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The 4 Game Changers in Employee Wellness - Transcript

Hello and welcome to this webinar on the 4 Game Changers in employee wellness. My name is Jesse Hercules. I’m the President of Extracon, and I’ll be presenting the webinar today.

We have a pretty packed agenda, so if we don’t get to all of them today we’ll be following up with you directly. We will be using examples from Extracon’s wellness portals and apps – but this is NOT a full demonstration of the portal. If you’re interested in that just let us know and we’d be happy to arrange something for you.

We have a straight forward agenda today. We want to tell you a little bit about ourselves, and then go right into the 4 Game Changers and explain what they are. Then we’d like to give you a high level overview of Extracon’s portal as an example of how you can implement the 4 Game Changers. Then we’ll wrap up with some next steps.

I’d like to start by introducing our business. Extracon is a cloud-based software company that builds and implements innovative, practical and incredibly powerful wellness portals for employers, wellness companies, benefit brokers and health plans.

The amazing thing is that our customers come in all shapes and sizes. Our customers include insurance organizations like Highmark Blue Cross. They include large employers like MARS, and Costco, and University of Phoenix. The include smaller organizations like Fremont County in Wyoming. They include wellness vendors like Spectrum Health, RepuCare and Allegeant. And they include Hospitals and healthcare organizations like Methodist, and Indiana University Health.

So now let’s move on to the 4 Game Changers.

According to a recent RAND Corp. Study, 92% of self-funded employers have had a wellness program for five or more years. And yet there’s a growing sense within the employer community that these programs haven’t reached their potential. A number of studies have called into question the effectiveness and ROI of these programs, including the RAND study and the Pepsico Study.

And here’s what I think is the biggest reason. This chart is based on a study that was published in the Journal of Occupational and Environmental Medicine in 2006. The study was done by D. Edington at the University of Michigan, one of the leading researchers in our field.

Here’s how to read this chart. Going from left to right, it shows all the things you do each year in a traditional wellness program. On the left, we start with everybody – 100% of the population. And then you do an HRA and screening, and about half the people participate. So we take that 100% and cut in half. Then you identify the ones we think are high-risk, and that cuts it in half again. So we’re down from 100% to 50% to a little under 25%. That’s the second bar. Then you try to contact them, and when you get to the number you actually contact it’s cut in half again. Down to 12%. Then you cut it in half again since only half the people we contact agree to participate in a program. Then you cut it in half again since only about half of those who participate stay with the program.

Can you see what’s happening? This is the game that most wellness programs are playing. It’s the “cut it in half game”. Start with 100% of the population, lose half of them at each step, and you’re only helping a couple of percent by the time you get to the end. I don’t want to play this game, and I don’t think you do either.

So where can we change the game? We’ve identified four areas. First, participation. For most programs, that’s measured by the number of people who do a health assessment or biometric screening. Wellness programs are using incentives, currently averaging about $150, to get people to take the HRA and do the screening. And yet, they are seeing participation in the 50% to 75% range at best. And if you look beyond the HRA and screening, most wellness leaders see small and scattered amounts of participation in onsite programs, online Challenges, coaching, flu shots, and other aspects of their program. It’s everything we just saw on the previous slide. What do we need? Full participation in those initial steps, without paying more in incentives. That’s a game changer. Second, biometrics. Programs do an annual biometric screening, and then find the people who are high-risk – and identify them for followup. In many cases there’s a participation incentive if those high-risk people talk to a coach for 2 or 3 sessions during the year. But there’s a problem. Usually we don’t know if your numbers improved or not, since biometrics are generally not measured again until the next year. And here’s a little secret – most programs don’t actually connect the dots to see which participants improved or got worse. So they are going through this cycle of screening and outreach, the aggregate numbers aren’t moving much if at all, and we keep repeating the cycle. So what would a game-changer look like? Clinically significant Biometric improvements within 90 days. That’s what we should be doing.

Third, Lifestyle. What as a wellness leader, you’re doing combination of onsite and online programs for physical activity, weight loss, nutrition, and other topics. Typically, a wellness program will run an 8-week program for weight loss, or a Challenge program for physical activity. These are short term, lightweight programs based on self-report data. Often it’s only 15 or 20% of the population that is participating at any one time. And when the program’s over, many people go right back to their old lifestyle. Many programs are hosting onsite fitness classes, or upgrading their campus and stairways to be more walkable. Again, these are not bad efforts, but it’s hard to say what the impact is since we’re not measuring the change in physical activity or how it’s sustained over time. What are we looking for? (Click) – People walking a ton of steps, and losing a couple of pounds a month, all year long. Accurately measured, not self report. In other words, sustained lifestyle change throughout the year for those who were sedentary and overweight. That’s a game changer. Finally, Administration work and scalability. It still amazing to me how many paper forms and faxes we see in wellness programs. At the same time, with onsite classes and events, attendance is often not even taken. We see lots of programs that try to bring all their data together in Excel for incentives and reporting. In other words, they are trying to use a spreadsheet as a database. And if you try to use it that way, you are going to create a high burden of administrative work. The hidden issue with administrative work is tied to participation. The only way you can run your program on paper and Excel is if participation stays low. So when we talk to many programs about increasing participation, all they can see is how much paperwork that’s going to cause! You would be surprised at how common this is. So what do we need? A program that scales up so it can serve the whole population without needing more staff or more budget.

So here are the 4 Game Changers. First, Full Participation. Second, Biometric Improvement. Third, Sustained Lifestyle Change. And last, it has to be scalable and support full participation without needing more staff or more budget. Let’s talk about each of these in turn.

Game Changer #1 is Full Participation. Wellness leaders know they have to reach the whole population in order to change population health. Studies have shown that nonparticipants tend to have more health risks and costs than participants – so the people that your program is not reaching today are exactly the ones you most need to reach. What does full participation mean? You’re never going to get 100%. That’s just not possible. But you’re looking for at least 90% participation in the HRA and screenings. 95% is better. Remember, we have to reach the ones who are avoiding the program today. 90%+ participation without more incentives is a game changer.

Biometrics are the test of whether your program is really changing the health of your participants. If a participant finds they have high blood pressure, high cholesterol or high blood glucose at the screening – we want them to work with their doctor to improve those numbers, as soon as possible. The goal is clinically significant improvements in biometrics within 90 days after the screening. As an example, lowering blood pressure 10 points for systolic, and 5 points for diastolic. Lowering LDL Cholesterol by 30 points. Lowering fasting blood glucose by 15 points. Right away, not next year. So, A wellness program where participants work with their doctors and show clinically significant improvements in biometrics within 90 days? That’s a game changer.

Lifestyle habits are the biggest driver of chronic disease in advanced countries today. Changing daily behaviors around physical activity and BMI is a critically important task for employee wellness programs. Good lifestyle habits require a significant and ongoing time commitment from participants – it takes time and effort to eat healthy and be active every day. What are we looking for? Something like 500,000 steps per quarter. About 5lbs of weight loss per quarter. And continuing all year long . So, High levels of physical activity and moderate weight loss that continue throughout the year? That’s a game-changer.

Wellness leaders are practical. They understand that game-changing results can only happen within the limits of today’s staffing, budgets, and technology. It can’t depend on a huge, expensive increase in one-on-one coaching and interaction. It can’t depend on labor-intensive review of paper forms and faxes. They can’t change the way physicians operate or the way the payroll systems work. They can’t hire the staff to work with each participant one-on-one every day. They can’t buy expensive tracking devices for every employee – or health kiosks for every worksite. So the only game-changers that can work are the ones that scale up to full participation and results using existing staff, technology and budgets.

Since we’re talking about game change, I’d like to give an example from a different field. Looking back to 2007, when the iPhone was introduced, it’s clear that the iPhone changed everything. What was new? Touchscreen, email, apps, music. Wait a minute. (CLICK) Actually, the iPhone was not the first to have email, a touchscreen, apps or music. Blackberry had been successful with email for several years. HTC and others had internet browsers and the ability to download Apps downloads on phones. Sony had a Walkman phone that had music. All of these features had been done before. One at a time. The iPhone was a transformed its industry because it brought together all four of those features into one elegant, integrated design. And Apple was able to produce the iPhone at large scale – with over 700 million produced as of 2015. Here at Extracon, we think employee wellness is on the verge of the same kind of breakthrough.

When wellness programs bring together full participation, biometric improvement, sustained lifestyle change, and the ability to scale up easily – they will achieve unprecedented levels of results and success. But it takes all 4. And here’s why. For example, full participation by itself doesn’t do anything. We’ve seen programs with almost 100% of the people taking an HRA and then nothing changes for population health. To be a Game Changer, Full participation must be coupled with changes in lifestyle and biometrics. They have to participate AND they have to change. At the same time, we’ve seen labor intensive, one-on-one programs that might produce biometric improvements and lifestyle change, but only for a small slice of the population. A program like that can’t scale up to allow full participation. You can never afford to have a health coach following around every employee every day of the year. And many employees don’t want an intensive one-on-one program, even if it were available. As another example, we’ve seen technology-intensive programs that focus on lifestyle and ignore biometrics. We’ve also seen programs that focus on biometrics and ignore lifestyle. If you look at these four elements, nobody is really doing it all. That’s what needs to change. What’s needed today is to bring them into an integrated program design. Let’s talk about how to do it.

So lets start with #1. This one is all about program design and incentive design – actually not a lot of new technology here. Let me tell you how we’re doing this for our customers today. I’m going to talk about a large healthcare employer in Memphis, Tennessee which is Methodist LeBonheur Healthcare. They have just over 10,000 employees in over a dozen sites in west Tennessee. In the year before they brought Extracon in, they offered the health plan’s HRA along with a $150 incentive for taking the HRA. They got 26% participation, and spent $390,000 in incentives. Folks, that’s a lot of money for a pretty small participation rate. In 2014, they partnered with Extracon to offer the Extracon HRA. They took our advice and changed the $150 incentive to a $225 penalty for those who did not take the HRA. Lo and behold, they participation rate immediately went up to 94%. They did not pay out even a single dollar in incentives. In fact, they took in almost $90,000 in penalty dollars that they could use to fund the wellness program. By the way, they offered a free biometric screening, with no incentive attached. They got exactly 10% to participate. We are not the first to shift from an incentive approach to a penalty approach for HRA’s. Across the board, with many other employers besides Methodist, and other vendors beyond Extracon, this is the way to reach near 100% levels of participation. The screening did not have incentives or penalties, so participation was low. For 2015, they combined the HRA plus the screening into one big penalty structure. There was also a tobacco question on the HRA that was linked to an incentive. Now the good news is – they got 85% to do both an HRA and a Screening. The HRA participation was down somewhat from 2014, but the main reason was that a lot of the smokers decided they would rather not to the HRA – and get their penalty for that – than to get the same penalty for admitting they are smoking which is one of the HRA questions. So we can actually tweak the design there and get that number back up next year. Beyond Extracon, beyond Methodist, if you look at the industry across the board, the employers who get 85%+ or 90%+ participation in HRA’s and screenings are using a penalty approach. Employees largely are OK with this approach because everyone needs to know their numbers and learn about their health. I want to say we do not advocate penalties for everything. We don’t think penalties are the best tool for every job. But for HRA and screening participation, this is how you do it. If you look across employee health and wellness at people who are getting 85%, 90%, 95% participation, this is how it’s done.

So here’s our philosophy on incentives and penalties. The research on incentives makes a really strong point about sticks and carrots. Penalties really work well. Our experience as well as the experience of everyone we’ve talked to is that the only way to get those high HRA & screening participation rates is to use a penalty approach. But common sense says you can’t stop with the sticks. You need to balance them out with carrots, so the overall program is a positive for employees. That means you offer big, valuable levels of incentives for biometric outcomes. For most programs, this means blood pressure, cholesterol, glucose, BMI, and cotinine (a metabolite of nicotine that shows tobacco use). And for those who don’t meet the initial standard, your alternative standards are based on improving those biometrics, and validated changes in lifestyle – like physical activity and weight loss. That’s where you want to put your dollars. You’ll see the big dollars are never for participation. It’s OK to offer prizes and small incentives for onsite and online programs – that’s a way to keep it fun for the participants.

OK, let’s move on to the second game-changer. To change biometrics it takes science, technology and common sense program design. So here’s the program and incentive design. First, reward participants who pass the screening. Then, for those who don’t pass the screening, reward clinically significant improvements that happen within 90 days of the screening. That’s how you make Game Changer #2 actually happen. There’s also a role for technology to play, in terms of collecting updated biometrics and simplifying the administration of the ACA compliance requirements.

So here’s the process flow: It starts with your biometric screening for things like blood pressure, LDL Cholesterol, and blood glucose. Participants whose levels are too high will be told to see their physician. For most participants, at the first visit the physician will retest the biometrics and confirm the screening results. Then, he or she will prescribe a medication and schedule a followup visit. At the followup visit, the physician will retest and confirm that the medication is working to improve the employee’s levels. Then the employee earns their incentive based on the improved biometrics. If you’re looking for clinically significant improvements in biometrics – that’s where you want to put the incentive. So let’s review. To improve biometrics, the wellness program has to work within Physicians’ existing treatment process, collect updated biometrics from physicians, and reward improvements in biometrics for those who don’t meet the initial standard. Got it? The wellness program also has to work with special cases. In some cases the screening value was an anomaly, and the biometrics are OK as verified by the physician. And sometimes, the employee has a medical condition that makes it unreasonably difficult or medically inadvisable to meet the improvement target. Now, much of this has been done by wellness programs in the past. But it’s been expensive and slow. What’s the problem?

The problem is that paper doesn’t scale. Unfortunately, most of those programs have relied heavily on paper and FAX communications with doctor’s offices. Ever seen one of these forms, where it has 100 boxes on the page and you fill out different parts for a Type I appeal versus a Type II appeal? Then you turn the form over and do a different set of boxes for the follow-up appointment? Paper forms don’t map well onto a complex, multi-step process like employee wellness. The forms are confusing for participants and doctors. And they’re a serious headache for the wellness program. They are often incomplete or illegible. It’s a lot of work for someone to decode the form, make a decision on whether to award the incentive, and communicate back with the participant. If you had a stack of 200 of these to go through and make decisions on this week – you’d probably look a lot like the lady in the photo here. So we think outcome incentives are great, but the paper forms used to implement them are a nightmare.

If we move away from paper and fax, the technology we use must be practical. For example, your wellness portal is never going to connect to 1000 different physician EMR’s. Even the health plans can’t really pull this off. The data is never going to come over automatically from the doctor’s office. And of course the physicians won’t log into your wellness portals. We have to use the physicians we’ve got. We can’t expect them all to change the way they do things, just to help us with our wellness program.

We recommend using a smartphone app to securely collect updated physician biometrics and simplify administration of alternative standards and physician waivers. The app should from the maker of your wellness portal, so it’s secure and trusted. It should send the data directly to the wellness portal, where incentives and deadlines are calculated and applied automatically. The app design should be simple and intuitive – and it can be better than the paper forms used by most outcomes-based wellness programs today. So let’s go through an example. Imagine you have a participant did the screening, and their cholesterol was much too high. Now they’re at the doctor’s office. They are logged into the wellness program’s app. In the exam room, instead of handing the doctor a paper form to fill out and sign, they hand the doctor the smartphone so he or she can enter the biometrics there. The doctor can also sign off on a medical exception or alternative standard if needed. They can sign it using the touchscreen. The App can even take a picture of the doctor’s face so we know who is signing off on the biometrics. In developing the App we talked with quite a few physicians about this. Would they use the App this way? Or not? We did not find a single example of a physician who said they would refuse to use the app. The dominant response was that patients hand them all kinds of things to sign every day, and this was just the logical next step to move that to an App. Now we were talking about cholesterol. What if the bloodwork has to go to a separate lab, and the lab report is sent later? Once again, we recommend using a secure app to scan in the lab report.

Game Changer #3 is sustained lifestyle change. Now as we’ve discussed, you’re not going to get there with an 8-week program. How do you get there?

Sustained lifestyle change requires frequent goals throughout the year. The incentive research is clear that one big annual goal is not as motivating as a series of smaller goals during the year. We recommend quarterly targets. Participants can choose a goal of 500,000 steps (about 5,000 steps a day) or 5 lbs of weight loss. Quarterly targets are near enough to motivate behavior, but not so frequent as to cause problems for your payroll department. The choice of physical activity or weight loss allows the employer to accommodate a wide range of participant needs and limitations. Another approach is to set quarterly physical activity goals for all employees (regardless of weight), with an additional alternative of weight loss for those who are overweight. This works well for organizations that don’t want to tie an incentive directly to BMI.

Incentives for lifestyle change require accurate measurement of activity and weight. However, most organizations don’t have the budget to buy wearable activity trackers for every employee and weight kiosks for every worksite. We recommend using a smartphone app to automatically collect accurate step data, and allow participants to submit photo-validated weights. The app should come from your portal vendor so it’s secure, trusted and integrated with the portal for incentive administration.

Other than BMI, the other thing you’re likely to find on the biometric screening is that someone is using tobacco. Now, the bad news is that the ACA says we can’t actually require an improvement target. So we can’t actually require them to quit. We have to give them a way to earn the incentive just for completing a cessation program. So once again we think that quarterly targets are the way to go. We think the right strategy is to have a choice of fairly easy, simple cessation programs, but to require them to keep after it and do something every quarter. That way it’s more likely that one of these deadlines will actually coincide with a time in their life when they are motivated to quit. So that matching of requirement and motivation is 4 times more likely to happen than with an annual target. I wish we could require them to test tobacco free, but unfortunately we can’t.

I want to contrast our recommended approach with what is typical for outcome incentives. Many programs that are doing outcome incentives typically do the HRA and screening in the fall, then they have a 90 day period for participants to improve BMI as well as all other biometrics like blood pressure, cholesterol, and glucose. At the end of that 90 days, they close the book and lock in the incentives for the next year. And this causes a lot of problems. For example, some programs require participants to lose as much as 10% of their bodyweight in 90 days, then they get the rest of the year off until the next screening. This is basically an invitation to yo-yo dieting. Lose a bunch of weight, rapidly, gain it back, go again next year. These programs typically are not collecting physical activity data at all, since they are so focused on screening numbers. So they are only paying attention to half of the picture. And of course the biggest problem is that for ¾ of the year, the participants are off the hook – total lack of motivation for lifestyle change. So your smokers are only making one quit attempt per year, and you’re not moving the needle on physical activity or BMI. (CLICK) Remember our point from a few slides ago. Sustained lifestyle change requires frequent goals throughout the year. Not a one and done approach.

Designing for all 4 Game Changers means you’re providing the right action plan and the right incentives for a variety of different participants. Here are 3 examples: Nancy discovered at the biometric screening that her LDL cholesterol was higher than the recommended levels. She already lives a healthy lifestyle, and her other biometrics are excellent. To earn the full reward under the wellness program, she will work with her doctor to treat the high cholesterol. No other changes needed. Jen has a BMI over 30, but all of her other biometrics are still in the healthy range. To earn the full reward under the wellness program, she will need to change lifestyle habits to include more physical activity and/or losing a moderate amount of weight. With these changes, she’s much less likely to need medication later in life. Bill has a BMI over 30, and also has high blood pressure and elevated blood glucose. To earn the full reward under the wellness program, he will need to work with his doctor to treat his high blood pressure and blood glucose levels. He will also need to change lifestyle to be more active and /or lose a moderate amount of weight. This makes sense, because for most high-risk participants it takes a combination of medication and lifestyle change to really impact health outcomes.

Now we move to the last game changer. Full participation, lifestyle change and biometric improvement are great, but they can only happen if the program is easy to administer for groups of any size. They can only happen if the program can get there using existing staff, technology and budgets.

You’ve already heard some of the story on scalability. We recommend using a smartphone app for physician biometric data. That means no paper and no fax. We recommend using a smartphone app for steps and weight – accurate data and no expensive devices to buy, repair, deploy and keep track of. We recommend using a cloud-based online portal to connect the data and administer incentives. All these things add up to a program that’s easy to deploy across a small company, a large company, or even a health plan. That’s scalability. Notice what’s not here. We do not recommend buying every employee an expensive fitness tracker device. We do not recommend buying expensive health kiosks for every worksite. We do not recommend using labor-intensive paper and FAX. Having to deploy hundreds or thousands of physical devices kills scalability. So does processing hundreds or thousands of paper forms.

Now a lot of you are asking, do my participants really have internet access? Do they really have a smartphone? And what if some of them don’t? We think it’s a huge mistake for wellness programs to design everything based on the lowest common denominator – paper and fax. And here’s why. The Pew Internet & American Life project has been tracking adoption of home internet service, cellphones and smartphones, and other technologies for many years. If you look at working adults with a household income over $50,000 it turns out that almost 95% have internet access at home. About 85% have a smartphone in the household. When you actually narrow down on the group of adults young enough to still be working, and with the kind of incomes that go along with employer provided health insurance – technology access is very good. To put it another way, most of the adults with no internet and no smartphones are either older people who are retired, or younger people who have the kind of low-income jobs that don’t come with health insurance. So we think it’s critical to design your process around the 85% of working adults with a smartphone and internet access in their household. That’s the approach that works best for the vast majority of your workforce. A paper process misses out on all the benefits of tailored, step-by-step presentation of participant status and next steps based on real-time data. Wellness programs are complex, multi-step processes that don’t map well onto paper forms. Once you’ve designed your process, we recommend that you handle the exceptions as exceptions: If you have onsite clinics, you can take updated biometrics at the onsite clinic. If you have onsite fitness, you can take updated weights at the fitness center. You can allow employees to send in paper forms along with their check for a small paper processing fee. It’s amazing how a $10 or $20 fee drives people away from paper and onto the apps and websites.

Let’s go through a high level demo of how to implement.

Bring up SampleSite1. So let’s talk first about full participation in HRA’s and screenings. First, make it easy for participants. So there’s one place to go to take your HRA (SHOW), schedule your screening appointment, (SHOW) and see your incentive do-to list (SHOW). If you’re going to use a penalty approach to get high HRA and screening participation, you have to do everything possible to make it easy and clear for participants. Second, let’s talk about biometric improvement. After the screening, participants will see if their biometrics met the standards (SHOW ON HRA PAGE). For this participant, you can see that blood pressure and LDL cholesterol are all within the target ranges, but glucose is high – indicating a risk of prediabetes. So to earn the full reward, the participant will make an appointment with their doctor, and take their smartphone along.

So here are the App screens. You can see the top link is what participants use at the doctor’s office – it’s the button for physician biometrics and incentives. The next button is to verify your weight. You can see we also have a food log below that, and the last button is for the pedometer portion of the app. So you can see this is an Extracon app. We think it’s critical that the app needs to come from the maker of your wellness portal, so it’s secure, it’s trusted, and it works seamlessly. Ever time we’ve deployed 3rd party apps or devices, there’s always an extra step to connect the 3rd party app or device to the portal and keep things in synch – and that extra steps drives a huge amount of participant confusion and dissatisfaction. The lesson is, the app needs to be part of the portal so it’s seamless.

So here are some more screenshots to really show how it works. The pedometer is running all the time, in the background. It automatically synchs with the portal, so your data is stays current in both places. When you open the app, you can see how many steps you’ve taken each day for the last 10 days or so, as well as the totals on the top. You can scroll back through and see up to 90 days of data. In the middle you can see the photo-based food log. This is really useful for participants to keep track of what they are eating. This is so much better than a paper food log, since you can see the portion sizes. Our clients are starting to use this feature within weight-loss programs, and within coaching programs so the coaches can see what participants are eating. Finally, you can see the app that shows your weight and your face. So this is how you get a validated weight number, without buying a $5,000 kiosk for the worksite.

Let’s move on to the summary. 4 Game Changers in Employee Wellness: Full Participation, Biometric Improvement, Sustained Lifestyle Change, and Scalability. They Work Together: It takes all four, working together, to transform your program. Don’t design for one or two at the expense of the others. Incentives Matter: Make sure your incentives actually reward the outcomes you’re trying to achieve. Leverage Existing Technology: design for the 85% of your population with internet access and a smartphone in their household.

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