Health Activation: The Latest Innovation in Employee Health

Executive Summary


For years, companies in a variety of industries have instituted wellness programs to encourage healthy habits among their employees, improve productivity and lower health care costs. Today, these programs are a nearly $8 billion industry in the U.S. and are expected to grow at nearly 7.8 percent annually through 2021.1 Increasingly, companies are expanding these programs to target employees’ emotional and financial well-being, as well as their physical health.

But despite their popularity among employers, many wellness programs yield mixed results in helping participants - particularly those with chronic conditions - improve their health over the long run.

Limits of traditional wellness programs

Basic wellness programs typically include weight loss challenges, smoking cessation classes, fitness center discounts and educational materials. Such programs generally result in limited employee engagement and short-term success. Furthermore, wellness programs that rely heavily on self-reporting tools like health risk assessments (HRAs) may produce unreliable data and not fully capture participants’ complete health picture.

An innovative alternative

A health activation approach – based on clinical data - is a more effective way for self-funded employers to engage employees in their own health, sustain healthy behaviors and lower costs.

How health activation works

Unlike traditional wellness programs, health activation programs are structured around clinical evidence. Participants’ eligibility files and claims data are aggregated from multiple sources. Sophisticated analytics are then applied to this rich data base.

The claims data typically includes:

  • Medical
  • Prescription
  • Dental
  • Vision
  • Biometric / HRA

Next, employees are risk stratified by demographics, medical history and certain health risk factors.

Armed with this information, the programs’ nurse case managers develop a holistic view of participants’ health status and identify those with complex, high-cost conditions and those with risk factors that could lead to such conditions.

That, in turn, enables the nurses to devise informed interventions based on each participant’s clinical profile. This can include things like encouraging employees to get an annual physical exam, discussing an appropriate diet with an individual with type 2 diabetes, counseling an asthmatic patient on the proper way to use her inhaler or referring a participant with joint pain to a rheumatologist.

Incentives drive compliance

Incentives are a key part of the program. To receive premium discounts, reduced co-payments or other inducements selected by the plan sponsor, participants will typically be required to fulfill basic age and gender-appropriate preventive measures.

Common preventive requirements include:

  • Annual physical exam
  • Cholesterol screening
  • Mammogram
  • Annual flu vaccine
  • Dental cleaning twice per year
  • Periodic eye exam

Participants with chronic conditions, such as diabetes, coronary artery disease, asthma, high cholesterol and hypertension must take additional steps – including regularly visiting their doctor, monitoring or reporting their health measures (such as cholesterol levels) and filling their prescriptions - to receive incentives. Employers can couple a health activation program with a value-based benefit design which encourages the use of clinical services with the greatest potential to improve health.

Highly trained case managers

Data-based wellness programs are designed to ensure that all participants – from healthy to sick – are engaged in managing their health. Thus, the programs focus on both preventive measures and chronic disease management. Close collaboration between case managers and participants helps uncover what is deterring participants from taking their medications, adhering to their diet or otherwise changing unhealthy behaviors. 

Achieving this goal requires case managers who are registered nurses with wide-ranging expertise, such as training in motivational interviewing and behavior modification, and certification as health coaches and case managers. 

Enrollees in traditional wellness programs who seek advice typically must interact with multiple specialists such as a health coach, nutritionist and exercise physiologist. Participants in a health activation program, on the other hand, need only reach out to their nurse case managers.

Pinpointing gaps in care

High Price

Here’s an example of how these programs seek to close gaps in care. While reviewing the three-year claims history of a 51-year-old male with asthma, the nurse case manager sees no claims for an annual medical exam with a primary care doctor. That scenario raises a red flag because individuals over age 50 should generally have a preventive exam on a yearly basis, according to national medical guidelines. So, the nurse would reach out to the participant and strongly encourage him to make an appointment for a physical exam. The annual exam helps his primary care doctor identify potential problems before they get serious and allows the doctor to keep track of health measures like his blood pressure over time. The nurse follows up with him about the doctor visit and communicates with the doctor about his questions and concerns. 

Another example: claims data may reveal that a participant with diabetes is having annual check-ups with her primary care physician, but that her condition is not being controlled by the medications the physician prescribed. In that case, the nurse may identify an endocrinologist in her area who can help to can adjust her medication regimen.

Beyond the disease state

Keeping in mind the program’s goal of managing the whole person, not just the disease state, nurse case managers try to broaden conversations with participants by inquiring about their everyday health status. 

Most chronic conditions are heavily influenced by lifestyle. When reaching out to a participant with diabetes for example, a nurse may engage in lifestyle coaching by discussing the importance of weight management, reducing stress, exercising and eating healthy. Additionally, the nurse may help enter the participant in a weight management or fitness program, connect her to a wellness coach or recommend resources to manage her condition. 

As appropriate, nurse case managers may also ask participants about socio-economic, psychological, behavioral or other factors which may be hindering them from managing their health. For example, in exploring why an asthmatic participant isn’t taking her medication regularly, the nurse learns that the patient visits her sick mother every day before and after work, organizes her medications, takes time off from work to take her to doctor appointments and cleans her house, leaving little time for her own health. In response, the nurse might assist the participant by referring her to local social service agencies who can help relieve the strain of caring for her mother.

Personalized and timely

The dynamic nature of a health activation program enables nurse case managers to be far more proactive than is the case with traditional wellness programs. At many companies, traditional wellness programs are rolled out at the beginning of the year and participants are categorized into static risk groups.

With data-based wellness programs, however, new claims are continually being received, enabling nurse case managers to reclassify participants from a lower risk to a higher risk cohort on an ongoing basis. This agility – the ability to intervene based on an individual’s clinical changes at any given time - is a unique feature of these programs.

Consider these examples:

  • A new claim for a discharge from the hospital of a participant who is risk stratified as “low risk” triggers nurse outreach.
  • A “moderate-risk” participant who has two emergency room visits for chest pain may be recategorized as “high-risk”. The nurse case manager would then contact the individual to discuss changing to a heart healthy diet, losing weight and perhaps referring him to a cardiologist.
Getting Results

Conclusion

Motivating employees to adopt healthy change isn’t easy. Many traditional wellness programs struggle to engage employees which is a major obstacle to program success. Offering discounts to the local fitness center for completion of biometric screenings or health assessments, while of some value, is unlikely to lead to sustained healthy behaviors.

Evidence-based, innovative approaches such as a health activation program represent a major leap forward in employee wellness. Leveraging clinical data as their foundation, health activation combines education, counseling and targeted interventions to those most in need to ensure they feel confident in managing their conditions and have access to the right providers.


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1 IBISWorld Industry Report. OD4621 Corporate Wellness Services in the US. February 2016. Accessed January 8, 2018
2 https://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2016/aag-workplace-health.pdf
3 http://vbidcenter.org/v-bid-in-action-a-profile-of-connecticuts-health-enhancement-program-2/