents might sponsor walking clubs, provide pedometers, and/or create financial incentives tied to losing weight. Those with a lot of smokers might offer a preferred health insurance premium rate to those who quit smoking. Employers can also tie incentives to participating in certain activities; for example, one employer gave $50 gift cards to employees who engaged in a certain number of sessions with coaches.
Contact the InnovatorBrian J. Thomas
Chief Executive Officer
Quality Health Solutions, Inc.
PO Box 82849
Portland, OR 97282-0849
Janice M. Prochaska, PhD
President and Chief Executive Officer
Pro-Change Behavior Systems, Inc.
1174 Kingstown Road
South Kingston, RI 02879
Innovator DisclosuresMr. Thomas reported receiving compensation (including distribution of stock) as an employee and board member of Quality Health Solutions, Inc. and reported that Quality Health Solutions, Inc. received payment for a variety of speaking engagements. Dr. Prochaska reported receiving compensation (including distribution of stock) as an employee and board member of Pro-Change Behavior Systems, Inc. Information on other organizations that have financially supported the work described in this profile is available in the Funding Sources section.
ResultsWhile results vary across employers, one representative, large employer with 14,000 covered lives across 26 states implemented a comprehensive program that attracted broad participation and achieved meaningful improvements in health-related behaviors and risk factors, which in turn led to a leveling off of overall health care costs.
Moderate: The evidence comes from one large employer with 14,000 covered lives that implemented a comprehensive wellness program with meaningful financial incentives for participation; data include post-implementation participation rates; pre- and post-implementation comparisons of the prevalence of health-related behaviors and associated risk factors (e.g., smoking, alcohol intake, cholesterol and triglyceride levels, symptoms of depression); and pre- and post-implementation trends in overall health care costs.
- Broad participation: The vast majority of eligible individuals enrolled in the program, with participation ranging from 88 to 95 percent between 2005 and 2010. Among those who signed up, 99 percent had their cholesterol and blood pressure checked each year.
- Improved behaviors: During the first 6 years of the program, over one-third of smokers (35 percent) quit smoking, while nearly three-fourths of those exhibiting risky behaviors related to alcohol began limiting their intake. More than two-thirds (68 percent) of participants changed behaviors to reduce stress.
- Fewer risk factors: Between 2007 and 2010, participating employees significantly reduced their risk factors for future disease. The percentage with no risk factors roughly doubled (from around 20 to 40 percent), with concomitant declines in those with two or more risk factors. (The proportion with one risk factor remained relatively stable.) Specific improvements related to depression and cardiovascular risk are outlined below:
- Fewer symptoms of depression: During the first 6 years of the program, the vast majority (79 percent) of those with or at risk for depression exhibited improvement in symptoms.
- Less cardiovascular risk: Among 3,980 individuals completing a health risk assessment each year between 2007 and 2010, measures of cardiovascular risk dropped significantly, as outlined below:
- Lower cholesterol: Average total cholesterol fell by 9.7 points, from 195.1 to 184.4 milligrams per deciliter of blood (mg/dl). The proportion of individuals with borderline or high cholesterol fell from 43.1 to 31.4 percent. Average low density lipoprotein (also known as LDL or "bad" cholesterol) levels fell by 8.3 points, from 121.4 to 113.1 mg/dl, and the proportion of individuals with borderline or high LDL fell from 37.6 to 29.0 percent.
- Lower triglycerides: Average triglycerides fell by 4.7 points, from 129.0 to 124.3 mg/dl.
- Stable costs: Health care costs remained flat for the first 4 years of the program (2005 through 2008), well below historical increases of 8 percent a year between 2000 and 2005. Since 2008, health care costs have grown quite modestly and well below historical trends, with average annual increases of 2 to 3 percent. Organizational leaders attribute this stabilization to the comprehensive wellness program and associated incentives, as no other meaningful changes to the company's health benefits occurred during this time.
Context of the InnovationFounded in 2001, Quality Health Solutions works with employers to put in place comprehensive wellness programs that help employees and their dependents reduce risk factors for future disease and improve health-related quality of life. Quality Health Solutions was formed through a collaborative agreement with Pro-Change Behavior Systems, a company launched by James O. Prochaska, PhD, who developed the Transtheoretical Model of Behavior Change. This model recognizes change as a process, not an event. Consequently, it groups the change process into distinct stages of readiness (precontemplation, contemplation, preparation, action, maintenance). Pro-Change researches, develops, and tests (in randomized trials) evidence-based, computerized, tailored interventions for helping people move forward through these stages at their own pace. Quality Health Solutions licenses intellectual property from Pro-Change, integrating it and its own intellectual property into a suite of comprehensive wellness services. These services include a health risk appraisal and various lifestyle management interventions, including smoking cessation, weight management, stress management, healthy eating, exercise management, depression prevention, antihypertensive and lipid-lowering medication adherence programs, a proactive health consumer program, and the Health in Motion program for adolescents.
Planning and Development ProcessThe major steps required for an employer to put in place this type of comprehensive wellness program are listed below; if the implementing employer so desires, a vendor can assist with or take the lead on any of these tasks:
- Upfront needs assessment: This assessment identifies the critical needs within the organization related to health and wellness. It includes a review of the degree to which the organization's culture promotes wellness (and how it does so) and of previous and ongoing wellness programs, including how employees/dependents reacted to them and what impact they had.
- Defining target population: While a comprehensive program targeting all benefit-eligible employees, retirees, and dependents is often the ultimate goal, some organizations begin with benefit-eligible employees only.
- Creating incentive design: Typically in collaboration with a benefits consultant, the employer develops plan options that create financial incentives to participate in the various components of the voluntary wellness program.
- Developing communications program: The communications plan and accompanying materials can be used to introduce the program to eligible individuals and keep them engaged in it over time. The development process includes creation of letters (typically signed by the company head) and other program-related materials, including the rewards guide and brochures described earlier.
- Ongoing planning meetings: On an ongoing basis, senior human resource and administrative leaders hold regular meetings to review the program and program-related issues. The frequency of meetings will vary by employer, with some holding a brief session every week and others meeting on a monthly or quarterly basis. If a vendor is being used, vendor representatives typically attend as well, in many cases taking charge of setting the meeting agenda and developing relevant background materials (e.g., analysis of program participation and results). More details can be found in the Staffing and Resources section below.
Resources Used and Skills Needed
- Staffing: Upfront development of the program and/or contract negotiations with a vendor typically involve senior human resources staff, attorneys, and other administrative leaders, who participate in weekly meetings for a period of roughly 3 months. On an ongoing basis, the program requires several part-time staff, typically employer human resources staff along with part-time staff from the vendor, including an account manager, account coordinator, and database analyst. Health coaches generally have expertise in behavioral modification techniques and usually have a degree in a health-related area. Coaches may be registered nurses, registered dietitians, diabetes educators, fitness specialists, social workers, and/or health promotion specialists. Each full-time health coach can generally handle a caseload of 1,000 individuals; when used, the vendor often provides the health coaches as part of its contract with the company.
- Costs: Total costs for a comprehensive program (including worksite biometric screening) typically run $100 to $150 per covered life per year. These costs can be offset by the savings generated from improvements in health-related behaviors and risk factors.
Funding SourcesNational Institutes of Health; Healthways
Employers typically fund this program internally; if a vendor is used, the employer typically pays a per-person fee.
Tools and Other Resources
- More information on Pro-Change Behavior Systems and the Transtheoretical Model can be found at http://www.prochange.com/ttm.
- More information on Quality Health Solutions can be found at http://www.qualityhealthsolutions.com.
Getting Started with This Innovation
- Sell leaders on potential cost reductions, productivity gains: The potential cost savings and productivity enhancements generated by the program generally outweigh program-related costs.
- Leverage health benefits broker expertise: Many large companies already work with health benefits consulting firms that have expertise in benefit design and in screening vendors that implement and operate comprehensive wellness programs. These brokers can help companies identify vendors offering high-quality, evidence-based programs with a proven track record.
- Make program voluntary, with incentives to participate: Employees often resist being forced to do something by their employer, particularly when it relates to health benefits and health care. Consequently, participation should be voluntary, with meaningful incentives embedded in the benefit design and through other initiatives to encourage initial enrollment and ongoing use of the wellness program.
- Have company leaders sell program, using business approach: The chief executive officer and/or other respected leaders should play a highly visible role in explaining the rationale for the program to employees. The "sales pitch" should be straightforward, acknowledging the rapid historical rise in health care costs and the impact of such increases on the company's financial fortunes and its ability to maintain and/or increase employee head count and compensation going forward. The message should emphasize the program's potential not only to boost productivity and reduce costs, but also to improve health status and quality of life for employees and their dependents.
Sustaining This Innovation
- Monitor and share data on program impact: Routinely collect and analyze data on the program's impact on key metrics, including risk factors, health status, productivity, absenteeism, and health care utilization and costs. Sharing this information helps to identify opportunities for improvement and maintain enthusiasm among company leaders and rank-and-file employees.
- Continually improve and refine program: As appropriate, add new programs, contests, and incentives to keep the program "fresh" over time. New programs can address identified problem areas and/or target patient populations not well served by the program. For example, one company began offering programs targeted at healthy, low-risk individuals, including incentives for elite athletes to participate in triathlons.
- Expand program to dependents, retirees (if not included initially): While the most effective programs cover dependents and retirees from the beginning, companies unable or unwilling to offer an all-inclusive program at the outset should consider expanding to additional groups over time. Once leaders see the program's potential benefits, the decision to expand becomes easier to make.
- Maintain leadership visibility: Employees will be more likely to maintain enthusiasm if they see company leaders actively participating in the program, including the annual, onsite biometric screening. Company leaders should also routinely communicate information about the program, including evidence of its positive impact to date and new program offerings.
- Consider reallocating funds from employee assistance program (EAP): The health coaches often handle problems previously dealt with by EAP staff, thus reducing demand for EAP services. As this transition occurs, employers often shift financial resources from the EAP to this more comprehensive program.
Additional Considerations and Lessons
- The lifestyle management programs developed by Pro-Change Behavior Systems that are used in this program received the Gold Award in Health Management from URAC, a leading health care accreditation organization. This award recognizes innovative leadership and best practices in health care consumer empowerment and protection. Pro-Change's stress management and depression prevention programs have been recognized by the Substance Abuse Mental Health Services Administration (SAMSHA).
- Both Quality Health Solutions and Pro-Change Behavior Systems are private, for-profit companies that design, implement, and/or operate comprehensive wellness and behavior-change programs for clients. Consequently, the program developers could potentially benefit from the spread of this type of program.
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Service Delivery Innovation Profile
Original publication: February 15, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: January 08, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.