ORIGINAL ARTICLE
Evaluation of a Comprehensive Employee Wellness Program at an Organization With a Consumer-Directed Health Plan Wayne N. Burton, MD, Chin-Yu Chen, PhD, Xingquan Li, MS, Alyssa B. Schultz, PhD, David Kasiarz, PhD, and Dee W. Edington, PhD
Objective: Consumer-directed health plans (CDHPs) are popular among employers in the United States. This study examined an employee wellness program and its association with employee health in an organization that recently initiated a CDHP. Methods: This retrospective observational analysis compared the health risks, employer-paid health care costs, and short-term disability absences of employees of a large financial services corporation from 2009 to 2010. Results: The two-time health risk appraisal participants had a significant improvement in the percentage of employees in the overall low-risk category. The average annual employer-paid medical and pharmacy costs did not significantly change. For employees who improved their health risk category, there was a commensurate change in costs and absences. Conclusions: In a difficult economic climate, this organization began a health promotion program for employees as well as a new CDHP benefit structure. No short-term reduction in health care usage or overall health status was observed.
I
n the 1950s, the Framingham Heart Study1 and others like it were the first indicators that our lifestyle as Americans might be contributing to early morbidity and mortality. In those initial stages of the health promotion field, it was thought that as soon as individuals were educated about how their health behaviors might negatively impact their health, they would then take steps to change those behaviors. That was the driving force behind early health promotion efforts, which mainly consisted of health education. The health risk appraisal (HRA) tool was conceived by Louis Robbins2 and further developed by Canadian and U.S. Centers for Disease Control3 as the primary source for gathering health risk information in a given population. Usually, a report was returned to the participant that acted as a principal health education tool. Corporations, health insurers, physicians, municipalities, and other groups began to offer health education classes, activities, health coaching, and/or printed information to further educate participants. These programs typically focused on individual health risks. Weight management classes were recommended to an overweight individual, whereas smokers were encouraged to attend cessation programs. The World Health Organization defines health promotion as “the process of enabling people to increase control over their health and its determinants, and thereby improve their health.”4 This broad definition encompasses many different facets of health promotion. Certainly, many parts of society are focused on improving the health of the population: the medical profession, public health authorities, community organizations, and providers of health improvement From the American Express Company (Drs Burton and Kasiarz), New York, NY; University of Michigan Health Management Research Center (Drs Chen, Schultz, and Edington and Mr Li); and Edington Associates (Dr Edington), Ann Arbor, Mich. There have been no involvements that might raise the question of bias in the work reported or in the conclusions, implications, or opinions stated in this article. The authors declare no conflicts of interest. Address correspondence to: Wayne N. Burton, MD, American Express Company, 200 Vesey Street, New York City, NY 10285 ([email protected], [email protected]). C 2014 by American College of Occupational and Environmental Copyright Medicine DOI: 10.1097/JOM.0000000000000121
products such as weight loss programs and exercise facilities. One type of organization that has a particular vested interest in the health of its population is employers. In the United States, employers continue to be the major payer of health care costs for their employees. One of the universal business problems of the past few decades is the continuously increasing and unsustainable costs related to medical and pharmaceutical utilization, time away from work, worker’s compensation, lost on-the-job productivity, and other outcomes of poor health behaviors and medical conditions. Corporations often lead the efforts to provide health promotion activities for adults. Although there are altruistic motives for instituting these programs, a chief goal has often been health care cost control.5 Some of the landmark studies in the field of health promotion were those that established the link between health risks measured by commonly used HRAs and economic outcome measures such as health care costs, pharmacy costs, and productivity costs.6–9 The evidence for this association justified the cost of providing health promotion activities for employees and also provided ways to measure the success of those interventions. Despite the efforts of government, corporations, and other organizations in health promotion, health spending for the average American family more than doubled from 2002 to 2011.10 The United States has experienced double-digit increases in health care spending for many years,11 with only occasional decelerations in the growth of health services spending.12 Many early reports of wellness program success were published,13–18 and corporations continue to invest in employee health with wellness programs and strategies to encourage appropriate use of health care services. Past studies indicate positive clinical and cost outcomes associated with workplace wellness programs, although programs that do not demonstrate positive returns are not likely to be published. Nevertheless, once positive program results were reported early on, many organizations did not follow through with evaluation of program results. Many changes in employee health care plans have occurred in recent years. The consumer-directed health plan (CDHP), also known as a high-deductible health plan, has become common— with more than half of the large employers offering at least one CDHP option in 2010.19 CDHP use is increasing, which is associated with health care reforms in the United States.20 These types of plans are typically characterized by relatively high deductibles before coverage begins. Some preventive care such as routine physical examinations, immunizations, screening blood tests for diabetes and lipid abnormalities, and cancer screening testing (eg, mammography, colonoscopy, and Papanicolaou test) are generally covered at 100%. A tax-advantaged medical savings account (also known as a health reimbursement account or health spending account) is commonly offered to employees to set aside funds for some or all of their noncovered medical costs. By making health plan participants more cost conscious,21 CDHPs are one proposed strategy for reducing the large increases in health care costs paid by employers. Nevertheless, little is known about the effects of CDHPs on employee health. Concerns have been raised that the plans may discourage routine preventive care or appropriate medication use for chronic conditions. Fronstin et al22 recently reported on a 4-year follow-up of employees enrolled in a CDHP. They found that a population of employees in a CDHP had
JOEM r Volume 56, Number 4, April 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
347
JOEM r Volume 56, Number 4, April 2014
Burton et al
0.26 fewer physician office visits per enrollee per year, 0.85 fewer prescriptions filled, and 0.018 more emergency department visits compared with employees in another corporation enrolled in a nonCDHP. The likelihood of receiving a mammogram, cervical cancer screening, or colorectal cancer screening was also lower for CDHP enrollees in their study. In this study organization, the employee wellness program began in 2009, concurrently with offering only a CDHP to employees and their families for medical coverage. The purpose of this study was to examine a comprehensive employee wellness program and its association with health risks, health care costs, and short-term disability (STD) absences in an organization that recently initiated a CDHP.
METHODS Study Population The employee population used in this study is from a single major US-based financial services company. In 2009, this company employed approximately 60,000 people, with about 28,000 employees in the United States. About two-thirds of the employee population is female, with an average age of 42 years. Common employee tasks include accounting, receiving and sorting financial documents, telephone and in-person customer service, and other financial services functions. In 2009 and again in 2010, the company offered a web-based HRA to all of its employees and covered spouses/domestic partners. The employee participation rate in 2009 and 2010 ranged from 50% to 55%. In this study, we limit the sample to those employees who enrolled in the company’s CDHP medical plan in 2009 and 2010 and also participated in the HRA in both 2009 and 2010 for two risk measures over time. These restrictions resulted in a study sample of 7252 employees. This time one to time two population was used to assess changes in health risks, health care costs, and STD absences among employees from 2009 to 2010.
Health Promotion Program Description The Healthy Living program is a US-based health and wellness program designed to improve the health of employees and their families. Program goals include the following: 1. 2. 3. 4.
Improve access and remove barriers to care. Simplify and improve the experience with the health care system. Inform and educate participants about the benefits of good health. Deliver innovative and engaging benefit designs that reinforce the messages of good health. 5. Keep costs below the market trend with a high degree of satisfaction. Healthy Living is supported by a highly visible marketing/ communication strategy where: 1. Leaders become the role models and support positive healthseeking behaviors. 2. National campaigns focus on broad issues that are supplemented by local strategies that target local employee/family needs. 3. Employee success stories and Healthy Living champions are used as a cornerstone to drive employee awareness and engagement. 4. New programs and designs are introduced in collaboration with Employee Affinity/Networking Groups via a “We Heard You Campaign.” Affinity groups include the Black Employee Network, Latino group, and others. The firm also has seven US-based wellness centers at its major locations. Approximately 50% of employees have easy access to these clinics. Depending on the number of employees who are served, these clinics are staffed by nurse practitioners or physicians, nurses, a health coach and/or dietitian, and administrative personnel. 348
Only preventive services are offered consistent with the current laws governing CDHPs. These services include routine physical and women’s health examinations, wellness screenings, and routine immunizations such as influenza vaccinations.
Determining Health Risks Completion of the HRA is voluntary and the results are strictly confidential. HRA participants were asked about the presence of biological and lifestyle risks, various chronic diseases, and health conditions. The HRA was created by Health Fitness Corporation (Minneapolis, MN). As a result of HRA participation, employees were provided with an individualized report regarding their health risks and suggestions for health improvement. The questions regarding health risks on the HRA concern lifestyle or behavioral factors (eg, cigarette smoking, use of alcohol, and safety belt use), health or biological factors (eg, blood pressure, total and high-density lipoprotein cholesterol, height, and weight), and perceptual/psychological factors (eg, satisfaction with life or job and perception of health) that may predispose an individual to illness. See Table 1 for a list of the health risks and the at-risk range. Additional HRA questions inquired about the presence or absence of several chronic diseases. At selected worksite screening was available for HRA participants; 41% and 49% of HRA participants were screened in 2009 and 2010, respectively. Biometric testing for blood glucose, total cholesterol, and high-density lipoprotein cholesterol was performed on a fingerstick blood specimen using a Cholestech instrument. Blood pressure was measured. Employees were instructed to be fasting for at least 2 hours before performance of the test. These biometric test results were electronically downloaded and integrated with the HRA results for the individual employee. Measurements for height and weight were self-reported by participants. In the case of blood pressure and cholesterol, when participants do not know their actual values, they are considered low-risk for that risk factor unless they reported taking medication for either condition. Health risks were dichotomized as high or low according TABLE 1. Health Risk Criteria Health Risk Obesity (body mass index) Blood pressure Cholesterol Smoking Safety belt use Alcohol use Physical activity Medical problem Job satisfaction Life satisfaction Stress
Overall risk status Low risk Medium risk High risk
High-Risk Criteria ≥30 kg/m2 ≥130/90 or taking BP medicines ≥240 or taking cholesterol medicines Current cigarette smoker 14 drinks/wk; female, >7 drinks/wk
Evaluation of a Comprehensive Employee Wellness Program at an Organization With a Consumer-Directed Health Plan Wayne N. Burton, MD, Chin-Yu Chen, PhD, Xingquan Li, MS, Alyssa B. Schultz, PhD, David Kasiarz, PhD, and Dee W. Edington, PhD
Objective: Consumer-directed health plans (CDHPs) are popular among employers in the United States. This study examined an employee wellness program and its association with employee health in an organization that recently initiated a CDHP. Methods: This retrospective observational analysis compared the health risks, employer-paid health care costs, and short-term disability absences of employees of a large financial services corporation from 2009 to 2010. Results: The two-time health risk appraisal participants had a significant improvement in the percentage of employees in the overall low-risk category. The average annual employer-paid medical and pharmacy costs did not significantly change. For employees who improved their health risk category, there was a commensurate change in costs and absences. Conclusions: In a difficult economic climate, this organization began a health promotion program for employees as well as a new CDHP benefit structure. No short-term reduction in health care usage or overall health status was observed.
I
n the 1950s, the Framingham Heart Study1 and others like it were the first indicators that our lifestyle as Americans might be contributing to early morbidity and mortality. In those initial stages of the health promotion field, it was thought that as soon as individuals were educated about how their health behaviors might negatively impact their health, they would then take steps to change those behaviors. That was the driving force behind early health promotion efforts, which mainly consisted of health education. The health risk appraisal (HRA) tool was conceived by Louis Robbins2 and further developed by Canadian and U.S. Centers for Disease Control3 as the primary source for gathering health risk information in a given population. Usually, a report was returned to the participant that acted as a principal health education tool. Corporations, health insurers, physicians, municipalities, and other groups began to offer health education classes, activities, health coaching, and/or printed information to further educate participants. These programs typically focused on individual health risks. Weight management classes were recommended to an overweight individual, whereas smokers were encouraged to attend cessation programs. The World Health Organization defines health promotion as “the process of enabling people to increase control over their health and its determinants, and thereby improve their health.”4 This broad definition encompasses many different facets of health promotion. Certainly, many parts of society are focused on improving the health of the population: the medical profession, public health authorities, community organizations, and providers of health improvement From the American Express Company (Drs Burton and Kasiarz), New York, NY; University of Michigan Health Management Research Center (Drs Chen, Schultz, and Edington and Mr Li); and Edington Associates (Dr Edington), Ann Arbor, Mich. There have been no involvements that might raise the question of bias in the work reported or in the conclusions, implications, or opinions stated in this article. The authors declare no conflicts of interest. Address correspondence to: Wayne N. Burton, MD, American Express Company, 200 Vesey Street, New York City, NY 10285 ([email protected], [email protected]). C 2014 by American College of Occupational and Environmental Copyright Medicine DOI: 10.1097/JOM.0000000000000121
products such as weight loss programs and exercise facilities. One type of organization that has a particular vested interest in the health of its population is employers. In the United States, employers continue to be the major payer of health care costs for their employees. One of the universal business problems of the past few decades is the continuously increasing and unsustainable costs related to medical and pharmaceutical utilization, time away from work, worker’s compensation, lost on-the-job productivity, and other outcomes of poor health behaviors and medical conditions. Corporations often lead the efforts to provide health promotion activities for adults. Although there are altruistic motives for instituting these programs, a chief goal has often been health care cost control.5 Some of the landmark studies in the field of health promotion were those that established the link between health risks measured by commonly used HRAs and economic outcome measures such as health care costs, pharmacy costs, and productivity costs.6–9 The evidence for this association justified the cost of providing health promotion activities for employees and also provided ways to measure the success of those interventions. Despite the efforts of government, corporations, and other organizations in health promotion, health spending for the average American family more than doubled from 2002 to 2011.10 The United States has experienced double-digit increases in health care spending for many years,11 with only occasional decelerations in the growth of health services spending.12 Many early reports of wellness program success were published,13–18 and corporations continue to invest in employee health with wellness programs and strategies to encourage appropriate use of health care services. Past studies indicate positive clinical and cost outcomes associated with workplace wellness programs, although programs that do not demonstrate positive returns are not likely to be published. Nevertheless, once positive program results were reported early on, many organizations did not follow through with evaluation of program results. Many changes in employee health care plans have occurred in recent years. The consumer-directed health plan (CDHP), also known as a high-deductible health plan, has become common— with more than half of the large employers offering at least one CDHP option in 2010.19 CDHP use is increasing, which is associated with health care reforms in the United States.20 These types of plans are typically characterized by relatively high deductibles before coverage begins. Some preventive care such as routine physical examinations, immunizations, screening blood tests for diabetes and lipid abnormalities, and cancer screening testing (eg, mammography, colonoscopy, and Papanicolaou test) are generally covered at 100%. A tax-advantaged medical savings account (also known as a health reimbursement account or health spending account) is commonly offered to employees to set aside funds for some or all of their noncovered medical costs. By making health plan participants more cost conscious,21 CDHPs are one proposed strategy for reducing the large increases in health care costs paid by employers. Nevertheless, little is known about the effects of CDHPs on employee health. Concerns have been raised that the plans may discourage routine preventive care or appropriate medication use for chronic conditions. Fronstin et al22 recently reported on a 4-year follow-up of employees enrolled in a CDHP. They found that a population of employees in a CDHP had
JOEM r Volume 56, Number 4, April 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
347
JOEM r Volume 56, Number 4, April 2014
Burton et al
0.26 fewer physician office visits per enrollee per year, 0.85 fewer prescriptions filled, and 0.018 more emergency department visits compared with employees in another corporation enrolled in a nonCDHP. The likelihood of receiving a mammogram, cervical cancer screening, or colorectal cancer screening was also lower for CDHP enrollees in their study. In this study organization, the employee wellness program began in 2009, concurrently with offering only a CDHP to employees and their families for medical coverage. The purpose of this study was to examine a comprehensive employee wellness program and its association with health risks, health care costs, and short-term disability (STD) absences in an organization that recently initiated a CDHP.
METHODS Study Population The employee population used in this study is from a single major US-based financial services company. In 2009, this company employed approximately 60,000 people, with about 28,000 employees in the United States. About two-thirds of the employee population is female, with an average age of 42 years. Common employee tasks include accounting, receiving and sorting financial documents, telephone and in-person customer service, and other financial services functions. In 2009 and again in 2010, the company offered a web-based HRA to all of its employees and covered spouses/domestic partners. The employee participation rate in 2009 and 2010 ranged from 50% to 55%. In this study, we limit the sample to those employees who enrolled in the company’s CDHP medical plan in 2009 and 2010 and also participated in the HRA in both 2009 and 2010 for two risk measures over time. These restrictions resulted in a study sample of 7252 employees. This time one to time two population was used to assess changes in health risks, health care costs, and STD absences among employees from 2009 to 2010.
Health Promotion Program Description The Healthy Living program is a US-based health and wellness program designed to improve the health of employees and their families. Program goals include the following: 1. 2. 3. 4.
Improve access and remove barriers to care. Simplify and improve the experience with the health care system. Inform and educate participants about the benefits of good health. Deliver innovative and engaging benefit designs that reinforce the messages of good health. 5. Keep costs below the market trend with a high degree of satisfaction. Healthy Living is supported by a highly visible marketing/ communication strategy where: 1. Leaders become the role models and support positive healthseeking behaviors. 2. National campaigns focus on broad issues that are supplemented by local strategies that target local employee/family needs. 3. Employee success stories and Healthy Living champions are used as a cornerstone to drive employee awareness and engagement. 4. New programs and designs are introduced in collaboration with Employee Affinity/Networking Groups via a “We Heard You Campaign.” Affinity groups include the Black Employee Network, Latino group, and others. The firm also has seven US-based wellness centers at its major locations. Approximately 50% of employees have easy access to these clinics. Depending on the number of employees who are served, these clinics are staffed by nurse practitioners or physicians, nurses, a health coach and/or dietitian, and administrative personnel. 348
Only preventive services are offered consistent with the current laws governing CDHPs. These services include routine physical and women’s health examinations, wellness screenings, and routine immunizations such as influenza vaccinations.
Determining Health Risks Completion of the HRA is voluntary and the results are strictly confidential. HRA participants were asked about the presence of biological and lifestyle risks, various chronic diseases, and health conditions. The HRA was created by Health Fitness Corporation (Minneapolis, MN). As a result of HRA participation, employees were provided with an individualized report regarding their health risks and suggestions for health improvement. The questions regarding health risks on the HRA concern lifestyle or behavioral factors (eg, cigarette smoking, use of alcohol, and safety belt use), health or biological factors (eg, blood pressure, total and high-density lipoprotein cholesterol, height, and weight), and perceptual/psychological factors (eg, satisfaction with life or job and perception of health) that may predispose an individual to illness. See Table 1 for a list of the health risks and the at-risk range. Additional HRA questions inquired about the presence or absence of several chronic diseases. At selected worksite screening was available for HRA participants; 41% and 49% of HRA participants were screened in 2009 and 2010, respectively. Biometric testing for blood glucose, total cholesterol, and high-density lipoprotein cholesterol was performed on a fingerstick blood specimen using a Cholestech instrument. Blood pressure was measured. Employees were instructed to be fasting for at least 2 hours before performance of the test. These biometric test results were electronically downloaded and integrated with the HRA results for the individual employee. Measurements for height and weight were self-reported by participants. In the case of blood pressure and cholesterol, when participants do not know their actual values, they are considered low-risk for that risk factor unless they reported taking medication for either condition. Health risks were dichotomized as high or low according TABLE 1. Health Risk Criteria Health Risk Obesity (body mass index) Blood pressure Cholesterol Smoking Safety belt use Alcohol use Physical activity Medical problem Job satisfaction Life satisfaction Stress
Overall risk status Low risk Medium risk High risk
High-Risk Criteria ≥30 kg/m2 ≥130/90 or taking BP medicines ≥240 or taking cholesterol medicines Current cigarette smoker 14 drinks/wk; female, >7 drinks/wk
